Assisted Living of Paradise Valley

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB), for one of three employees who had or was expected to have more than eight hours of direct interaction with residents. The deficient practice posed a high potential health and safety risk to residents and staff of TB exposure. Findings include: 1 A review of E2's personnel record revealed that E2 was hired as a caregiver in December 2024. 2. A review of E2's personnel record revealed two TB skin tests dated December 2, 2024, and January 7, 2025. No additional documentation of freedom from infectious TB was available for review on or before E2 began providing services to the resident. This documentation was required based on E2's hire date. 3. In an interview, E1 acknowledged E2 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed the facility's disaster plan was reviewed in 2022 and 2023. However, no additional documentation for review was available. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for two of five personnel members sampled. Findings include: 1. The Compliance Officer observed E3 working on the premises with E1 and E2 throughout the duration of the inspection. 2. A review of facility documentation revealed a policy and procedure titled, "Administration" which stated, "...3. All employees will complete orientation before providing services to residents. 4. The skills of the orientation will be documented on Orientation checklist..." 3. Further review of facility documentation revealed a staffing schedule dated August 2023. The schedule revealed E3 was scheduled to work from 7:00 AM to 7:30 PM on August 1-4, 7-9, 13-17, 21-24, and 28, 2023. The schedule also revealed E4 was scheduled to work from August 1-4, 7-9, 14-17, and 21-24, 2023. 4. A review of E3's personnel record revealed documentation of completed orientation specific to the duties to be performed by E3 was not available for review. 5. A review of E4's personnel record revealed documentation of completed orientation specific to the duties to be performed by E4 was not available for review. 6. In an interview, E1 reported E1 had not gone through the orientation checklist with E3 and E4 prior to E3 and E4 starting at the facility. E1 acknowledged E3's and E4's completed orientation documentation was not available for review.

Based on observation, documentation review, record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for one of five personnel members sampled. Findings include: 1. A review of facility documentation revealed a staffing schedule dated August 2023. The staffing schedule revealed E5 worked from 7:00 AM to 7:30 PM on August 5-6, 10-13, 18-20, and 25-27, 2023. 2. A review of E5's personnel record revealed E5 was hired as an assistant caregiver. However, E5's qualifications, including skills and knowledge applicable to E5's job duties, were not available for review. 3. In an interview, E1 acknowledged E5's personnel record did not contain documentation of qualifications, including skills and knowledge applicable to E5's job duties.