Blue Lakes Assisted Living LLC

Based on record review and interview, the health care institution failed to administer a training program that included initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E2's personnel record revealed E2’s hire date as February 10th, 2025. A review of E2’s personnel record revealed no documentation of fall prevention and fall recovery training. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review, record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A., for two of two residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of R1 and R2's medical records revealed documentation of the aforementioned standardized form; however, it did not include the following: A copy of the residents' health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the residents' discharge 3. In an exit interview, findings were reviewed with E3, and no additional information was provided.

Based on record review and interview, the health care institution failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for one of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E2’s personnel record revealed a hire date of February 10, 2025. The personnel record revealed no documentation of training on recognizing the signs and symptoms of TB. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 3. Technical assistance was provided regarding this rule during the compliance inspection conducted on June 27, 2024.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for two of two employees reviewed. The deficient practice posed a safety risk to residents. Findings include: 1. A.R.S. § 36-411.C.3 states: C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. A review of E1’s personnel record revealed that E1 had a documented prior work history. However, the personnel file did not include documentation of documented, good-faith efforts to contact previous employers to obtain information or recommendations relevant to E1’s fitness for employment, only personal references. 3. A.R.S. § 36-411.C.3 states: "3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 4. A review of E2's personnel record did not include documentation that E2 was not on the adult protective services registry pursuant to section 46-459. 5. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure documentation was maintained for at least 12 months of the caregivers and assistance caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer observed E2 and E3 working at the facility at the time of the inspection started. 2. A review of the facility's employee work schedule revealed a schedule for 2025. The schedule included the caregivers scheduled to work January 1, 2025 - November 30, 2025. No further documentation of the caregivers scheduled to work and hours worked by each was available for Compliance Officer review. 3. In an exit interview, the findings were reviewed with E3, and no additional information was provided.