Carefree Assisted Living

Based on documentation review and interview, the manager failed to ensure the health care institution had developed and administered a training program for all staff regarding fall prevention and fall recovery. Findings Include: 1. A review of the facility's policies and procedures revealed there was no program developed for fall prevention and recovery. 2. In an interview, E1 acknowledged that no training program regarding fall prevention and fall recovery was developed for all staff.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation training certification specific to adults Findings Include: 1. A review of the facility's policies and procedures revealed a policy titled CPR and First Aid. One of the procedures listed stated, "Employees and volunteers shall provide documentation of CPR (Cardiopulmonary resuscitation) and First Aid Training, to include the method and content of the training which includes a demonstration of the caregiver's ability to perform CPR." 2. A review of E3 personnel records revealed CPR training from the National CPR Foundation. The National CPR Foundation website FAQs state, “Do you offer hands-on training? No, we do not offer hands on training.” 3. In an interview, E1 acknowledged that E3 did not have documentation of cardiopulmonary resuscitation training specific to adults, which includes a demonstration of the caregiver's ability to perform cardiopulmonary resuscitation before providing assistance to a resident.

Based on observation and interview, the manager failed to ensure that residents' electronic medical records had safeguards to prevent unauthorized access. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed an unattended computer with personnel login information already filled in. The Compliance Officers were able to access a resident's medical record. 2. In an interview, E1 acknowledged residents' electronic medical records did not have safeguards to prevent unauthorized access.

Based on observation and interview, the manager failed to ensure that medication was stored by the assisted living facility in a locked cabinet. Findings Include: 1. During an environmental inspection, the Compliance Officers observed a cabinet labeled PNR with a childproof latch. The Compliance Officers were able to disengage the latch and gain access to medication. 2. In an interview, E1 acknowledged the facility did not store the PNR medication in a locked cabinet.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery, which included initial training and continued competency training in fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed an undated policy and procedure titled "Fall Prevention program," which included six bullet points for preventing resident falls. However, the policy did not include details indicating the facility developed a training program which included initial training and continued competency training. 2. A review of E3's, E5's, and E6's personnel records revealed no documentation of initial training or continued competency training in fall prevention and fall recovery. 3. A review of E2's and E4's personnel records revealed no documentation of initial training or continued competency training in fall recovery. 4. In an interview, E1 acknowledged the facility did not develop and administer a training program for all staff regarding fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training and first aid training, for one of six employees sampled. Findings include: 1. A review of facility policies and procedures revealed a policy titled "CPR and First Aid" which stated, "It is the policy of this facility to ensure that all caregivers are trained in CPR and First Aid, and that their certification is maintained and in current [sic] as long as they are employed by this facility." 2. A review of E2's personnel record revealed E2 was hired by the facility as a caregiver. However, documentation of current CPR and first aid training for E2 was not available for review. 3. In a joint interview, E1 and E2 reported E1 and E2 did not realize E2's CPR and first aid certifications had expired. E1 and E2 acknowledged E2's personnel record did not contain documentation of current CPR and first aid training.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(C), for one of six employees sampled. Findings include: 1. A.R.S. \'a7 36-411(C) states: "C. Owners 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. The Compliance Officer observed E2 working at the facility for the duration of the time the Compliance Officer was on site. 3. A review of facility policies and procedures revealed a policy titled "Applicant and Employee Requirement" which stated, "Upon being hired by the facility the applicant must:...provide 2 Personal and 2 Professional/Work References (references to be verified by the facility manager)." 4. A review of E2's personnel record revealed E2 was hired as a caregiver. E2's personnel record revealed no documented good faith efforts to contact previous employers to obtain information or recommendations relevant to E2's fitness to work in a residential care institution. 5. In an interview, E1 acknowledged the personnel record for E2 did not include documentation of compliance with the requirements in A.R.S. \'a7 36-411(C).

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months, for one of one resident sampled who received directed care services. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services, dated March 20, 2023. However, a more recently reviewed and updated service plan was not available for review. 2. In an interview, E1 acknowledged R2's service plan was not reviewed and updated at least once every three months.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, the manager, or the nurse or medical practitioner who reviewed the service plan when updated, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a directed care service plan which was reviewed and updated on March 20, 2023. However, the service plan update was not signed and dated by the resident's representative, the facility manager, and the nurse or medical practitioner who reviewed the service plan. 2. In an interview, E1 reported a registered nurse had reviewed and updated R2's service plan on March 20, 2023, but the nurse must have forgotten to sign the completed plan. E1 acknowledged R2's service plan was not signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan when the plan was updated.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. Findings include: 1. The Compliance Officer observed the following during the environmental inspection of the facility: -A spray bottle of "Lysol All Purpose Cleaner" and a jug of "Clorox" liquid bleach in an unlocked cabinet under the kitchen sink; and -A jug of "Lysol Laundry Sanitizer with Bleach," a bottle of "Purex Crystals in-wash Fragrance Boosters," two jugs of "Pine-Sol multi-surface cleaner," an aerosol spray can of "Lysol Disinfectant Spray", and a spray bottle of "Comet Bathroom Cleaner" in the facility's laundry room. The door to the laundry room was unlocked. 2. In an interview, E2 reported all toxic chemicals are usually stored in the laundry room, which E2 reported is usually locked. However, E2 acknowledged the laundry room door was unlocked while the Compliance Officer was on site. E2 acknowledged the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents.