Cherry's Assisted Living

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, for two of two personnel records sampled. Findings include: 1. A review of the facility's policies and procedures, last reviewed January 17, 2017, revealed a fall prevention and fall recovery program had not been developed or administered. 2. A review of E3's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 3. A review of E4's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 4. In an interview, E1 and E2 acknowledged documentation of a fall prevention and fall recovery training program had not been provided 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, evidence of freedom from infections tuberculosis (TB), the individual's completed orientation and in-service education required by policies and procedures, and compliance with the requirements in A.R.S. \'a7 36-411(C); for one of two personnel records sampled. The deficient practice posed a risk if E4 was not able to meet the needs of residents. Findings include: 1. Upon arriving at the facility, the Compliance Officer was invited into the facility by E4. The Compliance Officer observed E4 working as a caregiver during the on-site inspection. 2. A review of the facility work schedule revealed E4 worked as a caregiver from 8 a.m. to 6:30 p.m. on Tuesday, November 7, 2023 and Wednesday, November 8, 2023, the day of the survey. 3. A review of E4's personnel record revealed E4 was hired as a caregiver in August of 2023. However, E4's personnel record did not include the following documentation: - evidence of freedom from TB, E4's personnel record included a single Mantoux skin test, however, the test result had been read less than 48 hours after the serum was injected and was not valid; - documentation of orientation; - documentation of verification of E4's skills and knowledge; - verification of the current status of E4's fingerprint clearance card; - documentation of good faith efforts to contact previous employers to obtain information or recommendations relevant to E4's fitness to work in a residential care institution; and - documentation of initial fall prevention and fall recovery training. 4. In an interview, E1 and E2 acknowledged the personnel record provided for E4 did not include all required documents.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative and the manager, when initially developed and when updated, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated October 27, 2023. However, the service plan was not signed and dated by the resident or the resident's representative or the manager. 2. A review of R2's medical record revealed a service plan dated October 13, 2023. However, the service plan was not signed and dated by the resident or the resident's representative or the manager. 3. A review of R2's medical record revealed a service plan dated July 13, 2023. However, the service plan was not signed and dated by the resident or the resident's representative. 4. A review of R2's medical record revealed a service plan dated April 13, 2023. However, the service plan was not signed and dated by the resident or the resident's representative. 5. A review of R2's medical record revealed a service plan dated January 13, 2023. However, the service plan was not signed and dated by the resident or the resident's representative. 6. In an interview, E1 and E2 acknowledged the provided service plans for R1 and R2 had not been signed and dated by the resident or the resident's representative and the manager, when initiated or when updated.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled who received medication administration. Findings include: 1. A review of R1's and R2's medical records revealed service plans which included medication administration. 2. A review of R1's and R2's medical records revealed orders for medications to be administered daily. 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated October 2023. The MAR documented the medication which had been administered to R1 during the month of October 2023. However, the MAR included multiple blank spots where scheduled medications had not been documented to have been administered as ordered. 4. A review of R1's medical record revealed a MAR dated September 2023. The MAR documented the medications which had been administered to R1 during the month of September 2023. However, the MAR included multiple blank spots where scheduled medications had not been documented to have been administered as ordered. 5. A review of R1's medical record revealed a MAR dated August 2023. The MAR documented medication had been administered to R1 during the month of August 2023. However, the MAR included multiple blank spots where scheduled medications had not been documented to have been administered as ordered. 6. A review of R1's medical record revealed a MAR dated July 2023. The MAR documented medication had been administered to R1 during the month of July 2023. However, the MAR included multiple blank spots where scheduled medications had not been documented to have been administered as ordered. 7. A review of R1's medical record revealed a MAR dated April 2023. The MAR documented medication had been administered to R1 during the month of April 2023. However, the MAR included multiple blank spots where scheduled medications had not been documented to have been administered as ordered. 8. A review of R2's medical record revealed a MAR dated October 2023. The MAR documented medication had been administered to R2 during the month of October 2023. However, the MAR included multiple blank spots where scheduled medications had not been documented to have been administered as ordered. 9. A review of R2's medical record revealed a MAR dated September 2023. The MAR documented medication had been administered to R2 during the month of September 2023. However, the MAR included multiple blank spots where scheduled medications had not been documented to have been administered as ordered. 10. In an interview, E1 and E2 acknowledged the MARs for R1 and R2 had not been completely filled out by each shift.