Christian Care Manor II, INC

Based on record review, documentation 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. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings Include 1. A record review of E2's personnel record revealed, E2 did not receive Fall Prevention and Recovery training as required upon initial hire. 2. A documentation review of the facility's Policies and Procedures titled, "Fall Prevention and Fall Recovery programs" stated, "All staff will be initially trained and continued competency training in fall prevention and recovery." 3. In an interview, E1 acknowledged the manager did not ensure E2 received fall prevention and fall recovery training at initial hire as required.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services. Findings include: 1. A record review of the personnel files for E2 revealed, the employee did not have a completed orientation, Fall Prevention and Recovery, or Tuberculosis (TB) training, available for review. 2. A documentation review of the facility's Policies and Procedures titled, "Caregiver qualifications" stated, "The AL Director shall ensure documentation of the following: Individuals Qualifications, Skills, Training, and Knowledge applicable to job duties by the following: A, Caregiver Training and Orientation Checklist." A documentation review of the facility's Policies and Procedures titled, "Tuberculosis" stated, " Annual training and education related to recognizing the signs and symptoms of Tuberculosis to individuals employed by or providing volunteer services for the healthcare institution." A documentation review of the facility's Policies and Procedures titled, "Fall Prevention and Fall recovery programs" stated, "All staff will be initially trained and continued competency training in fall prevention and fall recovery." 4. In an interview, E1 acknowledged the manager did not ensure E2's caregiver skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services, according to policies and procedures.

Based on record review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for two of four sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A record review of E3's and E4’s personnel records revealed, each employee provided one negative TB test. A second TB test was not submitted for either employee. 2. In an interview, E1 acknowledged E3 nor E4 did not provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113.

Based on documentation review and interview, the manager failed to ensure a 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 documentation review of the facility’s Policy & Procedures section titled “Disaster Plan Review and signature page”, showed the Disaster Plan was lasted reviewed on January 5, 2024. 2. A documentation review of the facility's Policies and Procedures titled, "Disaster Plan and Evacuation drill“ stated, "The disaster plan is reviewed and the review is documented at least once every 12 months and includes the date and time of the disaster plan review, the names of each employee or volunteer participating in the disaster plan review, a critique of the disaster plan view, and if applicable, recommendations for improvement.” 3. In an interview, E1 acknowledged the manager did not ensure the Disaster Plan was reviewed every 12 months as required.

Based on documentation review and interview, the manager failed to ensure the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A documentation review of the facility’s "Fire/Disaster Drill Participants” revealed, the last disaster drill was completed on December 18, 2024. 2. A documentation review of the facility's Policies and Procedures manual titled, "Fire and Disaster Drill Procedures" stated, "Drills are scheduled on a yearly calendar in general one drill per quarter per each of the 3 shifts for each type of drill.” 3. In an interview, E1 acknowledged the manager did not ensure a disaster drill for employees was conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted once every six months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A documentation review of the facility’s "Evacuation Drill” revealed that the last evacuation drill was completed on April 17, 2024. 2. A documentation review of the facility's Policies and Procedures manual titled, "Disaster Plan and Evacuation drill" stated, “Employee and resident evacuation drills will be completed every six months.” 3. In an interview, E1 acknowledged the manager did not ensure an evacuation drill for employees and residents was conducted once every six months and documented.

Based on documentation review and interview, the manager failed to ensure a fire inspection was conducted by the local fire department according to the time-frame established by the local fire department. Findings include: 1. A review of facility documentation revealed documented fire inspection reports. However, the documentation revealed the most current fire inspection from the City of Phoenix was conducted March 23, 2021 and expired March 22, 2024. 2. In an interview, E1 acknowledged the most current fire inspection was conducted March 23, 2021 and expired March 22, 2024.