Circle of Life Alzheimer Homes, LLC

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 that included initial training and continued competency training for three of four personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed an policy titled, "Direct Care Staff Training and Orientation." The policy stated, "(8) AZDHS new rules & regulations on Falls & recoveries - every direct care staff will be trained annually." 2. A review of E1's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated July 20, 2023. However, no documentation of further fall prevention and fall recovery training was available for Compliance Officer review. 3. A review of E2's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated July 20, 2023. However, no documentation of further fall prevention and fall recovery training was available for Compliance Officer review. 4. A review of E3's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated July 23, 2023. However, no documentation of further fall prevention and fall recovery training was available for Compliance Officer review. 5. In an interview, E1 acknowledged E1, E2, and E3 have not participated in annual fall prevention and fall recovery training per the facility's policies and procedures. E1 acknowledged the facility failed to administer a training program for staff regarding fall prevention and fall recovery that included continued competency training.

Based on record review and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of four personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E4's personnel record revealed a hire date of August 21, 2024. 4. A review of E4's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. 5. In an interview, E1 reported E1 was unaware of the new TB policies as specified in R9-10-113. E1 acknowledged E4 did not provided evidence of freedom from infectious TB as specified in R9-10-113.

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed an unsigned medication order dated August 23, 2023 for Eliquis 5 milligrams (mg), 1 tablet by mouth (po) twice a day (BID). 3. A review of R1's medication administration record (MAR) for August 2024 revealed the administration of Eliquis 5 mg, 1 tablet po BID, and indicated 1 tablet was administered at 8:00AM and 8:00PM August 1 - present. 4. The Compliance Officer observed Eliquis 5 mg stored by the facility for administration to R1. 5. In an interview, E1 acknowledged R1's medical record did not contain a medication order from a medical practitioner for each medication that was administered to the resident.

Based on documentation review, record review and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d) for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of the facility's policies and procedures revealed a policy titled, "19. Medical Records." The policy stated, "The Chief Executive and Office Assistant shall ensure that a resident's medical record contains: ... 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. \'a7 36-406(1)(d)." 3. A review of R2's medical record revealed R2 received the flu vaccine May 31, 2024. However, documentation was not available that indicated whether the pneumonia vaccine was received or refused. Based on R2's acceptance date, this documentation was required. 4. In an interview, E1 acknowledged R2's medical record did not contain documentation of R2's notification of the availability of vaccinations according to A.R.S. \'a7 36-406(1)(d).