Ebenezer Senior Care, INC.

Based on record review and interview, the manager failed to ensure a caregiver who was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis as specified in R9-10-113, on or before the date the individual began providing services at the assisted living facility for one of two personnel sampled. The deficient practice posed a potential TB exposure risk to residents. Findings Include: 1. A review of E2’s personnel record revealed a date of hire of February 7, 2025. 2. A review of E2’s personnel record revealed a baseline screening dated February 13, 2025, a first-step skin test dated August 2, 2025, and a second-step skin test dated August 19, 2025. 3. In an exit interview, the findings were reviewed with E1. E1 acknowledged E2 provided services at the assisted living facility and had not provided evidence of freedom from infectious TB as specified in R9-10-113. E1 indicated E2 provided a negative chest x-ray dated before E2’s hire date.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(G), for one of two personnel records reviewed. A.R.S. \'a7 36-411(G) states: "G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety." Findings include: 1. A review of E2's personnel record revealed E2 had been hired as a caregiver in September of 2024. 2. A review of E2's personnel record revealed E2 had a valid fingerprint clearance card issued on December 28, 2022, more than six months prior to E2's employment by the facility. 3. A review of E2's personnel record revealed an application listing two previous employer. However, the application did not document the dates at which E2 had worked for one previous employer, and listed an end date of July 2018 for the second employer. 4. A review of E2's personnel record revealed an employment record covering December 2022 through September 2024 was not available for review. 5. In an interview, E1 acknowledged the personnel record provided for E2 did not include documentation of compliance with all subsections of A.R.S. \'a7 36-411.

Based on observation, documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training for applicable employees to include the method and content of cardiopulmonary resuscitation training, to include a demonstration of the employee's ability to perform cardiopulmonary resuscitation, for one of two personnel records reviewed. The deficient practice posed a risk if the employee was unable to meet a resident's needs during an emergency. Findings include: 1. Upon arriving at the facility, the Compliance Officers observed E2 was the only caregiver present at the facility. 2. A review of E2's personnel record revealed E2 had been hired in September of 2024 as a caregiver. 3. A review of E2's personnel record revealed a CPR and First Aid training certification card from "NationalCPRFoundation," an online only provider for which the training had not included a hands on demonstration of E2's ability to perform CPR. 4. In an interview, E1 acknowledged E2's CPR training had not included a demonstration of E2's ability to perform CPR.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's experience applicable to the individual's job duties, for one of two personnel records reviewed. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of E3's personnel record revealed a valid caregiver certificate. However, E3's documentation of experience applicable to E3's job duties was not available for review. 2. In an interview, E1 acknowledged the personnel record did not include E3's experience applicable to the individual's job duties and was unable to locate the requested documentation.

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 when initially developed and when updated, for two of two resident records reviewed Findings include: 1. A review of R1's medical record revealed a service plan update, dated October 8, 2024, for directed care services. However, the service plan was not signed and dated by R1 or R1's representative. 2. A review of R2's medical record revealed a service plan updates dated March 10, 2024, July 10, 2024, and October 8, 2024, for directed care services. However, the service plans were not signed and dated by R2's representative. 3. In an interview, E1 acknowledged the service plans provided for R1 and R2 had not been signed and dated by each residents' representative when the service plans were updated.

Based on record review, documentation review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for two of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a service plan, updated October 8, 2024, for directed care services. However, the service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. A review of R2's medical record revealed a service plan, updated October 8, 2024, for directed care services. However, the service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 3. In an interview, E1 acknowledged R1's and R2's service plans did not include each resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.

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 resident records reviewed. Findings include: 1. A review of R1's and R2's medical records revealed service plans, updated October 8, 2024, for directed care services including medication administration. 2. A review of R1's and R2's medical records revealed electronic Medication Administration Records (eMAR) dated September 2024. The MARs documented the medications administered to R1 and R2 during the month of September, 2024. However, the eMARs documented the following: - E7 had administered medications to R1 and R2 on September 8 and September 10, 2024; and - E6 had administered all medications to R1 and R2, on both the first and second shifts, between September 21, and September 30, 2024. 3. A review of the facility work schedule revealed E7 had not worked at the facility in September 2024, and E6 had not worked on September 21, or September 22 on any shift, had worked only 8 AM to 4 PM on September 23, had not worked September 24, had worked only 8 AM to 4 PM on September 25, and September 26, and had not worked on September 27, 2024. 4. In a telephonic interview with E5, E5 reported the facility was having some difficulty with the eMAR software and some staff had entered the wrong initials due to how they had logged in. E5 reported E7 had not worked at the facility for a year. E5 acknowledged there were no corrections or documentation on the eMAR for this issue. 5. In an interview, E1 acknowledged the eMAR provided for R1 and R2 did not accurately document the medications administered to R1 and R2, to include who had administered the medication.

Based on record review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. The Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. A review of E2's personnel record revealed no documentation of fall prevention and fall recovery training. 2. In an interview, E3 reported being unable to locate fall prevention and fall recovery training for E2. This is a repeat citation from the compliance inspection conducted on October 31, 2022.

Based on documentation review and interview, the manager failed to ensure policies and procedures were available to employees and volunteers of the assisted living facility. The Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. During the on-site inspection, the Compliance Officer requested to review the facility's policies and procedures. However, the policies and procedures were not provided for review. 2. In an interview, E3 reported being unable to locate the facility's policy and procedures, and acknowledged the policies and procedures were not available to employees and volunteers of the assisted living facility.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. On November 20, 2023, the Compliance Officer requested the following documents during the on-site inspection: - The following documentation for E2, and E4's personnel record: - The individual's starting date of employment; - The individuals reference checks; - The individual's qualifications, including skills and knowledge applicable to the individual's job duties; - The individual's completed orientation and in-service education required by policies and procedures; - Fall Prevention training for E2; - Disaster Drills for employees; - Policy and Procedures manual; and - 12 months of staffing schedules, only partial of October and November received. 2. In an interview, E3 acknowledged this information was not provided to the Compliance Officer within the two hours after a Department request.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least 12 months of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not provided during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed E3 working at the facility upon arrival at 12:50 pm. 2. The Compliance Officer requested to review a daily staffing schedule maintained for at least 12 months of the caregivers working each day, including the hours worked by each. However, E3 could only find a partial schedule for October 2023 and a partial schedule for November 2023. No other documentation was not provided for review. 3. In an interview, E3 acknowledged being unable to locate the documentation of the caregivers working each day, including the hours worked by each for the previous 12 months had not been provided within two hours after a Department request. This is a repeat citation from the compliance inspection conducted on October 31, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure a personnel record for each employee or volunteer included the individual's name, date of birth, and contact telephone number, the individual's starting date of employment or volunteer service, documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, the individual's education and experience applicable to the individual's job duties, the individual's completed orientation and in-service education required by policies and procedures, the individual is a behavioral health technician, clinical oversight required in R9-10-115, for two of three sampled personnel members. The Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. A.A.C. R9-10-101(165) states a "Personnel member" means, "except as defined in specific Articles of this Chapter and excluding medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services." Findings include: 1. A review of documents handed to the Compliance Officer from E3 revealed documents with E2's name on them. The Compliance Officer observed the following: a Finger Print Clearance Card, a CPR and First Aid card, a Certificate of Training in Article 9 course, and a Direct Care Arizona Direct Care Worker Training. Missing was E2's application with name, date of birth, and contact telephone number, the individual's starting date of employment or volunteer service, documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, the individual's education and experience applicable to the individual's job duties, the individual's completed orientation and in-service education, and TB documentation. 2. A review of documents handed to the Compliance Officer from E3 revealed documents with E4's name on them. The Compliance Officer observed the following: a Finger Print Clearance Card a CPR and First Aid card, a Caregiver Certificate, and TB documentation. Missing was E4's application with name, date of birth, and contact telephone number, the individual's starting date of employment or volunteer service, documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, the individual's education and experience applicable to the individual's job duties, the individual's completed orientation and in-service education. 3. In an interview, E3 acknowledged E2, and E4 did not have a personnel record just these papers were found in a filing cabinet.

Based on record review, documentation review, and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for three of three directed care residents sampled. Findings include: 1. A review of R1's medical record revealed documentation of a service plan indicating R1 was receiving directed care services. However, the service plan did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; - Offering sufficient fluids to maintain hydration; and - Encouragement to eat meals and snacks. 2. A review of R2's medical record revealed documentation of service plan indicating R2 was receiving directed care services. However, the service plan did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; - Offering sufficient fluids to maintain hydration; and - Encouragement to eat meals and snacks. 3. A review of R3's medical record revealed documentation of service plan indicating R3 was receiving directed care services. However, the service plan did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; - Offering sufficient fluids to maintain hydration; and - Encouragement to eat meals and snacks. 4. In an interview, E3 acknowledged the service plans did not contain all of the requirements for directed care residents

Based on documentation review and interview, 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. The Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. A review of the facility's staffing schedule revealed two shifts: - 9:00 am - 5:00 pm (First Shift), and - 5:00 pm - 9::00 am (Second Shift). 2. A review of documentation titled, "Disaster Drill" revealed the following information: - January 2023, time: 5:00 pm (second shift), - January 2023, time: blank (first shift), - July 2022, time blank (first shift), - October 2022, 10:00 am (first shift); and - October 2022, 8:00 pm (second shift). There was no additional documentation or evidence to indicate a disaster drill was conducted on each shift at least once every three months and documented. 3. In an interview, E3 reported doing the drills, however, the documentation was not provided with-in the two hours as requested. This is a repeat citation from the compliance inspection conducted on October 31, 2023.