Elder Care & More II

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. 36-411(A) and (C), for one of two personnel sampled. The deficient practice posed a risk as required information could not be verified. Findings Include: 1. A review of the facility's schedule from January 21, 2026, through February 25, 2026, revealed E2 was scheduled to work as a caregiver on January 22, 2026, January 29, 2026, February 5, 2026, February 12, 2026, and February 19, 2026. 2. A review of E2’s personnel file included copies of E2’s Fingerprint Clearance Card (FPC); however, the FPC issue date was March 04, 1999. There were no other FPCs available for review. 3. In an interview, the findings were discussed with E1. E1 indicated E2 was told they were “grandfathered in” and did not have to obtain a new FPC as long as E2 was working at the same facility and E2 was still employed there. 4. In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency. Findings include: 1. A review of E2's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 2. In an interview, E1 acknowledged E2's personnel record did not include documentation of completion of fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed each resident had a current service plan describing the services which would be provided by the facility staff to each resident. 2. A review of R1's and R2's medical records revealed each record included documents titled, "ADL Sheet." The ADL sheets included the month and year and listed each service which was to be provided. The task sheets contained a box for each shift, for a caregiver to document if the service had been provided by initialing inside the box and to annotate if there was an exception. However, the task sheets had not been consistently filled out for each shift and included gaps or blank areas on multiple days, on all shifts, where documentation of the services provided had not been completed. 3. In an interview, E1 acknowledged the ADL sheets provided for review did not accurately document the services provided to each resident. Technical assistance for this rule was provided during the on-site compliance inspection conducted on August 23, 2022.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the hot water faucet in a hallway bathroom accessible from a common area was not functional. The Compliance Officer observed the hot water valve did not produce any water when turned on. 2. During an environmental tour of the facility, the Compliance Officer observed the water drain in a bathroom attached to a resident bedroom located on the north west corner of the facility was not functional. While checking the water temperature, the Compliance Officer turned on the water to the sink and to the shower and observed both the sink and the shower were not draining sufficiently. 3. In an interview, E1 acknowledged the manager had failed to ensure equipment used at the assisted living facility was maintained in working order.