Emerine Hills Adult Care Home

Based on documentation review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of E4's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 2. In an interview, E1 acknowledged E4's personnel record did not include documentation of a fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two residents sampled. 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 R1's medical record revealed documentation of R1's freedom from infectious TB was not available for review. R1's medical record included a negative Mantoux skin test, however, documentation of an assessment of R1 risks of prior exposure to infectious tuberculosis and a determination if R1 had signs or symptoms of tuberculosis, were not available for review. 3. A review of R2's medical record revealed documentation of R2's freedom from infectious TB was not available for review. R2's medical record included a negative Mantoux skin test, however, documentation of an assessment of R2 risks of prior exposure to infectious tuberculosis and a determination if R2 had signs or symptoms of tuberculosis, were not available for review. 4. In an interview, E1 acknowledged completed documentation of R1's and R2's freedom from infectious TB had not been provided for review

Based on record review and interview, the manager failed to ensure a documented residency agreement included the signature of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, and date signed, for one of two sampled residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(214) states "Signature" means: "a. A handwritten or stamped representation of an individual's name or a symbol intended to represent an individual's name, or b. An electronic signature." 2. A review of R1's medical record revealed a residency agreement. However, this residency agreement did not include the signature of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, and date signed. 3. In an interview, E1 acknowledged R1's residency agreement did not include the required signature.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a refrigerator located in the kitchen was not locked and was accessible to residents. Inside the refrigerator, the Compliance Officer observed a bottle of "Equate Stomach Relief," in the door stored along side food items. 2. During an environmental inspection of the facility, the Compliance Officer observed an unlocked drawer in a desk near the kitchen refrigerator. Inside the drawer, the Compliance Officer observed a box of, "Cloebetasol Propionate 0.05% cream." 3. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. A review of facility policies and procedures, reviewed and approved March 1, 2018, revealed a policy titled, "Emerine Hills Assisted Living, Disaster Plan and Evacuation Policy and Procedures for Assisted Living." This policy stated, "The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months." However, documentation to indicate the disaster plan had been reviewed at least once every 12 months was not available for review. 2. In an interview, E1 acknowledged a current disaster plan review had not been provided to the Compliance Officer upon request. E1 reported the documentation was not able to be provided during the on-site inspection due to the owner being unable to bring the documentation within the required two hour time frame.

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. Findings include: 1. A review of the facility work schedule revealed the facility worked on two shifts per day. 2. A review of facility disaster drills conducted during the previous twelve months revealed drills were not provided for review. 3. In an interview, E1 acknowledged documentation of disaster drills had not been provided to the Compliance Officer upon request. E1 reported the documentation was not able to be provided during the on-site inspection due to the owner being unable to bring the documentation within the required two hour time frame.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of facility documentation revealed documented evacuation drills were not provided for review. 2. In an interview, E1 acknowledged documentation of evacuation drills had not been provided to the Compliance Officer upon request. E1 reported the documentation was not able to be provided during the on-site inspection due to the owner being unable to bring the documentation within the required two hour time frame.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet above a counter adjacent to the kitchen. Inside the cabinet, the Compliance Officer observed two bottles of, "Spectracide Wasp and Hornet Killer." 2. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents.