Fountain Assisted Living Center

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for one of one personnel sampled. The deficient practice posed a potential TB exposure 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 E4's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB. Based on E4's hire date, this documentation was required. 3. In an interview, E2 acknowledged E4's personnel record did not include documentation of a risk assessment of prior exposure to infectious TB. Technical assistance was provided on this rule during the inspections conducted on April 14, 2023 and September 28, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of five residents sampled. The deficient practice posed a TB exposure 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 R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB signed by a registered nurse, medical practitioner or local health department. Based on R2's date of acceptance, this documentation was required. 3. A review of R4's medical record revealed no documentation of a determination if R4 had signs or symptoms of TB signed by a registered nurse, medical practitioner or local health department. Based on R4's date of acceptance, this documentation was required. 4. In an interview, E2 acknowledged R2 and R4 did not provide documentation of freedom from infectious TB as specified in R9-10-113. Technical assistance was provided on this rule during the inspections conducted on April 14, 2023 and September 28, 2023.

Based on documentation review, record review, and interview, the assisted living center failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9) for five of five sampled residents. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of R1's, R2's, R3's, R4's, and R5's medical records revealed that standardized emergency responder forms were not available for review. 3. In an interview, E2 acknowledged the facility failed to maintain a standardized form for each resident that included the information required in A.R.S. 36-420.04.A.

Based on documentation 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 which posed a health and safety risk to residents, for one of five sampled personnel records reviewed. Findings include: 1. At the beginning of the compliance inspection E2 received a list of the required documents that would be reviewed during this inspection. Later the compliance officer requested the review of the facility's documents for fall prevention and fall recovery training program for all staff. 2. Reviewed of the sampled employee personnel records revealed there was no documentation that E5 had completed the required training. 3. In an interview, E2 acknowledged the facility did not have documentation that E5 had completed the required fall prevention and fall recovery training as required. E2 reported that E5 started on September 17, 2023. E2 reported the E2 thought E5 had to the end of the month to complete the training. This is a repeat deficiency from the compliance inspection conducted on September 15, 2022.

Based on observation and interview, the manager failed to ensure a medication stored by the facility was stored in a locked room, closet, cabinet, or self-contained unit; which posed a health and safety risk. Findings include: 1. During the tour of the facility, E2 and the compliance officer observed the unlocked facility's kitchen there was an unlocked reach-in refrigerator where there was a large unlocked black box that contained liquid Lorazapam, Tuberculin vial, and Rock Latan Ophth Solution . 2. In an interview, E2 acknowledged the unlocked medications.

Based on documentation reviewed and interview, the manager failed to ensure there was the required documentation of the annual disaster plan review. Findings included: 1. At the beginning of the compliance inspection E2 received a list of the required documents that would be reviewed during this inspection. Later in the compliance inspection, the compliance officer requested and was not provide with the required documentation for the annual disaster meeting. E2 provided only the date of August 12, 2023 as the annual disaster plan meeting, however, none of the required documentation. There was no documentation that included the time of the disaster plan review, employees participating in the meeting, what did they critique of the disaster plan, and if applicable, recommendations for improvement. 2. In an interview, E2 acknowledged the disaster plan meeting was lacking the required documentation. Technical assistance was provided during the compliance inspection conducted on September 13, 2022.

Based on observation and interview, the manager failed to ensure the premises and equipment were free from a condition or situation that may cause a resident to suffer physical injury which posed a health and safety risk. Findings include: 1. During a facility tour, E2 and the surveyor observed in R5's bedroom there was a half-bedrail in the up position on the upper half of the bed on the side of the bed that R5 could exit the bed. The other side of the bed was against the bedroom wall. R5 was not capable of lowering the bedrail. 2. In an interview, E1 acknowledged the bedrail could become a hazard if the resident climbed over the bedrail or became entangled in the bedrail which could cause the resident to suffer physical injury. This is a repeat deficiency from the compliance inspection conducted on September 15, 2022.