Golden Residence Assisted Living LLC

Based on record review and interview, the health care institution failed to administer a training program that included initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E1’s personnel record revealed a hire date of December 6, 2023. Documentation showed completion of a training titled “Fall Prevention and Fall Recovery Training.” However, when reviewing the training content outline, the documentation listed instructions on fall prevention; however, the documentation did not outline that fall recovery training was completed as part of the training. 2. A review of E2's personnel record revealed E2’s hire date of December 12, 2024. Documentation showed completion of a training titled “Fall Prevention and Fall Recovery Training.” However, when reviewing the training content outline, the documentation listed instructions on fall prevention; however, the documentation did not outline that fall recovery training was completed as part of the training. 3. A review of the organization’s fall prevention fall recovery training program revealed that a required time frame for completion of the continued competency training was not specified. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager of an assisted living home failed to maintain a copy of the document provided to the emergency responder, which included the items listed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1) through (9), for one of two residents reviewed. The deficient practice posed a risk as the Department was unable to ensure the facility's compliance. Findings include: 1. A review of R1's medical record revealed a medication administration record not filled out from November 30, 2025, through the present. 2. In an interview, E1 reported R1 went in the ambulance to the hospital on November 30, 2025, around 2 am. 3. In an interview, E1 reported that E1 did not have a copy of the documents provided to the emergency responders, which included the items listed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1). 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedure manual revealed a three-year review page. However, the page was not signed. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. A review of the facility’s November 2025 work schedule revealed that E1 was scheduled to work day and night shifts Monday through Friday, and E3 was scheduled to work day and night shifts on the weekends. 2. A review of the facility’s December 2025 work schedule revealed that E1 was scheduled to work day and night shifts Monday through Friday, and E3 was scheduled to work day and night shifts on the weekends. 3. A review of R1 and R2’s medical records revealed that the medication administration records (MARs) were signed only by E1 for Monday through Sunday. 4. During an interview, E1 reported that E1 also worked on weekends and that E3 performed only administrative duties on weekends. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 6. This is a repeat deficiency from the inspection conducted on January 24, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure employees who had or were expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis (TB): on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113 for one of two employees sampled. The deficient practice posed a potential TB exposure risk to residents and false or misleading information was provided to the Department. 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 E1’s medical record revealed documentation of a TB screening and risk assessment; however, the record contained a photocopied signature. The signature on E1’s TB screening and risk assessment document was identical in appearance, placement, and formatting to the signature found on R2’s TB screening and risk assessment document. 3. In an interview, E1 reported E1 was unsure why it was a photocopied signature. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan included documentation of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for two of two residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. A review of R1’s medical record revealed a current service plan dated August 8, 2025. However, the service plan did not include R1’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. A review of R2’s medical record revealed a current service plan dated October 1, 2025. However, the service plan did not list R2’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents and false or misleading information was provided to the Department.  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 documentation of a TB screening and risk assessment; however, the record contained a photocopied signature, providing false and misleading documentation. The signature on R2’s TB screening form was identical in appearance, placement, and formatting to the signature found on E1’s TB screening and risk assessment document. 3. In an interview, E1 states E1 was unsure why it was a photocopied signature. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services provided to the resident, for two of two residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a current written service plan dated August 8, 2025, which indicated R1 received personal care services. R1’s service plan outlined assistance with dressing, grooming, and incontinence checks; however, it did not specify the frequency with which these services were provided. 2. A review of R2's medical record revealed a current written service plan dated October 1, 2025, which indicated R2 received directed care services. R2's service plan outlined assistance with dressing, grooming, toileting, and incontinence checks; however, it did not specify the frequency with which these services were provided. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the caregiver or assistant caregiver documented the services provided in the resident’s medical record. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1’s medical record revealed a service plan dated August 8, 2025, and an activities of daily living (ADL) sheet dated September, October, and November 2025. The service plan indicated that R1 was to receive oral care daily and linen changes when soiled. The ADL sheets included these services; however, they were not completed to indicate whether oral care and linen changes were actually provided, or when they were provided. R1 was admitted into the hospital November 30th, 2025. 2 In an interview, E1 reported that R1 received all services listed on R1's service plan but did not document. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is a repeat deficiency from the inspection conducted on January 24, 2023.

Based on record review and interview, the manager failed to ensure that a resident’s medical record contained the document signed by the resident consenting for the resident’s representative to act on the resident’s behalf or a copy of the health care power of attorney, for one of two residents sampled. Findings include: 1. A review of R2’s medical record revealed that R2 received directed level services; however, the record did not include documentation of a health care power of attorney. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review 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 two of two residents sampled. The deficient practice posed a risk as the medication administered could not be verified against a medication order. Findings Include: 1. A review of R1's medical record revealed the following: A current written service plan dated August 8, 2025. This service plan indicated R1 received medication administration. A medication order up to date as of September 4, 2025. However, the medication list was not signed by a medical practitioner. A review of the medical record revealed no medication orders signed or authenticated by a medical practitioner for any of the medications listed. Medication Administration Record (MAR) for January 2025, signed that the following medications were administered without a signed order: "Acetaminophen," "Aspirin," "Atorvastatin," "Furosemide," "Lisinopril," "Metformin Hydrochloride," "Metoprolol Tartrate," "Novolin N," "Novolin R," and "Tamulosin HCL." 2. A review of R2's medical record revealed the following: A current written service plan dated October 1, 2025. This service plan indicated R2 received medication administration. A medication order up to date as of May 8, 2025. However, the medication list was not signed by a medical practitioner. A review of the medical record revealed no medication orders signed or authenticated by a medical practitioner for any of the medications listed. MAR for January 2025 signed that the following medications were administered without a signed order: "Aspirin," "Amiodarone Hydrochloride," "Amlodipine Besylate," "Quetiapine Fumarate," and "Trazodone Hydrochloride." 3. In an interview, E1 reported that medications were administered to R1 and R2 and that the medication lists were not signed. In addition, E1 reported that E1 thought it was acceptable because the medical provider faxed over the medication lists. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

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. § 36-406(1)(d), for two of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 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 R1's medical record did not include documentation of R1's notification of the availability of vaccinations for flu and pneumonia. Based on R1's date of admission, this documentation was required. 3. A review of R2's medical record did not include the selection of R2's choice of vaccinations for flu and pneumonia. Based on R2's date of admission, this documentation was required. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. This is a repeat deficiency from the inspection conducted on January 24, 2023.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; offering sufficient fluids to maintain hydration; amd incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting, for one of one resident sampled. The deficient practice posed a health risk to the resident. Findings include: 1. A review of R1's medical record revealed a service plan dated August 8, 2025. The service plan revealed that R1 received personal care services. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; offering sufficient fluids to maintain hydration; and incontinence care that ensured that the resident maintained the highest practicable level of independence when toileting. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-814.F.1-3, for one of one resident sampled. The deficient practice posed a health risk to the resident. Findings include: 1. A review of R2's medical record revealed a service plan dated October 1, 2025. The service plan revealed that R2 received directed care services. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; offering sufficient fluids to maintain hydration; and incontinence care that ensured that the resident maintained the highest practicable level of independence when toileting. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a service plan for a resident receiving directed care services included cognitive stimulation and activities to maximize functioning; strategies to ensure a resident’s personal safety; encouragement to eat meals and snacks; documentation of the resident’s weight, or from a medical practitioner stating that weighing the resident is contraindicated; and coordination of communications with the resident’s representative, family members, and, if applicable, other individuals identified in the resident’s service plan one of one sampled residents receiving directed care services. The deficient practice posed a risk as the service plan directs services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a service plan, dated August 8, 2025, which indicated R2 received directed care services. However, the service plan did not include the following: Cognitive stimulation and activities to maximize functioning; Strategies to ensure a resident’s personal safety; Encouragement to eat meals and snacks; Documentation of the resident’s weight, or from a medical practitioner stating that weighing the resident is contraindicated; Coordination of communications with the resident’s representative or family members 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order and accurately documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a current written service plan dated August 8, 2025, which indicated R1 received medication administration services. 2. A review of R1’s medical record revealed no documentation of signed medication orders for the following medications: “Novolin R PenFill 100 units/mL solution for injection, inject 35 units subcutaneously three times daily before each meal.” “Gabapentin 300 mg tablet, take one tablet by mouth twice daily.” “Fluticasone Propionate 50 mcg/actuation nasal spray, one spray once daily.” 3. A review of R1’s medical record revealed a Medication Administration Record (MAR) that indicated the following: The MAR listed “Novolin R 100 units/mL FlexPen, inject 35 units subcutaneously before breakfast, before lunch, and before dinner.” The MAR documented administration before breakfast and lunch; however, there was no documentation of administration before dinner. The MAR inaccurately listed “Gabapentin 300 mg capsule, one capsule by mouth as needed (PRN).” The MAR inaccurately listed “Fluticasone Propionate 50 mcg spray, one spray into each nostril as needed (PRN)." 3. A review of R2’s medical record revealed a current written service plan dated October 1, 2025, which indicated R2 received medication administration services. 4. A review of R2’s medical record revealed no documentation of a signed medication order for “Quetiapine Fumarate 100 mg tablet, give one tablet by mouth every 12 hours as needed.” 5. A review of R2’s medical record revealed a MAR that listed “Quetiapine Fumarate 25 mg tablet, one tablet by mouth at bedtime.” 6. In an interview, E1 acknowledged that medication orders for R1 and R2 did not correspond with the Medication Administration Records and that the orders were not signed. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 8. This is a repeat deficiency from the inspection conducted on January 24, 2023.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of two residents sampled. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed a medication administration record not filled out from November 30, 2025, through the present. 2. In an interview, E1 reported R1 went in the ambulance to the hospital on November 30, 2025, around 2 am. 3. In an interview, E1 acknowledged that there was no documentation of the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were cleaned and disinfected according to policies and procedures to prevent, minimize, and control illness or infection. The deficient practice posed a risk as the facility had not implemented its established policy and procedure to reinforce and clarify standards expected of employees. Findings Include: 1. During an environmental inspection of the facility, the Compliance Officers observed the following: In R1’s room, multiple soiled bed pads were observed on the floor with a strong odor of urine. In R1’s room, numerous boxes were observed throughout the room, creating cluttered conditions. Bags of "Ultra underpads" were laid out on the bed. A trash can without a lid was observed to be full of trash and had not been emptied. In R2’s room, a trash can without a lid was filled with soiled briefs and emitted a strong odor of urine. In R3’s room, a large bottle containing urine was present and had not been emptied. 2. A review of R1's medical record revealed that R1 had been hospitalized since November 30, 2025. 3. In an interview, E1 reported that R1 was in the hospital, but R1's room remained the same since November 30, 2025. 4. In an interview, E1 reported that R2 had not yet been awakened or changed for the morning. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

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. The deficient practice posed a risk if personnel members were unable to safely evacuate residents in an emergency. Findings include: 1. A review of facility documentation revealed revealed no documentation of evacuation drills conducted at the facility within the last 12 months. 2. In an interview, E1 acknowledged there was no other documentation available for review at the time of the inspection to indicate evacuation drills for employees and residents were conducted at least once every six months.

Based on documentation review and interview, the manager failed to ensure required smoke detectors were tested at least once a month. The deficient practice posed a potential fire hazard. Findings include: 1. A review of facility documentation revealed no documentation to indicate the facility's smoke detectors were tested at least once a month. 2. In an interview, E1 reported being unsure if smoke detectors were tested each month as required. E1 acknowledged documentation of any conducted testing was not available for review at the time of the survey.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months, for one of one sampled resident who received directed care services. The deficient practice posed a risk if the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R3's medical record revealed a service plan for directed care services January 7, 2024. No more recent service plan for R3 was available for review at the time of the inspection. 2. In an interview, E1 acknowledged there was no updated service plan for R3 available for review at the time of the inspection.

Based on an observation and interview, the manager failed to ensure a means of exiting the facility controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a door leading from the common area to the back yard. The Compliance Officer observed the door had no mechanism to alert employees of the egress of a resident from the facility. 2. In an interview, E1 acknowledged the door had no mechanism to alert the staff of a resident leaving the facility.

Based on observation, documentation review, and interview, the governing authority failed to designate, in writing, a manager who either had a certificate as an assisted living facility manager issued under Arizona Revised Statutes (A.R.S.) \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3's assisted living facility manager license was posted in the facility. 2. A review of the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board) website revealed E3's assisted living facility manager license was voluntarily surrendered on November 8, 2023. 3. In an interview, E1 reported being unaware E3's assisted living facility manager license was voluntarily surrendered. E1 and E2 reported they reached out to E3 but were unable to make contact with E3 before the end of the inspection.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for one of two sampled caregivers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed staffing schedules for the previous 12 months. The schedules revealed E2 was scheduled to work at the facility as a caregiver on multiple shifts throughout February-May 2024. 2. A review of facility documentation reveal a policy titled "Verifying Caregiver's Skills and Knowledge". The Policy stated: "Policy: Before the caregiver provides physical health services or behavioral health services, his or her skills and knowledge are verified and documented. 1. The manager will interview and assess caregiver and test on caregiver skill using assessment sheet..." 3. A review of E2's personnel record revealed no documented verification of E2's skills and knowledge. 4. In an interview, E1 acknowledged E2's personnel record did not contain documented verification of E2's skills and knowledge.

Based on record review and interview, the manager failed to ensure a personnel record included documentation of current cardiopulmonary resuscitation (CPR) and first aid training, for one of three sampled caregivers. The deficient practice posed a risk if the employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3's personnel record revealed CPR and first aid training certifications. However, the certifications expired October 31, 2023. 2. In an interview, E1 acknowledged E3's CPR and first aid training certifications were expired, and there was no additional documentation available for review.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a health and safety risk to residents with access to the poisonous or toxic materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed "Bleach", "Great Value Disinfectant Spray", "Glass Cleaner", "70% Isopropyl Alcohol", a white spray bottle labeled "Bleach", and a clear spray bottle containing an unknown purple solution stored in an unlocked cabinet under the sink in the hallway bathroom. The bathroom was accessible to residents, and the cabinet door had a locking device installed, but it was left unlocked at the time of the observation. 2. In an interview, E1 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents. This is a repeat citation from the compliance inspection conducted on January 24, 2023.

Violation cited

Violation cited

Based on record review, documentation review, and interview, the administrator failed to ensure documentation required by Article 8 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. Findings include: 1. A review of E2's personnel record revealed documentation demonstrating E2's skills and knowledge were verified and documented was not available for review. 2. A review of E1's personnel record revealed documentation of the requirement in R9-10-806(C)(1)(c)(iii) was not available for review. 3. A review of E3's personnel record revealed documentation of the requirement in R9-10-806(C)(1)(c)(iii) was not available for review. 4. A review of E4's personnel record revealed documentation of the requirement in R9-10-806(C)(1)(c)(iii) was not available for review. 5. A review of personnel records provided by E2 revealed personnel records for E1, E2, E3, and E4. However, a personnel record for E5 was not provided for review. 6. A review of the facility's policies and procedures revealed a disaster plan (dated March 1, 2021). However, documentation of disaster plan reviews were not available for review. 7. In an interview, E1 acknowledged documentation required by Article 8 was not provided to the Department within two hours after a Department request. This Rule was cited on January 24, 2023. A letter sent to the facility, dated February 22, 2023, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date."

Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge was verified and documented before providing physical health services and according to policies and procedures, for one caregiver. The deficient practice posed a risk if E2 was unable to meet a resident's needs, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed E2 on the premises and working alone when the Compliance Officer arrived on the premises. 2. A review of the facility's policies and procedures revealed a policy titled "VERIFYING CAREGIVER'S SKILLS AND KNOWLEDGE" (dated March 1, 2021). The policy stated "Before the caregiver provides physical or behavioral health services, his or her skills and knowledge are verified and documented...1. The manager will interview and assess caregiver and test on caregiver skill using assessment sheet. 2. The manager will make effort to contact the previous employers to inquire about the caregiver's work background and attitude. 3. The manager will put the information from previous employers in the employee's [sic]." 3. A review of E2's personnel record revealed documentation demonstrating E2's skills and knowledge were verified and documented was not available for review. 4. In an interview, E2 acknowledged documentation demonstrating E2's skills and knowledge were verified was not available for review. This Rule was cited on January 24, 2023. A letter sent to the facility, dated February 22, 2023, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date."

Violation cited

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the requirements in R9-10-806(C)(1)(c)(iii), for three of four personnel members sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance, and the documentation was not provided within two hours after a Department request. Findings include: R9-10-101.165 "Personnel member" means, except as defined in specific Articles in this Chapter and excluding a medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services to a patient. R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. The Compliance Officer observed E2 on the premises and working alone when the Compliance Officer arrived on the premises. 3. A review of E1's (hired in 2021) personnel record revealed documentation of the requirement in R9-10-806(C)(1)(c)(iii) was not available for review. 4. A review of E3's (hired in 2021) personnel record revealed documentation of the requirement in R9-10-806(C)(1)(c)(iii) was not available for review.. 5. A review of E4's (hired in 2021) personnel record revealed documentation of the requirement in R9-10-806(C)(1)(c)(iii) was not available for review. 7. In an interview, E2 acknowledged a personnel record for E1, E3, and E4 to include the requirement in R9-10-806(C)(1)(iii) was not available for review. This Rule was cited on January 24, 2023. A letter sent to the facility, dated February 22, 2023, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date."

Based on observation and interview, the manager failed to ensure a personnel record for an employee was maintained throughout the individual's period of providing services in or for the assisted living facility. The deficient practice posed a risk as required information could not be verified for E5, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed E5's license, issued by the Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), posted on the premises and was issued on September 19, 2022. 2. The Compliance Officer requested to review E5's personnel record. 3. A review of personnel records provided by E2 revealed personnel records for E1, E2, E3, and E4. However, a personnel record for E5 was not provided for review. 4. In an interview, E2 acknowledged E5's personnel record was not available for review. This Rule was cited on January 24, 2023. A letter sent to the facility, dated February 22, 2023, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date."

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

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. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of the facility's policies and procedures revealed a disaster plan (dated March 1, 2021). However, documentation of disaster plan reviews were not available for review. 2. In an interview, E2 acknowledged the disaster plan was not reviewed at least once every twelve months. This Rule was cited on January 24, 2023. A letter sent to the facility, dated February 22, 2023, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date."

Violation cited