Golden Senior Living

Based on record review and interview, the manager did not ensure a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for two of two residents sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A review of R1's and R2's medical records revealed a packet titled "Special Emergency Resident Medical Record" with documentation of a standardized emergency responder patient information form completed as required by Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9). However, the following were not included in the documentation: A standardized space to be filled in with the reason or reasons the emergency responder was requested on behalf of the resident; and 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. 2. In an interview, E1 acknowledged the information required in A.R.S. § 36-420.04 was not prepared in a standardized emergency responder patient information form as required.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis 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. Findings include: 1. A review of R2's medical record revealed documentation of negative TB blood test from June 2025. However, documentation of a TB screening questionnaire was not available for review at the time of inspection. 2. In an exit interview, the findings were discussed with E1 and no additional information was added.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia annually for two of two resident's sampled. Findings Include: 1. A review of R1's medical record revealed no documentation of offering the influenza and pneumonia vaccinations since October, 2024. 2. A review of R2's medical record revealed no documentation of offering the influenza and pneumonia vaccinations was available for review. 3. In an interview, E1 acknowledged that there was no documentation of offering the influenza and pneumonia vaccinations to R1 and R2 annually.

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. Findings include: 1. A review of the facility's personnel schedule revealed the facility had two staff shifts. 2. A review of the facility's disaster drill documentation revealed a disaster drill conducted on the following dates and shifts: April 1, 2025 at 10:30AM indicated as the AM shift; and July 25, 2025 at 5:00PM. However, no documentation of disaster drills for each shift every three months was available for review. 3. In an interview, E1 acknowledged a disaster drill for employees was not conducted at least once every three months on each shift and documented.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. A review of the facility's evacuation drill documentation revealed documentation of evacuation drills conducted on two shifts April 30, 2025. However, documentation of additional drills was not available for review. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility documents revealed a policy and procedure titled "Fall Prevention" reviewed and signed by E1 July 20, 2022. This policy stated "...All employees upon hire will take part in an in-service training program regarding Fall Prevention and Fall Recovery, which will include initial training and continued competency at least every 12 months..." 2. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of February 21, 2022. The personnel record revealed documentation of fall prevention training dated February 20, 2022. However, current documentation was not available indicating E2 completed fall prevention and fall recovery training. 3. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of June 23, 2022. The personnel record did not include documentation showing E3 completed fall prevention and fall recovery training. 4. Review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of January 2, 2023. The personnel record did not include documentation showing E4 completed fall prevention and fall recovery training. 5. Review of E5's personnel record revealed E5 worked as an assistant caregiver and had a hire date of February 21, 2022. The personnel record did not include documentation showing E5 completed fall prevention and fall recovery training. 6. Review of E6's personnel record revealed E6 worked as a caregiver and had a hire date of November 11, 2022. The personnel record did not include documentation showing E6 completed fall prevention and fall recovery training. 7. In an interview, E1 acknowledged documentation was not available showing E2, E3, E4, E5, and E6 had completed initial training and continued competency training for fall prevention and fall recovery.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of six employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution..." 2. Review of E1's personnel record revealed E1 worked as the facility manager and had a hire date of April 5, 2022. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E1's fitness to work in a residential care institution. 3. Review of E2's personnel record revealed E2 worked as a facility caregiver and had a hire date of February 21, 2022. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution. 4. In an interview, E1 acknowledged documentation was not available showing E1's and E2's work references were obtained upon hire at the facility.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training, before providing assisted living services, for two of six caregivers. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "First Aid and CPR Training" reviewed and signed by E1 July 20, 2022. This policy stated "1. The hiring person will require that each new employee or volunteer have CPR training specific for adults from a CPR training organization...2. The hiring person will require that each new employee or volunteer to have First Aid training from a first aid training organization..." 2. Review of E5's personnel record revealed E5 worked as an assistant caregiver and had a hire date of February 21, 2022. The personnel record revealed no documentation of first aid and CPR training. 3. Review of E6's personnel record revealed E6 worked as a caregiver and had a hire date of November 11, 2022. The personnel record revealed no documentation of first aid and CPR training. 4. Review of the July 2023 personnel schedule revealed E5 worked the 7am - 7:30pm shift on Sundays and E6 worked the 7am - 7:30pm shift Mondays - Saturdays. 5. In an interview, E1 acknowledged documentation was not available showing E5 and E6 had documentation of first aid and CPR training.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area that allowed residents to be at least 30 feet away from the facility and 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. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility with E1, the Compliance Officer observed an exit door on the east side of the facility did not have a device that alerted employees to the egress of a resident to the outside area. 3. During an environmental inspection of the facility with E1, the Compliance Officer observed an exit door on the south side of the facility had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not work. 4. In an interview, E1 acknowledged there were means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility which did not control or alert employees of the egress of a resident from the facility.