Goodyear Assisted Living Home, LLC

Based on observation, record review, and interview, the manager failed to ensure that at least one manager or caregiver was present at the assisted living facility when a resident was on the premises. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. Upon entry at approximately 9:30 AM, the Compliance Officer observed O1 and E3 were the only staff in the facility with eight residents. O1 reported to the compliance officer to be E2. 2. A review of E3's personnel file revealed E3 was hired as an assistant caregiver. There was no documentation of a caregiver training certificate in E3's file. 3. In a review of E2's personnel record, E2's record revealed an fingerprint clearance card dated July 19, 2022. E2's fingerprint clearance card reflected E2's date of birth, E2's height of 4'10" and weight of 135 pounds. 4. The compliance officer observed O1 to not match the description of E2 as reflected on E2's fingerprint clearance card. O1 was observed to be approximately 5'6" in height. There was no available personnel record matching O1's description. 5. In an interview, O1 was unable to confirm the date of birth as indicated in E2's personnel record. 6. In an interview, E1 acknowledged O1 was not able to recall the date of birth in E2's personnel file.

Based on observation, record review, and interview, the manager failed to ensure one of five sampled employees had a personnel record. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs, and false and misleading documentation was presented. Findings include: 1. The compliance officer arrived to the facility at approximately 9:30am. The compliance officer observed O1 in the facility working with E3. O1 reported to the compliance officer to be E2. 2. In a review of E2's personnel record, E2's record revealed a fingerprint clearance card dated July 19, 2022. E2's fingerprint clearance card reflected E2's date of birth, E2's height of 4'10" and weight of 135 pounds. 3. The compliance officer observed O1 to not match the description of E2 as reflected on E2's fingerprint clearance card. O1 was observed to be approximately 5'6" in height. There was no available personnel record matching O1's description. 4. A request to review O1's personnel file, revealed there was no personnel file for O1. 5. In an interview, O1 was unable to confirm the date of birth as indicated in E2's personnel record. 6. In an interview, E1 acknowledged O1 was not able to recall the date of birth in E2's personnel file, and that there was no personnel file for O1.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. The Compliance Officers observed ten oxygen containers stored upright in R1's bedroom closet. One oxygen container was on a two-wheel vertical medical cylinder cart, eight containers were secured in a metal crate, however, one oxygen container was not secured. 2. In an interview, E3 acknowledged there was an unsecured oxygen container in R1's bedroom closet.

Based on documentation review, record review and interview, the health care institution failed to implement a training program regarding fall prevention and fall recovery training to include initial training and continued competency, for three of three personnel members sampled. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed an undated policy and procedure titled "Fall Prevention and Fall Recovery." The policy and procedure stated "The training program requires initial training and continued competency review on an annual basis..." 2. A review of E1's personnel record revealed a training certificate for fall prevention and fall recovery, dated February 13, 2023. However, documentation of subsequent fall prevention and fall recovery training was not available for review. 3. A review of E2's personnel record revealed a training certificate for fall prevention and fall recovery, dated February 13, 2023. However, documentation of subsequent fall prevention and fall recovery training was not available for review. 4. A review of E3's personnel record revealed a training certificate for fall prevention and fall recovery, dated February 13, 2023. However, documentation of subsequent fall prevention and fall recovery training was not available for review. 5. In an interview, E3 acknowledged E1, E2 and E3 did not have updated fall prevention and fall recovery training since the initial training had been conducted with E1, E2 and E3. This is a repeat deficiency from the compliance inspection conducted on November 3, 2022.

Based on observation and interview, the manager failed to ensure a calendar of planned activities was prepared at least one week in advance of the date the activity was provided. Findings include: 1. The Compliance Officers observed an activity calendar posted on the refrigerator in the kitchen. However, the posted activity calendar was for February 2024. 2. In an interview, E3 acknowledged the February 2024 activity calendar was posted and no current activity calendar was prepared at least one week in advance.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officers observed six small plastic pill containers lying on the kitchen counter. Each container was labeled with a resident's name. None of six the containers were able to be locked. 2. The Compliance Officers observed the following in the unlocked kitchen refrigerator: - A large plastic container with numerous boxes of diabetic medications belonging to R1 - A sealed white mailer with R1's name written with a blank marker on it (reported to be additional diabetic medications for R1) The medications were stored in a plastic container, however, the container was not locked. 3. In an interview, E3 acknowledged the medications found in the refrigerator were not stored in a separate locked room, closet or cabinet. E3 reported the containers on the kitchen counter were accessible due to caregivers providing medications, however, E3 acknowledged the medications were accessible to residents and were not locked away.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. The Compliance Officers observed a posted food menu. This food menu was titled "Week 1: 1-7," however, did not include the month and the actual date did not match the days of the week. 2. In an interview, E3 acknowledged the current food menu had not been posted conspicuously.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed an unlocked cabinet beneath the kitchen sink. The cabinet contained a full sharps container with numerous needles protruding from the top of the sharps container. 2. The Compliance Officers observed numerous ambulatory residents on the premises. 3. In an interview, E3 acknowledged the sharps container was accessible to residents and contained used needles that posed a risk to the physical health and safety of residents.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a health and safety risk to residents. Findings include: 1. The Compliance Officers observed an unlocked cabinet beneath the kitchen sink. The cabinet contained the following poisonous or toxic materials: -Five containers of Disinfectant wipes -Febreeze air freshener -Two cans of Pledge multi-surface cleaner -Windex glass cleaner -Glade air freshener -All-purpose cleaner -Simple Green cleaner The bottles were accessible to residents and contained warning labels. 2. The Compliance Officers observed the following poisonous or toxic material on the kitchen counter: -Sanidry disinfectant wipes The container was accessible to residents and contained a warning label. 3. The Compliance Officers observed the following poisonous or toxic material in a resident bedroom: -Gorilla Glue The container was accessible to residents and contained a warning label. 4. In an interview, E3 acknowledged the unlocked materials throughout the facility were accessible to residents and were poisonous or toxic.