Haven Health Prescott Alf, LLC

Based on documentation review, record review, and interview, the manager failed to ensure caregivers had the qualifications, experience, skills and knowledge necessary to meet the needs of the residents and ensure their health and safety, for two of three caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1 . A review of facility documentation revealed a policy titled "Verification of Skills/Knowledge Policy." The policy stated, "Haven Health will verify skills of caregiver/assistant caregivers upon hire. A certified caregiver mentor or a licensed nurse will verify skills of employees by signing off on verification sheets." 2 . A review of E3's and E4's personnel records revealed documentation of a skills and knowledge verification sheet was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E5 and no additional information was provided.

Based on record review and interview, the health care institution failed to initiate cardiopulmonary resuscitation (CPR) in accordance with its certification training for CPR before the arrival of emergency medical services, to a resident who was nonresponsive or has a cessation of normal respiration, in accordance with that resident's advance directives, if known. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of department documentation revealed a report which stated, "Resident was discovered in cardiac arrest at 0720, 911 was not called until 0744... Pt was left in cardiac arrest while calling supervisors and looking for a DNR..." 2. Review of facility documentation revealed an incident report involving R2 dated December 3, 2024. The incident report stated, "... resident was not breathing ... [CCG] called 911...CCG ran down to see if resident was DNR/Full Code. Residents POA at bedside instructed staff to not start CPR. Fire department started CPR due to no orange DNR form present ... Fire department called time of death @0817." 3. In an interview, E1 reported CPR was not initiated because R1 had a signed DNR form. However, acknowledged the advance directive was not known at the time of the incident and CPR should have been initiated until R2's advanced directives status was known.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of two sampled employees. 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 E2's personnel record revealed E2 worked as a caregiver and had a hire date of June 13, 2024. A further look into E2's record revealed current documentation of E2's CPR training from the "NationalCPRFoundation" issued May 05, 2024 and was valid for two years. However, the CPR training did not include a hands-on demonstration of techniques as required. 2. Review of resident medical records revealed E2 worked through the month of November 2024. 3. A review of the facility's policies and procedures revealed a policy titled, "CPR and First Aid Training" which stated, "II. CPR certification/re-certification must be obtained from a trainer authorized to train and certify individuals in CPR, in accordance with the curriculum of the American Heart Association, American Red Cross, or National Safety Council." 4. In an email exchange, a representative from NationalCPRFoundation, stated "Our courses are online only." 5. In an interview, E1 acknowledged E2's CPR training was online and did not include a demonstration of the individual's ability to perform CPR, as required.

Based on record review, documentation review and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. Findings include: 1. A review of E2's and E3's personnel records revealed documentation titled "Caregiver Skills Checklist." 2. A review of facility policies and procedures revealed a policy on how skills and knowledge were verified and documented was not available for review. 3. In an interview, E1 acknowledged a policy and procedure for verifying a caregiver's or assistant caregiver's skills and knowledge was not established.

Based on interview and record review, the manager failed to ensure the requirements in R9-10-814(B)(2) were met for a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, for one of one non-ambulatory resident sampled. Findings include: 1. In an interview, E1 revealed R1 was non-ambulatory upon admission and required a wheelchair as an assistive aide. 2. A review of R1's medical record revealed admission orders dated July 18, 2018, signed by the resident's primary care provider stating the resident's needs could be met by the assisted living facility within the facility's scope of services. 3. Further review of R1's medical record revealed signed continued residency orders dated May 29, 2019. 4. A review of R1's medical record did not reveal any additional continued residency orders as required every six months in R9-10-814(B)(2). 5. In an interview, E1 acknowledged R1 was a non-ambulatory resident and the requirements in R9-10-814(B)(2) for retention of a resident who was confined to a bed or chair because of an inability to ambulate even with assistance were not being met.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures for medication administration were implemented for documenting medication administration. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Management." The policy stated, "A separate medication record is maintained for each resident receiving assistance in self-administration or medication administration that includes: a. Name of resident b. Name of medication, dosage, directions and route administration; c. Date and time medication is scheduled to be administered; d. Date and time of actual administration; and e. Signature or initials of the staff member administering the medication." 2. A review of R1's, R2's, R3's, R4's, R5's, R6's, and R7's medical records revealed each resident received medication administration. 3. A review of R1's, R2's, R3's, R4's, R5's, R6's, and R7's medication administration record (MAR) revealed each medication administered was listed on the MAR, including the name of the resident, the name of the medication, dosage, directions, and route administration. The time of medication administration was documented as "AM", "EVE", or "PM/HS". However, the time of actual administration was not documented as required. 4. In an interview, E1 acknowledged the facility's policies and procedures were not implemented for documenting medication administration as the time of medication administration was not documented. E1 reported E1 would correct the problem in the electronic documentation system as soon as possible.

Based on documentation review, observation, and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. A review of Department documentation revealed R2 attempted to obtain access to a biohazard bin containing pills to be disposed of. The biohazard bin was located in an unlocked office near the entrance of the facility. 2. The Compliance Officer observed the office door was able to be locked. However, there was a large sliding glass window that did not have the capability of locking. The window was large enough for a person to crawl through. The compliance officer observed ambulatory residents on the premises. 3. In an interview, E1 acknowledged the unlocked sliding glass window presented a condition or situation that may cause a resident or other individual to suffer physical injury. E1 reported E1 would figure out a way to lock the sliding glass door.