Holy Name Assisted Living 2

Based on documentation review, observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), when there was a change in the manager and identifying the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: A.R.S. \'a7 36-425(I) states "A health care institution shall immediately notify the department in writing when there is a change of the chief administrative officer..." 1. A review of Department documentation revealed O1 listed as the manager. 2. During an environmental inspection of the facility, the Compliance Officers observed E5's manager's certificate posted near the front door of the facility. 3. A review of E5's personnel record revealed E5 was hired as the manager on March 1, 2023. 4. In an interview, E1 reported E5 was the current manager and acknowledged the Department was not notified in writing of the change in manager. 5. A review of Department documentation revealed E5 notified the Department in writing, the change of manager on May 7, 2024.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental tour, the Compliance Officers observed two bottles of Megestrol AC SUS 40MG/ML unlocked in the kitchen refrigerator. 2. In an interview, E1 reported the medications were discontinued and should have been disposed. 3. In an interview, E1 acknowledged medications were stored unlocked.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery including initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Fall Prevention and Fall Recovery" (dated June 28, 2022). However, the policy did not include initial and continued competency training for personnel members. 2. A review of E2's personnel record revealed training in fall prevention. However, training in fall recovery was not included. 3. A review of E4's personnel record revealed fall prevention and fall recovery training was not available for review. 4. A review of E5's personnel record revealed training in fall prevention, dated July 27, 2022. However, documentation of continued competency training and training in fall recovery was not available for review. 5. In an interview, E1 acknowledged a fall prevention and fall recovery training program was not developed, E2's and E5's training did not include fall recovery, E4 did not have fall prevention and fall recovery training, and E5 did not have continued training. This is a repeat deficiency from the on-site compliance inspection conducted on July 14, 2022.