Ksc Care, LLC

Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident which cover required skills and knowledge. Findings include: 1 . A review of facility documentation revealed a policy titled "Personnel." The policy stated, "A caregiver's or assistant caregiver's skills and knowledge are verified and documented before the caregiver or assistant caregiver provides physical health services it must follow policies and procedures." However, the policy did not state how skills and knowledge are verified and documented. 2 . In an interview, E2 acknowledged a policy describing how skills and knowledge are verified and documented was not available for review at the time of inspection.

Based on record review and interview, the manager failed to ensure service plans for a resident receiving directed care services included documentation of the resident's weight, for one of two residents sampled. Findings include: 1 . A review of R1's medical record revealed a service plan dated March 4, 2025. The service plan reported R1 received directed care services. However, there was no documentation of the resident's weight on the service plan. 2 . In an interview, E2 acknowledged R1's service plan did not include documentation of the resident's weight.

Based on observation and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that controls or alerts employees of the egress of a resident from the facility. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed the front door and screen door leading to the front yard. The screen door has a double-sided key-locked deadbolt, and the front door had an alert at the top of the door. However, the screen door was unlocked, and the door alert was not functional at the time of inspection. 2 . During an environmental inspection of the facility, the Compliance Officers observed the sliding glass door leading to the backyard of the facility. The door had an alert. However, the alert was not functioning at the time of inspection. 3 . During an environmental inspection of the facility, the Compliance Officers observed a sliding glass door from an empty resident room leading to the backyard. The empty resident room door was unlocked, and the sliding glass door had no control or alert. 4 . In an interview, E2 acknowledged the doors that allow egress from the facility were not controlled or alerted.

Based on documentation review and interview, the manager failed to ensure a training program for all staff regarding fall prevention and fall recovery included initial training and competency training. Findings include: 1 . A review of facility documentation revealed a policy titled "Fall Prevention." However, the policy did not cover when initial training and competency training would be conducted for all employees. 2 . In an interview, E2 acknowledged a program for all staff regarding initial and competency training for fall prevention and fall recovery was not available for review.

Based on document review, observation, record review and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), which requires immediate notification to the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager. Findings include: 1. Review of Department records indicated O1 as the facility manager. The Department records revealed no written notification received by the Department identifying a change in the facility's manager from O1 to E1. 2. At the time of the survey, the compliance officer observed E1 present at the facility. The compliance officer observed a notification posted on the wall near the front door indicating E1 was the manager. 3. Review of E1's record revealed E1 was the facility's manager. 4. In an interview, E1 reported E1 became the facility's assisted living manager on April 3, 2023. E1 reported E1 had believed E1 provided written notification to the Department. However, E1 reported E1 reviewed E1's records and E1 only provided notification to the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). E1 acknowledged E1 did not have documentation to demonstrate the governing authority immediately notified the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. Findings include: 1. A review of Department documentation revealed the license issued by the Department stated the facility was authorized to provide directed care services. 2. A review of the facility's policies and procedures revealed a policy to include the methods by which the assisted living facility is aware of the general or specific whereabouts of a resident. The facility policies and procedures identified "...Personal level of care residents are allowed to go on outings on their own or accompanied by family...when leaving the facility the resident, or the individual accompanying resident will need to sign out of the facility, communicate the approximate length of time threat they will be away and approximate location site and whereabouts during the outing If in any way possible, the facility should be able to reach the resident or the individual accompanying the resident by telephone. Upon returning to the facility the resident or individual accompanying the resident will sign the resident back into the facility. 3. A review of R1's medical record revealed the facility was unaware of R1's whereabouts on July 4, 7, and 8, 2023, due to R1 leaving the facility without notifying personnel, or complying with the facility's policies and procedures. R1's medical record revealed when R1 leaves the facility with no notice, R1 has returned to the facility under the influence of alcohol. 4. In an interview, E1 reviewed the facility's policies and procedures. E1 acknowledged R1 has a history of leaving the facility without notifying the facility and does not comply with the facility's policies and procedures. E1 acknowledged the manager failed to implement methods by which the assisted living facility was aware of the general or specific whereabouts of a resident.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's date of hire, contact telephone number; qualifications, including skills and knowledge applicable to the individual's job duties; and the individuals completed orientation required by policies and procedures; and the individual's education and experience applicable to the individual's job duties, for one of two personnel records sampled. Findings include: 1. The compliance officer observed E1 and E2 present at the facility at the time of the inspection. 2. A review of the facilities policies and procedures dated April 11, 2023, revealed a policy titled Employee and Volunteers Qualifications. The policy stated "...Employment requirements: Full name, date of birth, current address and phone number, date of hire...verification of skills and knowledge documented before providing assisted living services to residents." 3. A review of E1's personnel record revealed E1's date of hire, contact telephone number, documentation to include the individual's qualifications, including skills and knowledge applicable to the individual's job duties; and the individual's education and experience applicable to the individual's job duties were not available for review. 4. In an interview, E1 reported E1 became the manager in April 2023. E1 reported the personnel documentation provided to the Department for E1 were the only documents available for review. E1 acknowledged E1's personnel record did not include E1's date of hire, contact telephone number, documentation to include E1's qualifications, including skills and knowledge applicable to the individual's job duties; and the individual's education and experience applicable to the individual's job duties.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, 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 a facility tour with E1, the compliance officer and E1 observed R3's bedroom has a patio door that leads to the facility's backyard that allows R3 to get more than thirty feet away from the facility with no means of alerting the facility of egress. 3. In an interview, E1 reported R3's bedroom did previously have an alarm on the door however, it was taken down by R3. E1 acknowledge the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility.