Lakeview Assisted Living Home LLC

Based on documentation review, record review, and interview, the health care institution 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 training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Fall and Fall Prevention.” The policy stated, “All new caregivers will have training on fall prevention one month after hire date. All caregivers will have a fall prevention training every year or every six months if there are at least 2 incidents of resident falls for the quarter.” 2. A review of E1's personnel record revealed E1’s hire date of September 1, 2025. A review of E1’s personnel record revealed no fall prevention and fall recovery training. 3. A review of E2's personnel record revealed E2’s hire date of November 30, 2013. A review of E2’s personnel records revealed the following: Fall prevention training completed on July 12, 2024. No fall recovery training. No training per facility policy. 4. A review of E3's personnel record revealed E3’s hire date of December 6, 2016. A review of E2’s personnel record revealed the following: Fall prevention training completed in 2024. No fall recovery training for 2024 and 2025. No training per facility policy. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 6. This is a repeat deficiency from the compliance inspection conducted on July 13, 2023.

Based on record review, documentation review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution and annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. The Compliance Officer observed E1 and E2 providing services to the resident during the inspection. 2. A review of the facility’s September 2025 personnel schedule revealed the following: E1 was not listed on the schedule for September 2025. E2 was scheduled for every day except September 7, 14, 21, and 28. 3. A review of E1's personnel record revealed E1’s hire date of September 1, 2025. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 4. A review of E2's personnel record revealed E2’s hire date of November 30, 2013. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 5. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment. 6. In an interview, E2 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted, nor was the employee's annual training. 7. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 8. Technical assistance was provided on this Rule during the compliance inspection on July 13, 2023.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of three employees reviewed. The deficient practice posed a risk if the employees were unable to meet residents' needs. Findings include: 1. The Compliance Officer observed E1 providing services to the resident during the inspection. 2. A review of E1's personnel record revealed E1’s hire date of September 1, 2025. However, the record revealed no documentation showing E1 had received orientation specific to the duties to be performed. 3. A review of the facility’s policies and procedures revealed a policy titled "Applicant and Employee Requirement" (dated January 13, 2023). The policy and procedure stated "...After the employee is hired by this facility, ...the new employee completes the New Employee Orientation within 10 days from the employee's date of hire ..." 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 5. This is a repeat deficiency from the compliance inspection conducted on July 13, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. § 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. The Compliance Officers observed residents’ medical records sitting on a bookshelf on the desk in plain sight. The bookshelf, where the medical records were stored, had no doors to lock up the records. The office was near the front door, towards the left as you walked in. The office was an open space that had a clear path to the living room and dining room. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that an employee disaster drill 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 the disaster plan and the Department was provided false or misleading documentation. Findings include: 1. During the inspection, the Compliance Officer (CO) heard the printer printing. The CO went to the kitchen and found E2 printing documents. E2 had filled out three different pages prior to the CO questioning E2. The CO observed the title on one of the pages stated disaster drill. 2. In an interview, E2 acknowledged that E2 was filling out the disaster drill pages. 3. A review of the facility's documentation revealed the following: A disaster plan was filled out for August 5, 2025, and signed by E2. This was one of the documents that the CO saw E2 filling out. A disaster plan was conducted on May 5, 2025, at 9:00 am, 3:00 pm, and 7:00 pm, which was signed by E3. A disaster plan was conducted on February 5, 2025, at 9:00 am, 3:00 pm, and 7:00 pm, which was signed by E3. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, documentation review, record review, and interview, the manager failed to ensure an assistant caregiver received orientation specific to the duties to be performed by the assistant caregiver before providing assisted living services, for one of one assistant caregiver sampled. The deficient practice posed a risk if E4 was unable to meet a resident's needs. Findings include: R9-10-101.155 "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. The Compliance Officer observed E4 working at the facility upon arrival at 11:40AM. 2. A review of facility documentation revealed a policy and procedure titled "Applicant and Employee Requirement" (dated January 13, 2023). The policy and procedure stated "...After the employee is hired by this facility, ...the new employee completes the New Employee Orientation within 10 days from the employee's date of hire ..." 3. A review of E4's (hired in 2023) personnel record revealed completed orientation was not available for review. 4. In an interview, E2 reported E4 had not completed orientation.

Based on observation, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for one of one assistant caregiver sampled. The deficient practice posed a risk if E4 was unable to meet a resident's needs. Findings include: 1. The Compliance Officer observed E4 working at the facility upon arrival at 11:40AM. 2. A review of E4's (hired in 2023) personnel record revealed documentation of the verification of E4's skills and knowledge was not available for review. 3. In an interview, E2 reported E4's skills and knowledge were not verified before E4 provided services.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed in-service education, for two of three caregivers sampled and one of one assistant caregiver sampled. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention" (dated January 13, 2023). The policy and procedure stated "...The manager of the assisted living home will review with staff and provide employee training information for fall prevention every 6 months ..." 2. A review of E2's, E3's, and E4's personnel records revealed completed in-service education to include fall prevention training was not available for review. 3. In an interview, E2 reported E2, E3, and E4 had not completed training in fall prevention. E2 reported E1 scheduled an in-service training for all staff in fall prevention and fall recovery to be completed in July 2023.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(2), for four of four employees sampled. Findings include: A.R.S. \'a7 36-411(C) Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card. 1. A review of E1's, E2's, E3's, and E4's personnel records revealed valid fingerprint clearance cards. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 2. In an interview, E2 acknowledged E1's, E2's, E3's, and E4's fingerprint clearance cards were not verified.

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 an accessibility risk to residents. Findings include: 1. The Compliance Officer observed two ambulatory residents on the premises. 2. The Compliance Officer observed an unlocked laundry room contained and unlocked cabinet with no fewer than nine bottles of poisonous or toxic chemicals. hallway closet contained a bottle of Lysol spray. 3. In an interview, E2 acknowledged the poisonous or toxic materials were not secured with a lock and were accessible to residents. Technical Assistance was provided on this Rule during the onsite compliance inspection conducted on May 11, 2022.