Legend Ddd Services - Ursula Nsgh

Based on record review, documentation review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training, for three of three staff sampled. Findings include: 1 . A review of staff records revealed the E2, E3 and E4 had not completed the training requirements for Fall Prevention and Fall Recovery. 2 . A review of facility documents revealed a policy titled, Personnel Hiring and Training Plan, which included, on page 177 under REQUIRED TRAININGS - Fall Prevention and Fall Recovery - at hire and every year after. 3 . In an exit interview, E1 acknowledged that the staff had not completed training for Fall Prevention and Fall Recovery.

Based on record review and interview the health care institution failed to ensure that annual training was provided related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution. Findings include: 1 . A review of employee records revealed that E2, E3, and E4 had not completed training related to the signs and symptoms of infectious tuberculosis upon hire. 2 . In an exit interview, E1 acknowledged that employees had not received the required training for recognizing signs and symptoms of infectious tuberculosis upon hire.

Based on documentation review and interview the administrator failed to ensure that a personnel member who has or is expected to have direct interaction with a resident for more than eight hours a week provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at or on behalf of the nursing-supported group home as specified in R9-10-113. Findings include: 1 . A review of E2's records revealed a tuberculosis test that was negative, however there was only one test available for review, not the two step required. 2 . In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on record review and interview the health care institution failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the residents' admission and as specified in R9-10-113. Findings include: 1 . A review of R1's medical records revealed no evidence of testing for infectious tuberculosis before being admitted or within seven calendar days after being admitted to the facility. 2 . In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on documentation review and interview the administrator failed to ensure that a disaster drill for employees was conducted on each shift at least once every there months and documented. Findings include: 1 . A Review of facility documents revealed a disaster drill completed on December 17, 2025 for the day shift, however there was no documentation of disaster drills for the evening and night shift, as indicated on the disaster drill form. E1 also reported that there are three shifts that the employees work. 2 . In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on document review and interview, the administrator failed to ensure documentation of the nurses and other personnel members present on the nursing-supported group home ' s premises each day as maintained and included the name and actual number of hours each nurse or other personnel member worked that day. Findings include: 1 . A review of facility schedule revealed with "open shifts", going back to July 13, 2025 to present. E1 reported to the Compliance Officer that all shifts were covered and the schedule should be updated daily, to reflect the position was filled, however when E1 expanded the "open shift" tab, there was no name to show someone covered the open shift. 2 . A review of facility documents revealed a nursing staffing schedule, however there were several shifts labeled "Open Shift". E1 reported to the Compliance officer that the schedule was to be updated, daily, with the name of the nursing staff that filled the open shift, however, when the tab was expanded there was no name entered for coverage for that day. The Compliance Officer looked back 3 weeks and found all open shifts to be blank. 3 . In an interview, E1 acknowledged that documentation of the nurses and other personnel members present on the nursing-supported group home ' s premises each day was not maintained and included the name and actual number of hours each nurse or other personnel member worked that day.

Based on 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 that included initial training and continued competency training, for one of four personnel sampled. Findings include: 1. A review of E3's personnel record did not include documentation of completed fall prevention and fall recovery training. 2. In an interview, E3 acknowledged E3's personnel record did not include documentation of completed fall prevention and fall recovery training.

Based on documentation review and interview, the administrator failed to ensure that a documented report was submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1. While on-site for the complaint inspection, the Compliance Officers requested the facility's quality management documentation at 11:20 AM. However, no documentation was available for Compliance Officer review. 2. In an interview, E5 reported a quality management meeting was conducted on November 23, 2024. E3 acknowledged a documented quality management report was not available for review.

Based on documentation review, record review, and interview, the administrator failed to ensure that a personnel member's skills and knowledge were verified and documented before the personnel member provided physical health services, habilitation services, or behavioral care, for two of four personnel sampled. The deficient practice posed a risk if employees were unable to meet the needs of residents. Findings include: 1. A review of the facility's personnel schedule for November 29, 2024 revealed E2 was scheduled to work as the house nurse during the day shift. 2. A review of E2's personnel record did not include documentation of verification of E2's skills and knowledge. 3. A review of E3's personnel record did not include documentation of verification of E3's skills and knowledge. 4. In an interview, E3 reported E3 was the facility's director of nursing and provided health services at the facility. E3 acknowledged that E2's and E3's skills and knowledge were not verified and documented before the personnel member provided physical health services, habilitation services, or behavioral care.

Based on documentation review, record review, and interview, the administrator failed to ensure that a personnel record was maintained for each personnel member that included documentation of training in preventing, recognizing, and reporting abuse or neglect, required according to R9-10-2203(C)(1)(d)(i), for two of four personnel sampled. Findings include: 1. R9-10-2203(C)(1)(d)(i) states, "C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: Include methods to prevent abuse or neglect of a resident, including: i. Training of personnel members, at least annually, on how to recognize the signs and symptoms of abuse or neglect; and ii. Reporting of abuse or neglect of a resident." 2. A review of E2's personnel record revealed no documentation of training in preventing, recognizing, and reporting abuse or neglect, required according to R9-10-2203(C)(1)(d)(i). 3. A review of E4's personnel record revealed no documentation of training in preventing, recognizing, and reporting abuse or neglect, required according to R9-10-2203(C)(1)(d)(i). 4. In an interview, E3 acknowledged that E2's and E4's personnel records did not include documentation of training in preventing, recognizing, and reporting abuse or neglect, required according to R9-10-2203(C)(1)(d)(i).

Based on documentation review and interview, the administrator failed to ensure that a nursing-supported group home had smoke detectors that are tested at least once a month, with documentation of the test maintained for at least 12 months after the date of the test. Findings include: 1. While on-site for the complaint inspection, the Compliance Officers requested the facility's smoke detector test documentation at 11:20 AM. However, documentation of the completed tests was not provided for Compliance Officer review. 2. In an interview, E3 reported maintenance staff completed smoke detector tests monthly, but documentation of the tests was not maintained by the facility. E3 acknowledged documentation of smoke detector tests was not maintained for at least 12 months after the date of the test

Based on documentation review and interview, the governing authority failed to notify the Department in writing immediately when there was a change of administrator. Findings include: 1. During the onsite inspection, E1 stated they were the administrator of the facility. 2. A review of department records revealed E2 was the last known designated administrator. Documentation of notification of E1's subsequent appointment as administrator had not been received from the governing authority. 3. In an interview, E1, E3, and E4 acknowledged the Department had not been immediately notified when E1 was appointed as administrator of the facility. E1 provided a copy of a document appointing E1 the administrator, dated the day of the on-site inspection.

Based on documentation review an interview, the administrator failed to obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal, and maintain documentation of a current fire inspection. Findings include: 1. During the on-site inspection conducted on August 1, 2024, the Compliance Officer requested to review a current fire inspection. However, a fire inspection was not provided for review. 2. In an interview, E1, E3, and E4 acknowledged a current fire inspection report had not been provided for review.

Based on documentation review and interview, the administrator failed to designate, in writing, individuals who were present on the premises of the nursing-supported group home and accountable for the nursing-supported group home when the administrator was not present on the nursing supported group home's premises. Findings include: 1. The Compliance Officers requested to review a written designation by the Administrator of all individuals who would be present on the premises when the Administrator was not present, however, a designation was not provided for review. 2. In an interview, E1, E3, and E4 acknowledged the administrator had not designated, in writing, all individuals who would be present at the nursing supported group home and accountable for the facility when the administrator was not present.

Based on documentation review and interview, the administrator failed to ensure policies and procedures were reviewed and updated at least once every three years. Findings include: 1. A review of the facilities policies and procedures revealed a policy manual was available for review. Some individual policies has revision dates within the past three years, and other policies had revision dates more than three years prior to the onsite survey. However, the policy manual as a whole did not include documentation of periodic review by the administrator or their designee. 2. In an interview, E1, E3, and E4 acknowledged the provided policy manual did not include documentation of who had last reviewed the full policy manual or when the review had occurred.

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include all required documentation, for six of six sampled personnel members. The deficient practice posed a risk if employees were unable to meet a residents needs. Arizona Revised Statutes (ARS) \'a7 36-406 states: "In addition to its other powers and duties: 1. The department shall: (c) Have access to books, records, accounts and any other information of any health care institution reasonably necessary for the purposes of this chapter. 2. The department may: (a) Make or cause to be made inspections consistent with standard medical practice of every part of the premises of health care institutions which are subject to the provisions of this chapter as well as those which apply for or hold a license required by this chapter." ARS \'a7 36.424(C) states: "A. Except as provided in subsection B of this section, the director shall inspect the premises of the health care institution and investigate the character and other qualifications of the applicant to ascertain whether the applicant and the health care institution are in substantial compliance with the requirements of this chapter and the rules established pursuant to this chapter. C. ...Any application for licensure under this chapter constitutes permission for and complete acquiescence in any entry or inspection of the premises during the pendency of the application and, if licensed, during the term of the license. " R9-10-2203(C)(5)(a) states: "C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and" ARS \'a7 36.411 states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprin

Based on documentation review, record review and interview, the administrator failed to ensure a resident's medical record contained all required documentation, for two of two sampled residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medical Records." This policy listed all documents required to be in a resident's medical record and included a copy of all 29 items found in R9-10-2212(C). 2. A review of R1's medical record revealed R1's medical record did not include the following documentation: - Documentation of the initial assessment required in R9-10-2207(3) to determine acuity and to include authentication by a registered nurse; - Documentation of the resident's comprehensive assessment required in R9-10-2214(A); - Individual program plans, incorporating nursing care plans and medical care plans, as required in R9-10-2214(B); - Documentation of physical health services, habilitation services, and behavioral care provided to the resident to include documentation of assistance with activities of daily living; - Documentation of freedom from infectious tuberculosis required in R9-10-2207(10). 3. A review of R2's medical record revealed R2's medical record did not include the following documentation: - Documentation of the initial assessment required in R9-10-2207(3) to determine acuity and to include authentication by a registered nurse; - Documentation of the resident's comprehensive assessment required in R9-10-2214(A); - Individual program plans, incorporating nursing care plans and medical care plans, as required in R9-10-2214(B); - Documentation of physical health services, habilitation services, and behavioral care provided to the resident to include documentation of assistance with activities of daily living; - Documentation of freedom from infectious tuberculosis required in R9-10-2207(10). 4. In an interview, E1, E3, and E4 acknowledged the provided medical records for R1 and R2 did not include all required documentation.

Based on observation, record review, and interview, for two of two sampled residents who were provided respiratory care services, the administrator failed to ensure the resident's medical records included documentation of the respiratory care services provided to include the date of time of administration, the type of respiratory care services provided, the effect of the respiratory care services, the resident's adverse reaction to the respiratory care services, if any, and the authentication of the individual providing the respiratory care services. Findings include: 1. The Compliance Officer observed R1 and R2 were both receiving ventilator care throughout the on-site inspection. 2. A review of R1's and R2's medical record revealed documentation of the respiratory care services provided to R1 and R2 were not available for review. 3. In an interview, E1, E3, and E4 acknowledged the resident records provided for R1 and for R2 did not include documentation of the respiratory care services provided to each resident.

Based on documentation review, record review and interview, the administrator failed to ensure the policies and procedures for medication services included procedures to ensure a pharmacist reviewed each resident's medication at least once every three months and provided documentation to the resident's designated medical practitioner and the director of nursing indicating potential medication problems such as incompatible or duplicative medications, for two of two sampled residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Services/Pharmacy Review." The policy stated, "Pharmacy reviews must be conducted once every 3 months, by a licensed pharmacist." 2. A review of R1's and R2's medical records revealed documentation a pharmacist had reviewed each resident's medications within the prior three months was not available for review. 3. In an interview, E1, E3, and E4 acknowledged documentation a pharmacist had reviewed each resident's medications at least once every three months and provided documentation to the resident's designated medical practitioner and the director of nursing indicating potential medication problems such as incompatible or duplicative medications, had not been provided for review.

Based on documentation review and interview, the Administrator failed to ensure policies and procedures for medication administration were reviewed and approved by a pharmacist. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Administration". However, the policy was not signed by a pharmacist. 2. In an interview, E1, E3, and E4 acknowledged the provided medication administration policy did not include documentation of review and approval by a pharmacist.