Liberty Manor Residency II

Based on record review, documentation review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of the personnel records for E1, E2, and E3, revealed that all employees received Fall Prevention and Recovery training from an outside source. 2. A documentation review of the facility's policies and procedures revealed, that there is no policy regarding Fall Prevention and Recovery initial and ongoing training. 3. In an interview, E1 acknowledged that there was no documented training program regarding Fall Prevention and Recovery. This is a repeat deficiency from the on-site compliance inspection conducted on June 8, 2022.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training, for two 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. A review of the personnel file for E1 revealed that the employee’s Cardiopulmonary resuscitation (CPR) and First Aid (FA) certification expired on June 1, 2025. No other documentation of Cardiopulmonary resuscitation (CPR) and First Aid (FA) certification was available for review. A review of the personnel file for E2 revealed that the employee’s Cardiopulmonary resuscitation (CPR) and First Aid (FA) certification expired on May 29, 2025. No other documentation of Cardiopulmonary resuscitation (CPR) and First Aid (FA) certification was available for review. 2. In an interview, E1 acknowledged that E1 and E2 did not provide current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Based on record review and interview, the manager accepted an individual before the individual submitted documentation, dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for two of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of the residency agreement for R1 revealed that the resident was admitted into the facility in April, 2025. 2. A review of the "Consent for Resident's Stay In Facility" stated that R1 was examined by a physician two days after R1's date of admission and determined eligible to stay in an assisted living facility. 3. In an interview, E1 acknowledged that the manager accepted an individual before the individual submitted documentation, dated within 90 calendar days before the individual was accepted by the facility.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated at least once every 12-months for a resident receiving supervisory care services, at least once every six-months for a resident receiving personal care services. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R2's medical records revealed a current written service plan for Personal Care services dated November, 2024. However, a service plan after November 2024 was not available for review. 2. In an interview, E1 acknowledged R2 received personal care services and the service plan was not updated at least once every six months.

Based on documentation review and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1, A review of the facility’s Policy & Procedures section titled “Annual Disaster Plan and Incident Critique”, showed that the signature page was blank and contained no documentation of the disaster plan being reviewed. 2. In an interview, E1 acknowledged that the Policy and Procedures for Disaster Plan was not reviewed every 12 months as required.

Based on documentation review and interview, the manager failed to ensure that an Evacuation drill for employees and residents was conducted every six months and documented. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. A review of the facility's policy and procedures titled," Evacuation Drill Every Six Months", showed that the last evacuation drill was completed on February 13, 2023. 2. In an interview, E1 acknowledged that an evacuation drill for employees and residents was not conducted every six months.

Based on documentation review and interview, the administrator failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed no documentation to indicate a fall prevention and fall recovery program, including initial and continued competency training, was developed. 2. In an interview, E1 acknowledged there was no fall prevention and fall recovery training program developed. This is a repeat citation from the previous compliance inspection conducted on June 8, 2022.

Based on documentation review and interview, the manager failed to ensure, as part of the policies and procedures required in Arizona Administrative Code (A.A.C.) R9-10-803(C)(1)(h), a plan was documented to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. The deficient practice posed a risk if no qualified employee was available to meet a resident's needs. Findings include: 1. A review of facility documentation revealed no documented plan to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. 2. In an interview, E1 acknowledged the facility did not have a documented plan regarding having a back-up caregiver.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees and residents was conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed the most recent disaster drill was conducted November 1, 2022. There was no additional documentation indicating a disaster drill was conducted every three months. 2. In an interview, E1 acknowledged there was no documentation to indicate a disaster drill was conducted at least once every three months.