Manor on Paradise

Based on record review, documentation review, and interview, the health care institution failed to administer Fall Prevention and Fall Recovery training as required by A.R.S. § 36-420.01.A and the facility's policies and procedures, for two of four personnel reviewed. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E3's personnel record revealed that E3 had a hire date of June 21, 2024. Further review revealed that E3 completed Fall Prevention/Fall Recovery training on July 1, 2022 (prior to hire), but not again until February 1, 2025. There was no other documentation available for review to indicate that E3 had current training at the time of hire and through February 1, 2025. 2. A review of E4's personnel record revealed that E4 had a hire date of April 6, 2023. Further review revealed that E4 completed Fall Prevention/Fall Recovery training on February 7, 2025. There was no other documentation available for review to indicate that E4 had current training at the time of hire and through February 7, 2025. 3. A review of the facility's policies and procedures revealed a policy titled "Fall Prevention and Recovery." The policy stated, "Pursuant to A.R.S. § 36-420.01, all staff will be required to complete an initial Fall Prevention and Fall Recovery Training Program, as well as yearly continued competency training in fall Prevention and fall recovery." 4. In an interview, E1 acknowledged that E3 and E4 did not have the required Fall Prevention and Fall Recovery training completed at their respective dates of hire. Furthermore, E1 acknowledged that no other documentation of completed training was available for review other than E3's certificate from February 1 2025, and E4's certificate from February 7, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis (TB) infection control activities that included initial training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution for three of four personnel reviewed. The deficient practice posed a risk to the physical health and safety of a resident as the caregiver received no instruction or information upon hire related to recognizing the signs and symptoms of tuberculosis. Findings include: 1. A review of E2's personnel record revealed that E2 had a hire date of June 12, 2025. Further review revealed that there was no documentation of training and education related to recognizing the signs and symptoms of TB. 2. A review of E3's personnel record revealed that E3 had a hire date of June 21, 2024. Further review revealed that E3 had documentation of training and education related to recognizing the signs and symptoms of TB dated January 1, 2025. 3. A review of E4's personnel record revealed that E4 had a hire date of April 6, 2023. Further review revealed that E4 had documentation of training and education related to recognizing the signs and symptoms of TB dated December 13, 2023, and January 6, 2025. 4. A review of the facility's policies and procedures revealed a policy titled "Tuberculosis Infection Control and Screening." The policy stated, "2. Staff c. Training i. Each individual who is employed by Manor on Paradise or provides volunteer services receives annual training and education related to recognizing the signs and symptoms of tuberculosis." 5. In an interview, E1 acknowledged that E2 did not have the required training on recognizing the signs and symptoms of tuberculosis available for review at the time of the inspection. E1 also acknowledged that E3 and E4 did not have the required training completed upon hire, but had since completed the annual requirements for the training. 6. Technical assistance on TB rules (specifically R9-10-113) was first provided at the compliance inspection conducted on June 23, 2022, and additional clarifying technical assistance was also provided on TB rules (specifically R9-10-113) at the compliance inspection conducted on December 1, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that caregivers provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for two of four personnel reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of the Centers for Disease Control (CDC) and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 2. A review of E2’s personnel record revealed documentation of a negative TST before the hire date; however, there was no documentation of a second TST. Based on E2's date of hire, this documentation was required. 3. A review of E3’s personnel record revealed documentation of a negative TST before the hire date; however, there was no documentation of a second TST. Based on E3's date of hire, this documentation was required. 4. A review of the facility's policies and procedures revealed a policy titled "Tuberculosis Infection Control and Screening." The policy stated, "2. Staff a. Initial Screening i. All new staff and volunteers must undergo the following before starting work: a) Two (2) Tuberculin Skin Test [TST] or b) One (1) Interferon-Gamma Release Assay [IGRA]." 5. In an interview, E1 acknowledged that E2 and E3 did not have the required second TST completed at their respective dates of hire as recommended by the CDC and as stated in the facility's policies and procedures. 6. Technical assistance on TB rules (specifically R9-10-113, R9-10-806.A.8, and R9-10-807.A) was first provided at the compliance inspection conducted on June 23, 2022, and additional clarifying technical assistance was also provided on TB rules (specifically R9-10-113, R9-10-806.A.8, R9-10-806.C.1.c.vi, R9-10-807.A, R9-10-811.C.7) at the compliance inspection conducted on December 1, 2023. According to the Compliance Officer who conducted both the June 23, 2022, and the December 1, 2023 inspections, "TA [was] given twice because the rules were still very new and not clear when TA was given the first time."

Based on record review and interview, the manager failed to ensure that a resident had a service plan that documented the level of service the resident was expected to receive for one of two applicable residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed service plans dated September 2, 2025, and December 2, 2025. Both of the service plans had a section titled "Level of Care," which allowed for the service provider to select Supervisory Care, Personal Care, Directed Care, or Memory Care; however, neither of the service plans had a level of care designated. 2. In an interview, E1 acknowledged R2's service plans from September 2, 2025, and December 2, 2025, did not have a level of care checked off or indicated. 3. Technical assistance was provided on this requirement at the compliance inspection conducted on December 1, 2023.

Based on record review and interview, the manager failed to ensure that a service plan for a resident receiving directed care services included either documentation of the resident’s weight or documentation from a medical practitioner stating that weighing the resident was contraindicated, for one of two applicable residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed service plans dated September 2, 2025, and December 2, 2025. Both of the service plans had a section titled "Weight," which allowed for the service provider to document R2's weight; however, neither of the service plans included R2's weight. Further review revealed there was also no documentation from a medical practitioner stating that weighing R2 was contraindicated. 2. In an interview, E1 acknowledged that R2's service plans from September 2, 2025, and December 2, 2025, did not include R2's weight. E1 reported that there was no documentation from a medical practitioner stating that weighing R2 was contraindicated. 3. Technical assistance was provided on this requirement at the compliance inspection conducted on June 23, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented according to policies and procedures. Findings include: 1. A review of facility documentation revealed no policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge were verified and documented. 2. A review of the personnel records of E2 and E3 revealed E2's and E3's skills and knowledge were verified and documented. 3. In an interview, E1 acknowledged the facility did not have policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge were verified and documented. E1 stated, "I'm gonna add that in there." Technical assistance was provided on this rule during the compliance inspection conducted on June 23, 2022.

Based on observation and interview, the manager failed to ensure a swimming pool on the premises of the assisted living facility was enclosed by a wall or fence with a self-closing, self-latching gate that was locked when the swimming pool was not in use. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a pool in the backyard enclosed by a fence with three gates. The Compliance Officer observed the pool was not in use during the inspection. The Compliance Officer observed the following: -The gate to the north-west of the pool was closed, but was not self-latching and was not locked; -The gate to the south-west of the pool was closed, but was not locked; and -The gate to the east of the pool was closed, but was not self-latching due to vegetation in the way and was not locked. 2. In an interview, E1 stated, "It was working" when referring to the gate to the north-west not being self-latching during the inspection. E1 acknowledged two of the three gates were not self-latching and all three gates were not locked at the time of the inspection. Technical assistance was provided on this rule during the compliance inspection conducted on June 23, 2022.