Mingus Manor Assisted Living Home

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 as required in A.R.S. \'a7 36-420.01. Findings include: 1. Review of the record for E1 (hired June 17, 2008), failed to reveal documentation of fall prevention and fall recovery training. 2. Review of the record for E3 (hired December 10, 2023), failed to reveal documentation of fall prevention and fall recovery training. 3. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been administered to all staff. This is a repeat deficiency from the compliance inspection conducted on March 1, 2023.

Based on record review and interview, the manager failed to ensure that for three of three sample resident records, a standardized emergency responder patient information form as described in subsection A. of this section, was completed and maintained for each resident. Findings include: 1. The record for R1 failed to contain the completed emergency responder patient information documentation. 2. The record for R2 failed to contain the completed emergency responder patient information documentation. 3. The record for R3 failed to contain the completed emergency responder patient information documentation. 4. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure that one of one personnel records contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. Findings include: 1. The record for E3 (Caregiver, hired December 10, 2023) contained documentation indicating that only one TB test was administered within the past 12 months. No other TB test documentation conducted within the past 12 months was found in the record. 2. During an interview, E1 acknowledged that the employee worked more than 8 hours per week and the documentation did not reflect that the employee record contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.

Based on record review and interview, the manager failed to ensure for one of three sample records, that before providing services to a resident, a manager or caregiver provides documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults. Findings include: 1. The record for E3 (hired December 10, 2023), revealed documentation of CPR and First aid certifications that expired on June 20, 2022. 2. During an interview, E1 acknowledged that the caregiver provided services to residents without documentation of current first aid and CPR training certification.

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services. Findings include: 1. The record for R3 contained a service plan review reflecting the last plan was completed on July 1, 2023. 2. During an interview, E1 acknowledged the service plan documentation did not reflect that the plan was reviewed and updated at least once every six months.

Based on record review and interview the manager failed to ensure that two of three sample resident records contained service plans that when updated, were signed and dated by the resident or resident's representative. Findings include: 1. The record for R1, contained a service plan dated December 13, 2023 that did not contain the dated signature of the resident or the resident's representative. 2. The record for R3, contained service plans dated July 1, 2023 and January 6, 2023 that did not contain the dated signature of the resident or the resident's representative. 3. During an interview, E1 acknowledged that the service plans did not reflect the required dated signature. This is a repeat deficiency from the compliance inspection conducted on March 1, 2023.

Based on observation and interview, the manager failed to ensure that a current drug reference guide was available for use by personnel members. Findings include: 1. No facility drug reference guide was available for review. 2. During an interview, E1 stated, "We had it on the facility computer but the computer got a virus and I removed it. We can install it on a resident's computer though." 3. During an interview, E1 acknowledged that a drug reference guide was not available for use by personnel members.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. No facility toxicology guide was available for review. 2. During an interview, E1 stated, "We had it on the facility computer but the computer got a virus and I removed it. We can install it on a resident's computer though." 3. During an interview, E1 acknowledged that a toxicology guide was not available for use by personnel members.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. Facility disaster drill documentation revealed that the last disaster drill was conducted on January 5, 2023. No other disaster drill documentation was available for review. 2. During an interview, E1 acknowledged that documentation failed to reflect that employee drills were conducted on each shift, at least once every three months.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. Twelve months of facility evacuation drill documentation was requested. Review of the evacuation drill documentation provided revealed that evacuation drills for residents and employees were conducted on the following dates: January 5, 2023 and February 4, 2023. No other evacuation drill documentation was available for review. 2. During an interview, E1 acknowledged the requested documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that monthly smoke detector tests were documented, and that documentation of the tests were maintained. Findings include: 1. Facility documentation of smoke detector tests failed to indicate that tests were conducted for the following months: March, 2023 - December 2023. 2. During an interview, E1 acknowledged that documentation failed to reflect that monthly smoke detector tests had been conducted as required.

Based on record review and interview, the chief administrative officer failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. Review of the record for E1 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 2. Review of the record for E2 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 3. Review of the record for E3 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 4. During an interview, E1 acknowledge that the required documentation was not available.