Mingus Terrace 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 March 20, 2007), failed to reveal documentation of fall prevention and fall recovery training. 2. Review of the record for E2 (hired May 24, 2022), failed to reveal documentation of fall prevention and fall recovery training. 3. Review of the record for E4 (hired May 25, 2023), failed to reveal documentation of fall prevention and fall recovery training. 4. 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 two of three sample personnel records, contained evidence of freedom from infectious tuberculosis (TB), on or before the date the individual began providing services to residents as specified in R9-10-113. Findings include: 1. The record for E3 (Caregiver, hired October 1, 2023) contained documentation indicating that only one TB test was administered. No other TB test documentation conducted within the past 12 months was found in the record. 2. The record for E4 (Caregiver, hired May 25, 2023) contained documentation indicating that only one TB test was administered. No other TB test documentation conducted within the past 12 months was found in the record. 3. During an interview, E1 acknowledged that the employees worked more than 8 hours per week and the documentation did not reflect that the employee records contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.

Based on interview and record review, 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. Review of the record for E4 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. 5. During an interview, E1 acknowledge that the required documentation was not available.