Mountain Care of Snowflake, LLC

Based on record review and interview the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. The training program shall include initial training and continued competency training as identified in facility training program documentation. Findings include: 1. Review of the record for E1 (hired April 4, 2022), failed to reveal that fall prevention and fall recovery continued competency training had been conducted on an ongoing basis. Documentation indicated that the last training had been conducted on August 3, 2023. 2. Review of the record for E2 (hired May 21, 2023), failed to reveal that fall prevention and fall recovery continued competency training had been conducted on an ongoing basis. Documentation indicated that the last training had been conducted on August 3, 2023. 3. Review of the record for E3 (hired April 28, 2021), failed to reveal that fall prevention and fall recovery continued competency training had been conducted on an ongoing basis. Documentation indicated that the last training had been conducted on August 3, 2023. 4. Review of the facility policy and procedure for fall prevention and fall recovery continued competency training indicated that training would be conducted upon hire and annually thereafter. 5. During an interview, E1 acknowledged that continued competency training for fall prevention and fall recovery had not been conducted as specified in policy and procedure.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority that included 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. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care and any changes made or action taken as a result of the identification of a concern about the delivery of services related to resident care. 2. Review of the reports submitted to the governing authority revealed that the reports failed to include recommendations for changes regarding the concerns identified. 3. During an interview, E1 acknowledged that the required documentation was not included in the reports.

Based on record review and interview, the manager failed to ensure that one of three sample personnel records contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. Findings include: 1. The record for E2 (Manager Designee) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. Based on the employee's date of hire this documentation would be required. 2. During an interview, E1 acknowledged that the employee worked more than eight 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 documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that include the information found in subsections a. through f. of this rule. Findings include: 1. Review of facility documentation failed to reveal information indicating that the health care institution had established and documented tuberculosis infection control documentation and activities that include subsections a. through f. of this rule . 2. 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 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.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

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 November 11, 2019), failed to reveal documentation of fall prevention and fall recovery training. 2. Review of the record for E2 (hired April 4, 2022), failed to reveal documentation of fall prevention and fall recovery training. 3. Review of the record for E3 (hired June 1, 2022), failed to reveal documentation of fall prevention and fall recovery training. 4. During an interview, E1 indicated that training for fall prevention and fall recovery had not been developed and administered to all staff. This is a repeat deficiency from the compliance inspection conducted on April 14, 2022.

Based on documentation review and interview, the manager failed to ensure that all required policies and procedures were established, documented and implemented. Findings include: 1. No policy and procedure manual was available for review. 2. During an interview, E1 stated, "We have a policy and procedure manual, I can't find it." 3. During an interview E1 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that snacks provided by the assisted living facility were served according to posted menus. Findings include: 1. A review of 60 days of menus failed to reveal a record of snacks provided. 2. No additional snack menu documentation was available for review. 3. During an interview, E1 stated, "We serve the snacks. That used to be on the menu." 4. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on observation and interview, the manager failed to ensure that the premises and equipment were cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. Findings include: 1. Observation of the North resident bathroom shower stall revealed a black discoloration running along the floor and molding edge outside the shower. The area appeared to be unclean. 2. Observation of the East resident bathroom revealed a black discoloration running along the back edge of the shower stall. The area appeared to be unclean. 3. Review of the facility policies and procedures indicated the premises will be maintained in a clean condition. 4. During an interview, E1 acknowledged the premises was to be maintained clean according to policies and procedures.

Based on observation and interview, the manager failed to ensure that equipment used at the assisted living facility was maintained in working order. Findings include: 1. Observation of the South resident bathroom revealed a three foot vertical section of trim molding was missing on the entry doorway. The molding had a jagged edges and appeared to have been broken from the jamb leaving the inner wall exposed. 2. Observation of the South resident bathroom toilet stalls revealed two stalls each with a 6" by 24" section of rusty metal where the grab bar was attached to the stall wall. 3. Observation of the North resident bathroom revealed a 10" section of rust running along the sink countertop and the metal bathroom stall wall. 4. Observation of the North resident bathroom heat radiator, located on the floor behind the entry door revealed that the radiator cover was missing exposing the heating elements. 5. During an interview, E1 stated "We will get those items fixed." 6. During an interview, E1 acknowledged the bathroom equipment was not maintained in working order.