Mulberry Assisted Living-nido

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three sampled personnel. The deficient practice posed a risk if the employees were not qualified to provide the required services and false or misleading information was provided to the Department. Findings include: 1. A review of E2’s personnel record revealed that E2 was hired as a caregiver on September 20, 2024. 2. A review of E2’s personnel record revealed a caregiver training certificate with conflicting information regarding the training institution that provided the certification. The certificate provided listed Platinum Training Services, LLC, ALTP0152 and an issue date of March 13, 2013. 3. A review of the https://azcg.tmutest.com/search revealed no documentation of a caregiver training certificate for E2. A search using the parameters of ALPT0152 revealed the name of the training program as Comprehensive Training Services, LLC. A search using the parameters of Platinum and ALTP0152 yielded no results. A search using the parameter Platinum Training Services, LLC yielded an ALTP0185, Platinum Training Services. A search using E2's name in various formats did not yield any results. 4. In an interview, E4 reported that E2 was employed at the facility as a caregiver based on the documentation received from E2. 5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked, self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the environmental inspection, the Compliance Officer observed the kitchen cabinet closest to the refrigerator was unlocked. The cabinet contained several bottles of pill, liquid and cream based medications. Some of bottles had labels removed and other medications found were prescribed for current residents. 2. In an exit interview, findings were reviewed with E4, and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection, the Compliance Officer observed Clorox spray, Lysol spray, Lysol wipes, Dawn dishwashing detergent, dishwasher cleaning pods, along with several other cleaning items in an unlocked cabinet underneath the kitchen sink. 2. In an interview with E4, E4 reported that the door was locked. However, the Compliance Officer (CO) explained to E4 that the CO did not have the magnetic key, or any key, to unlock the door. The CO was able to open the cabinet door because it was unlocked. 3. During the environmental inspection, the CO observed Glade air freshener cans placed in several areas of the facility and not locked in a secure location. 4. During the environmental inspection, the CO observed Seventh Generation disinfectant spray in an unlocked cabinet under the bathroom sink. 5. In an exit interview, findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to implement a plan for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Policy on Quality Management." The policy stated, "I. The Team shall: 1. Conduct a self-audit on the Facility Grounds at least once a year. Make notes on any findings and corrective actions when necessary. 2. Conduct a self-audit on the resident's file every six (6) months. Make notes on any findings and the necessary corrective actions. 3. Conduct a self-audit on personnel files and review the skills and knowledge of the caregivers every six (6) months to ensure that caregivers will be able to provide the services offered by the facility as specified in the Scope of Services and meet the needs of the residents. 4. Conduct a self-audit on miscellaneous files every six (6) months. Make notes on any findings and corrective actions when necessary. 5. Match residents' medications with the resident's doctor's orders and the Medication Administration Record every end of the month. 6. Identify, document and evaluate incidents and accidents (e.g. falls, medication errors, adverse reactions to medications including opioid treatments and deaths resulting from overdose of opioid treatments, etc.) every six (6) months to address identified risks to health, safety and welfare of residents. A tally of these reports shall be made by the Manager for easy identification of areas of concern...III. A report of the results of these meetings shall be submitted by the Manager to the Governing Authority and a copy of which shall be kept in the facility and filed for at least 12 months." 2. The Compliance Officer requested the facility's quality management documentation for review. 3. In an interview, E1 reported the facility has not implemented their quality management program. E1 reported there was no documentation available for review. 4. In an interview, E1 acknowledged the quality management program had not been implemented in the facility.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. Upon arrival, the Compliance Officer observed E2, E3, and E4 working at the facility. 2. The Compliance Officer requested the employee schedules for the last 12 months as well as the current schedule for review. 3. A review of the September 2024 employee schedule revealed E3 and E4 were not listed on the schedule at all, even though they were present and providing services on the day of the inspection. 4. In an interview, E1 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day. E1 reported E3 recently started working at the facility but was leaving the next day and would be gone for a month. E1 reported E4 typically worked at another home owned by E1 and was on a trial period at this home.

Based on documentation review, record review, and interview, the manager failed to ensure a complete personnel record was available for two of two employees reviewed. The deficient practice posed a risk as required information could not be verified for E3 and E4. Findings include: 1. Upon arrival, the Compliance Officer requested all personnel records for review. 2. A review of E3's personnel record revealed the following required information was not documented in E3's personnel record: -Qualifications, including skills and knowledge applicable to the individual's job duties; and -Compliance with A.R.S. \'a7 36-411(C)(1); 3. In an interview, the Compliance Officer requested E4's personnel record for review. E1 reported E4 did not have a personnel file on-site. E1 was unable to provide the Compliance Officer with any documentation for review. 4. In an interview, E1 acknowledged E3's and E4's personnel records were incomplete or not available for review. E1 reported E3 recently started working at the facility but was leaving the next day and would be gone for a month. E1 reported E4 typically worked at another home owned by E1 and was on a trial period at this home.