Neighbors Assisted Living South

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of Department documentation revealed this statute went into effect on October 1, 2021. 2. A review of E1's, E3's, E4's, and E5's personnel records revealed no training in fall prevention and fall recovery. The review revealed E1, E3, and E5 were employees when the statute went into effect and E4 was hired in early 2024. 3. In an interview, E4 reported E4 did not receive training specific to fall prevention and fall recovery when E4 was hired as a caregiver. 4. In a separate interview, E2 reported E1, E3, E4, and E5 did not have documentation of training regarding fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services and according to policies and procedures, for two of three sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed no policy and procedure (P&P) covering how the manager would verify and document a caregiver or assistant caregiver's skills and knowledge. 2. A review of E3's and E4's personnel records revealed E3 and E4 were hired as caregivers. However, the review revealed no documentation of E3's and E4's skills and knowledge verification. 3. In an interview, when the Compliance Officer asked for assistance in finding the P&P for this rule, E2 reported E2 did not see it. E2 reported being unable to locate the required documentation at the time of the inspection.

Based on record review, documentation review, and interview, the manager failed to ensure an employee 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 as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of four sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E4's personnel record revealed E4 was hired as a caregiver. However, the review revealed no evidence of freedom from infectious TB. 2. A review of facility documentation revealed a personnel schedule dated April 2024 which indicated E4 worked several shifts as a caregiver in April 2024. 3. In an interview, E4 stated, "I did not get a TB test when I started." E4 reported E4's previous place of employment administered a TB test two months prior to the date of the inspection, but the test was never read.