Nettie's Nest Assisted Living Care Home

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411. The deficient practice posed a risk as required information could not be verified for E1 and E2. Findings include: 1. A.R.S. § 36-411.C.3.4 states "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee." 2. A review of E1's and E2’s personnel records revealed no documentation of an Adult Protective Services (APS) Central Registry check as required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, for one of two employees reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency Findings include: 1. A review of E2's personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on April 9, 2025 with an expiration date of April 9, 2027. There was no other current documentation of CPR training that included a demonstration of E2's ability to perform CPR. 2. In an email exchange, a representative from NationalCPRFoundation, stated "Our courses are online only." 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided

Based on documentation review and interview, the manager failed to ensure documentation of the caregivers and assistant caregivers who worked each day, including the hours worked by each, was maintained. The deficient practice posed a risk if there was not sufficient staff to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a document titled "May 2024 employee work schedule." However, the documentation did not include the hours worked by each caregiver. 2. In an interview, E2 acknowledged the employee work schedule did not include the hours worked by each caregiver.

Based on observation and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility. Findings include: 1. During the environmental inspection of the facility, The Compliance Officers observed a sliding glass door leading to the back yard. The door had two black boxes attached to the top for an alert system when the door was opened. However, the alert system did not work when the Compliance Officers opened or closed the door. 2. In an interview, E2 reported the electronic system seemed to run out of battery quickly and the facility was looking for alternatives. E2 acknowledged the sliding glass door leading to the back yard did not control or alert employees of the egress of a resident from the facility at the time of the inspection.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of R2's medical record revealed documentation with a section titled "Vaccinations and Screening." The section included a document stating "TB screening...September 15, 2023." However, the documentation did not state the results of the reading, what type of test was done, or specify when the test was administered or read. 2. In an interview, E2 acknowledged R2 did not provide valid evidence of freedom from TB as specified in A.A.C. R9-10-113.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Facility's Scope of Services." The policy stated "Policy and Procedure manual is reviewd [sic] at least once every three years and updated as needed." However, the most recent signature and date indicating the policies and procedures were reviewed was January 19, 2020. 2. In an interview, E2 acknowledged the signature and date on the policies and procedures indicated they were not reviewed and updated at least once every three years.

Based on documentation review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a training program for all staff regarding fall prevention and fall recovery was not available for review. 2. In an interview, E2 acknowledged documentation of a training program for all staff regarding fall prevention and fall recovery was not available for review.