North Haven Assisted Living Home LLC

Based on the documentation review, record review, and interview, the governing authority failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. § 36-411 for one of three personnel records sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411 states, "A... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work..." 2. A review of E3's personnel record revealed E3 was hired as a caregiver in June 2024 3. A review of E3's personnel record revealed a fingerprint clearance card with an expiration date of March 21, 2025. 4. A review of the website from the Arizona Department of Public Safety revealed that E3's fingerprint card expired on March 21, 2025. 5. In an interview, E1 acknowledged that E3 did not have a valid fingerprint clearance card and that the facility was not in compliance with the requirements in A.R.S. § 36-411.

Based on the record review and interview, the manager failed to ensure an employee provided documentation 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 R9-10-113, for one of three caregivers reviewed. The deficient practice posed a potential risk of TB exposure to residents. Findings include: 1. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test healthcare personnel upon hire (pre-placement), two-step testing should be used." 2. A review of E3's personnel record revealed documentation of a negative TB skin test dated June 13, 2024. However, there was no documentation of a second TB skin test. 3. In an interview, E1 acknowledged E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of three sampled residents. Findings include: 1. A review of R3's medical record revealed no documentation to indicate whether R3 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged that R3's medical record did not include documentation to indicate whether R3 required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on the record review and interview, the manager failed to ensure that a resident medical record contained documentation showing the pneumonia vaccination was offered every 12 months to three of the three residents reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of R1's, R2's, and R3's records revealed no documentation showing that the pneumonia vaccination was offered or received. 2. In an interview, E1 acknowledged that R1's, R2's, and R3's records did not include current documentation showing that the pneumonia vaccination was offered or received.

Based on the record review and interview, the manager failed to ensure that the healthcare institution administered a training program for all staff regarding fall prevention and fall recovery, which included both initial training and continued competency training for one of the three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E2's personnel records revealed documentation of Fall Prevention and Fall Recovery Training for 2022 and 2023. However, no documentation of further fall prevention and fall recovery training was available for the Compliance Officer to review. 2. In an interview, E1 acknowledged that the facility failed to administer a training program for staff regarding fall prevention and fall recovery that included continued competency training.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed four ambulatory residents at the facility at the time of the inspection. 3. During the facility tour with E4, the Compliance Officer observed the facility's front door had an alarm attached. However, the alarm was not functioning. 4. During the facility tour with E4, the Compliance Officer observed the facility's back door had an alarm attached. However, the alarm was not functioning. 5. During an interview, E4 acknowledged the alarms on the front and back doors were not functioning, and stated the alarms needed new batteries.