Prescott Caring Homes

Based on the documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a review date of June 14, 2022. No documentation of further review was available for the Compliance Officer to review. 2. In an interview, E1 acknowledged that the polices and procedures were not reviewed at least once every three years and updated as needed.

Based on the documentation review and interview, the manager failed to ensure that a quality management plan was implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to manage services provided effectively. Findings include: 1. A review of the facility’s documents revealed no documentation of a quality management plan. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on a record review and interview, for one of the two residents reviewed, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident's weight and coordination of communications with the resident's representative. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a service plan dated August 7, 2025. However, the service plan did not include documentation of R1's weight and coordination of communications with the resident's representative. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interviews, the manager failed to ensure that pets or animals allowed in the assisted living facility are controlled to prevent endangering residents and maintain sanitation. Findings include: 1. Upon arrival at the facility, the Compliance Officer observed O1, a dog, barking nonstop. E2 had to put O1 in the backyard during the inspection, and O1 continued to bark. 2. During an exit interview, findings were discussed with E1 and E2, and no additional information was provided.

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. The training program shall include initial training and continued competency training as identified in facility training program documentation. Findings include: 1. Review of facility documentation failed to reveal that the health care institution had developed a fall prevention and recovery training program as required in A.R.S. \'a7 36-420.01. The training program failed to indicate initial training and continued competency training will be conducted. 2. Review of the record for E2 (hired June 1, 2024), failed to reveal documentation that fall prevention and fall recovery training had been administered. 3. Review of the record for E3 (hired January 1, 2024), failed to reveal documentation that fall prevention and fall recovery training had been administered. 4. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been developed and administered to all staff.

Based on documentation review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. Findings include: 1. Upon entry into the facility E2 was observed to be the only staff in the facility with four residents. 2. During an interview, E2 indicated that E2 was a caregiver. 3. During an interview, E2 stated, "I'm the only caregiver staff here right now, the Manager is out running errands." 4. After approximately 30 minutes E1 arrived at the facility. 5. Review of the record for E2 revealed that E2 was not a trained caregiver. 6. Review of the delegation of authority statement revealed that no caregiver had been designated to act as the manager designee in the managers absence. 7. During an interview, E1 acknowledged that documentation failed to indicate that a caregiver who was present on the facility premises had been designated to act as manager designee when the manager was not present.

Based on documentation review and interview, the manager failed to ensure that documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings Include: 1. No record of employee work schedules was available for review. 2. During an interview, E1 stated, "I don't have that." This is a repeat deficiency from the compliance inspection and complaint investigation conducted on September 11, 2023.

Based on record review and interview, the manager failed to ensure that two of three personnel records contained evidence of freedom from infectious tuberculosis (TB), on or before the date the individual began providing services to residents as specified in R9-10-113. Findings include: 1. The record for E2 (Assistant Caregiver) contained no documentation indicating that a TB test with negative results, was administered on or before the date the individual began providing services to residents. No other TB test documentation conducted within the past 13 months was provided for review. 2. The record for E3 (Assistant Caregiver) contained no documentation indicating that a TB test with negative results, was administered on or before the date the individual began providing services to residents. No other TB test documentation conducted within the past 13 months was provided for review. 3. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that either the manager or a trained caregiver was present in the assisted living facility when a resident was present. Findings include: 1. Upon entry into the facility E2 was observed to be the only staff in the facility with four residents. 2. During an interview, E2 indicated that E2 was a caregiver. 3. During an interview, E2 stated, "I'm the only caregiver staff here right now, the Manager is out running errands." 4. After approximately 30 minutes E1 arrived at the facility. 5. Review of the record for E2 revealed that E2 was not a trained caregiver. 6. During an interview, E1 acknowledged that a trained caregiver was not present in the facility when the manager was not present.

Based on record review and interview, the manager failed to ensure that two of three sample resident records contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services. Findings include: 1. The record for R3 contained a service plan review reflecting the last plan was completed on May 20, 2023. 2. The record for R4 contained a service plan review reflecting the last plan was completed on August 20, 2023. 3. During an interview, E1 acknowledged the service plan documentation did not reflect that the plans were reviewed and updated at least once every six months.

Based on record review and interview, the manager failed to ensure that one of one sample resident records, had a service plan that was reviewed and updated at least once every three months for a resident receiving directed care services. Findings include: 1. The record for R1 contained a service plan that was last updated on September 8, 2023. 2. During an interview, E1 acknowledged that service plan documentation did not reflect that the update was conducted at least once every three months.

Based on documentation review and interview, the manager failed to ensure that a calendar of planned activities was maintained for 12 months after the last scheduled activity. Findings include: 1. The following activity calendars were not available for review: May 1, 2024 - July 18, 2024. 2. During an interview, E1 stated, "I don't have the documentation."

Based on record review and interview for one of one directed care resident record, the manager failed to obtain documentation reflecting that the resident's medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition. Findings include: 1. During an interview, E1 indicated that R1 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 2. The last determination of residency signed by a medical practitioner indicating that the resident's needs were being met as per the facility's scope of services, was dated September 8, 2023. Based on the resident's date of acceptance this documentation was required. 3. During an interview, E1 acknowledged that documentation from the medical practitioner was not in the record at least once every six months throughout the duration of the resident's condition.

Based on documentation review and interview, the manager failed to ensure that a food menu is maintained for at least 60 calendar days after the last date noted on the menu. Findings include: 1. Two months of menus were requested, the following menus were not available for review: June 3, 2024 - July 18, 2024. 2. During an interview, E1 stated, "I can't find the menus."

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. Facility documentation failed to reflect that disaster drills had been conducted. 2. During an interview, E1 stated, "I don't have that."

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. No evacuation drill documentation was available for review. 2. During an interview, E1 stated "I don't have that."

Based on record review, documentation review and interview, the manager failed to ensure that when a resident has an emergency or injury that results in the resident needing medical services, a caregiver documents as per subsections a. through f. of this rule. Findings include: 1. Review of the record for R1 revealed that on July 16, 2024 the resident experienced an emergency that required medical services. No incident report documentation was available for review. 2. During an interview, E1 acknowledged the required documentation was not available for review.

Based on observation and interview, the manager failed to ensure that a smoke detectors were tested at least once a month. Findings include: 1. Twelve months of smoke detector test documentation was requested. No documentation was available for review. 2. During an interview, E1 stated "I test the smoke detectors but I don't document that." This is a repeat deficiency from the compliance inspection and complaint investigation conducted on September 11, 2023.

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 documentation review and interview, the manager failed to ensure that a quality management plan was established, documented, and implemented for an ongoing quality management program that, at a minimum, includes a method to identify, document, and evaluate incidents and the frequency of submitting a documented report required in subsection (3) to the governing authority. Findings include: 1. The facility quality management policy and procedure did not include the frequency of submitting a documented report required in subsection (3) to the governing authority. 2. The facility quality management policy and procedure included a method to identify, document, and evaluate incidents however incident report information was not included in the report to the governing authority. 3. During an interview, E1 stated, "We haven't been doing that." 4. 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 documentation is maintained for 12 months including the hours worked by each caregiver. Findings Include: 1. Twelve months of employee work schedules were reviewed. The schedules indicated "First shift" and "Second shift" but failed to indicate the hours worked by each caregiver. 2. During an interview, E2 stated, "We work 12 hour shifts and sometimes 24 hours on the week end." 3. During an interview, E2 acknowledged the required documentation was not available for review.

Based on observation and interview, the manager failed to ensure that a smoke detector was tested at least once a month. Findings include: 1. Twelve months of smoke detector test documentation was requested. No documentation was available for review for the following dates: September 2022 - January 2023, March 2023 - June 2023 and August 2023. 2. During an interview, E2 acknowledged that smoke detector test documentation failed to indicate that smoke detectors had been tested at least once a month.