Prestige Home

Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for BLANK of BLANK personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, “Orientation, and In-Service Trainings for Employees.” The policy stated, “5. There shall be at least 12 hours of training each year for each caregiver providing directed care to residents. The training may include but is not limited to the following subjects… f. Resident emergency response procedures, such as Heimlich Maneuver, resident falls, and First Aid/CPR procedures…” 2. A review of E1’s personnel record revealed documentation of completed fall prevention and fall recovery training conducted on April 1, 2024. However, E1’s personnel record did not include documentation of additional training on fall prevention and fall recovery. 3. A review of E2’s personnel record revealed documentation of completed fall prevention and fall recovery training conducted on April 1, 2024. However, E2’s personnel record did not include documentation of additional training on fall prevention and fall recovery. 4. In an interview, E2 acknowledged that the facility failed to administer a training program regarding fall prevention and fall recovery, for all staff, that included continued competency training. Technical assistance was provided regarding this regulation during the compliance inspection conducted on July 19, 2023.

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for three of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E1's date of hire, this documentation was required. 2. A review of E2's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E2's date of hire, this documentation was required. 3. A review of E3's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E3's date of hire, this documentation was required. 4. In an interview, E2 acknowledged E1's, E2's, and E3's personnel records did not include documentation of initial and annual training on recognizing the signs and symptoms of TB. Technical assistance was provided regarding this regulation during the compliance inspection conducted on July 19, 2023.

Based on observation, record review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of three personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. While on-site for the complaint inspection, the Compliance Officers observed E3 on-site and providing services to residents. 2. A review of E3's personnel record revealed a valid CPR certification dated December 5, 2023. However, E3’s personnel record did not include documentation of a first aid certification. 3. In an interview, E2 acknowledged E3's personnel record did not contain documentation of a current first aid training certification.

Based on observation, record review, and interview, the manager failed to ensure the resident's or the resident's representative's consent to photographing the resident. Findings include: 1. During an environmental inspection, the Compliance Officers observed cameras being used in the facility. 2. R2's medical record did not contain a photographic consent form signed by the resident or the resident's representative. 3. In an interview, E2 acknowledged R2's medical record did not contain consent to photographs by the resident or the resident's representative.

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. Findings Include: 1. During an environmental inspection of the facility, the Compliance Officers observed an open cabinet door. The door opened to reveal the resident's medical records and other documents. 2. In an interview, E2 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.

Based on record review and interview, the manager failed to ensure medication administration for a resident was in compliance with the medication orders. Findings Include: 1. A review of R1's medical record revealed a signed medication order dated March 3rd, 2025. Included on the list of medications was Colace 100mg 1 tab daily. 2. A review of R1's medication administration records revealed Colace 100mg was being administered twice daily. 3. In an interview, E2 acknowledged medication administration for R1 was not in compliance with the medication order.

Based on observation and interview, the manager failed to ensure that food stored by the facility was free from spoilage, filth, or other contamination and was safe for human consumption. Findings Include: 1. During an environmental inspection of the kitchen, the Compliance Officers opened a cabinet to reveal a bottle of syrup with the cap off, leaking, and covered in ants. 2. In an interview, E1 acknowledged that food stored by the facility was not free from spoilage, filth, or other contamination and was not safe for human consumption.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility are free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings Include: 1. During an environmental inspection of the kitchen, the Compliance Officers opened a cabinet to reveal a bottle of syrup with the cap off, leaking, and covered in ants. 2. In an interview, the manager failed to ensure the premises and equipment used at the assisted living facility are free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on record review and interview, the manager failed to ensure that within 90 calendar days before or on the day the individual was accepted by an assisted living facility there was completed the required documented determination. The documentation should have included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; this was based on the date of acceptance, for one of one sampled resident record reviewed which posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed no documentation of a pre-admission determination on or prior to their dates of acceptance. Based on the resident's date of acceptance this documentation was required. 2. During an interview, E2 acknowledged there was no evidence the pre-admission determination was completed as required for this resident.

Based on record review and interview, the manager failed to ensure two of three sampled residents' written service plans reviewed when initially developed and updated were signed and dated by the resident or resident's representative and the manager who reviewed the service plans, as required. Finding included: 1. Review of R1's medical record and service plan revealed the resident required directed care and medication administration services. The current service plan dated May 4, 2023 was never signed by the resident or the representative who had reviewed this service plan. 2. Review of R3's medical record and service plan revealed the resident required personal care and medication administration services. The current service plan dated May 4, 2023 was never signed by the resident or the representative and the manager who had reviewed this service plan. 3. In an interview, E2 acknowledged that R1's and R3's service plans had not been signed and dated as required.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccination for pneumonia according to A.R.S. \'a7 36-406(1)(d), which required the facility to make the vaccination available to a resident on site on a yearly basis; for one of one sampled resident record reviewed who had resided at the assisted living facility for more than 12 months, which posed a health and safety risk. Findings include: 1. Based on the date of acceptance, R3's medical record did not contain documentation to indicate R3 had received the pneumonia vaccine. There was no other documentation available in R3's medical record to indicate the vaccine had been offered, given, refused, or contraindicated within the past 12 months. 2. In an interview, E2 acknowledged there was no documentation available that this sampled resident had received the pneumonia vaccine or the vaccine had been made available to R3 during the past 12 months.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below which posed a health and safety risk. Findings include: 1. During a facility tour, E2 and the compliance officer observed the facility's black kitchen refrigerator that contained food had a thermometer that registered 44.8\'b0 F at the warmest area of the refrigerator. The compliance officer's thermometer registered at 44.8\'b0 F. The refrigerator was not in use during the observation. 2. During an interview, E2 acknowledged the facility's refrigerator was not maintained at 41\'b0 F or below.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months which posed a safety risk. Findings include: 1. During the review of the facility's documents that were requested earlier at the beginning of the compliance inspection revealed there was no documentation as evidence the facility had reviewed the disaster plan and documented as required during the past 12 months. The most current documentation of the review of the disaster plan was dated April 27, 2022. 2. In an interview, E2 acknowledged there was no documented evidence the disaster plan was reviewed and documented as required in the past 12 months.

Based on documentation reviewed and interview, the manager failed to ensure an employee disaster drill was conducted on each shift and documented which posed a safety risk. Findings include: 1. During an interview, E2 provided documentation of the personnel schedule that revealed the facility had two shifts: First shift from 6:00 AM to 6:00 PM, the second shift from 6:00 PM to 6:00 AM. 2. There was no documentation of an employee disaster drill that had been conducted on the second shift during the past twelve months. 3. In an interview, E2 acknowledged the required employee disaster drills had not been conduct as required on the second shift.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were maintained in a locked area. Findings include: 1. During a facility tour, E2 and the compliance officer observed the facility's kitchen cabinet under the kitchen sink was not locked and therefore could be easily opened. The cabinet contained unlocked chemicals: oven grill cleaner. disinfectant spray, ant and roach spray, furniture polish, and machine oil. 2. In an interview, E2 acknowledged the unlocked poisonous or toxic materials.