Raintree Assisted Living LLC

Based on record review and interview, the health care institution failed to administer a training program that included initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E2's personnel record revealed E2’s hire date as August 26, 2020. A review of E2’s personnel record revealed no documentation of fall prevention and fall recovery training. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the health care institution 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 one of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E2’s personnel record revealed a hire date of August 26, 2020. The personnel record revealed no documentation of training on recognizing the signs and symptoms of TB. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for one resident sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record did not include documentation of R1's notification of the availability of vaccinations for flu and pneumonia. Based on R1's date of admission, this documentation was required. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed that the facility provided medication administration services. 2. A review of the facility's policies and procedures revealed a policy for “Medication.” However, the medication policies and procedures were not reviewed, signed, and dated by a medical practitioner, registered nurse, or pharmacist. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, observation, record review, and interview, for one of two personnel reviewed, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: A.R.S. \'a7 36-411(A) states "Except as provided in subsections F, G, H and I of this section, 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 (FP)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." 1. In observation, E2 was the only caregiver on site with one resident (R1). 2. A review of E2's personnel record revealed E2 was hired as a caregiver on August 26, 2020. E2's fingerprint clearance card was issued on February 17, 2017 and expired on February 17, 2023. E2's personnel record did not include documentation of a current fingerprint clearance card. 3. A review of the Department of Public Safety website revealed E2's fingerprint clearance card was "not valid." 4. During an interview, E1 and E2 acknowledged E2's fingerprint clearance card expired.

Based on observation, record review, and interview, for one of one resident reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a manager or caregiver did not document a medication was administered. Findings include: 1. In observation, R1's medications were observed on site, and included a bottle of Furosemide medication; which was dispensed on September 10, 2024, (30 tablets), and 21 tablets remained. 2. In record review, R1's medical record (received personal care and medication administration services) included a medication order for "Furosemide 20mg tab - take 1 tab PO QD PRN for edema in legs." R1's medication administration record (MAR); did not include documentation of the Furosemide medication administration. 3. During an interview, E2 reported R1 was administered the Furosemide medication, approximately every two days, as needed; however, acknowledged the medication administration was not documented on the MAR. E1 and E2 acknowledged the medication administration was required to be documented.