River of Love Adult Care Home

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation and in-service education as required by policies and procedures, for three of five personnel records sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. The Compliance Officer observed E1 and E4 at the facility during the day of the survey. 2. A review of facility documentation revealed a document titled "Employee Work Schedule" dated August 2023. The schedule reflected E4 and E5 were scheduled to work on multiple days throughout August 2023. 3. A review of the facility's policies and procedures revealed a policy titled "Ongoing Training". The policy stated "4 hours of annual ongoing training requirements are mandatory for all care staff." 4. A review of E1's personnel record revealed three hours of ongoing training completed in 2022. 5. A review of E4's and E5's personnel records revealed no documented hours of ongoing training completed in 2022. 6. Further review of E5's personnel record revealed no documentation of completed orientation available for review. 7. In an interview, E1 acknowledged E5's record did not contain documentation of completion of orientation, and E1's, E4's, and E5's personnel records did not contain the required amount of ongoing training hours per the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure the requirements in Arizona Administrative Code (A.A.C.) R9-10-814(B)(2) were met for a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, for two of two sampled non-ambulatory residents. Findings include: 1. A review of R1's medical record revealed a service plan dated February 9, 2023 for personal care services. The service plan reflected R1 was bed-bound. 2. Further review of R1's medical record revealed a document titled "Authorization for Continued Residency" dated August 12, 2021. However, there was no recent authorization for continued residency available for review. 3. A review of R2's medical record revealed a service plan dated May 12, 2023 for personal care services. The service plan reflected R2 was bed-bound, however there was no authorization for continued residency available for review. 4. In an interview, E1 acknowledged there was no current documentation to authorize contained residency for R1 and R2.