Rubidium Assisted Living Home LLC

Based on observation and interview, the manager failed to ensure a resident's sleeping area had at least one door. Findings include: 1. The Compliance Officer observed R1's private sleeping area did not contain a door. 2. The Compliance Officer observed R2's private sleeping area did not contain a door. 3. In an interview, E2 reported the doors were removed by the previous facility owner and acknowledged R1's and R2's private sleeping areas did not contain at least one door.

Based on observation, record review, documentation review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to provide the services in the scope of services, to meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk as a qualified personnel member was not present to meet a resident's needs and ensure the health and safety of a resident. Findings include: 1. The Compliance Officer observed E1 working alone at the facility upon arrival at 8:22 AM. 2. A review of E1's personnel record revealed E1 was hired as a caregiver. 3. A review of E1's personnel record revealed a document indicating E1 completed a "ParaHealth Caregivers National Certification" dated February 2, 2011. However, a review of https://nciaboard.az.gov/news/fraudulent-caregiver-certificates revealed E1 had not received a caregiver certificate after August 3, 2013. 4. A review of https://nciaboard.az.gov/news/caregiver-certificate-verification website revealed "No Resources Found" for "ParaHealth Caregivers National Certification." 5. A review of facility documentation revealed staffing schedules (per R9-10-806.A.7.) for the months of July 2023 and August 2023. The schedules revealed E1 was scheduled to work alone on the following dates and shifts: -July 16-29, 2023 6PM-6AM; and -August 1-31, 2023 6AM-6PM. 6. In an interview, E2 acknowledged the assisted living facility did not have a caregiver with the qualifications, experience, skills, and knowledge necessary to provide the services in the scope of services, to meet the needs of a resident, and ensure the health and safety of a resident.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident, for three of three residents sampled. The deficient practice posed a risk as services provided could not be verified against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated in July 2023 for directed care services. The service plan stated R1 was to receive assistance in activities of daily living. However, documentation of assisted living services provided to R1 on August 9, 2023 were not available for review. 2. A review of R2's medical record revealed a service plan dated in June 2023 for directed care services. The service plan stated R2 was to receive assistance in activities of daily living. However, documentation of assisted living services provided to R2 on August 9, 2023 were not available for review. 3. A review of R3's medical record revealed a service plan dated in July 2023 for directed care services. The service plan stated R3 was to receive assistance in activities of daily living. However, documentation of assisted living services provided to R3 on August 8-9, 2023 were not available for review. 4. In an interview, E2 reported assisted living services were provided to R1, R2, and R3 and not documented.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed one ambulatory resident on the premises. 2. The Compliance Officer observed an unlocked in the unlocked kitchen refrigerator. The key in the lockbox was in the unlocked position. The lockbox contained the following medications belonging to R3: -INSULIN ASPART FLXPEN and INSULIN GLARGINE PEN. 3. In an interview, E2 acknowledged the medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. This is a repeat deficiency from the onsite compliance inspection conducted on July 7, 2022.

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed. Findings include: 1. A review of the facility documentation revealed a document titled "FALL PREVENTION AND FALL RECOVERY" (dated in June 2022). However, the training program did not include the initial training and continued competency training requirement. 2. In an interview, E2 acknowledged the facility's fall prevention and fall recovery training program did not include the initial training and continued competency training requirement. This is a repeat deficiency from the onsite compliance inspection conducted on July 7, 2022.

Based on observation, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers, for one of one individual hired as a caregiver. The deficient practice posed a risk if E1 was not qualified to provide the required services. Findings include: 1. The Compliance Officer observed E1 working alone at the facility upon arrival at 8:22 AM. 2. A review of E1's (hired in 2023) personnel record revealed E1 was hired as a caregiver. 3. A review of E1's personnel record revealed a document indicating E1 completed a "ParaHealth Caregivers National Certification" dated February 2, 2011. However, a review of https://nciaboard.az.gov/news/fraudulent-caregiver-certificates revealed E1 had not received a caregiver certificate after August 3, 2013. 4. A review of https://nciaboard.az.gov/news/caregiver-certificate-verification website revealed "No Resources Found" for "ParaHealth Caregivers National Certification." 5. In an interview, E2 reported to be unaware E1's certification was not valid. E2 acknowledged E1 had not completed a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers.