San Judas Group Home

Based on documentation review, record review, and interview, the manager 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 one of four 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 "Fall Prevention and Fall Recovery Policy" that was dated January 18, 2023. The policy stated, "Quality Improvement: This facility shall develop an initial training, conduct, and administer continued competency Training in Fall Prevention and Fall Recovery Program." 2. A review of the facility's in-service training documents revealed an inservice on fall prevention and fall recovery was administered; however, E3 was not included in this training. 3. A review of E3's personnel record did not include documentation of fall prevention and fall recovery training. Based on E3's date of hire, an initial training was required. 4. In an interview, E1 acknowledged that the facility failed to administer a training program for all staff regarding fall prevention and fall recovery that included initial training.

Based on record review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9), for three of three sampled residents. Findings include: 1. A review of R1's, R3's, and R4's medical records revealed standardized emergency responder forms were not available for review. 2. In an interview, E1 acknowledged the manager failed to maintain a standardized form for each resident that included the information prescribed in the statute. E1 was provided with a copy of the statute for review.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings include: 1. A review of facility documentation revealed no documentation of a policy to address how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. 2. In an interview, E1 acknowledged the facility did not have a policy and procedure available for review of how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. E1 reported that the facility did not have a hard copy or electronic copy that could be accessed for review at the time of inspection.

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident that cover methods by which an assisted living center was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living center is authorized to provide. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of facility documentation revealed no documentation of a policy to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. 3. In an interview, E1 acknowledged the facility did not have a policy to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for three of four personnel sampled. The deficient practice posed a risk if personnel did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of E1's personnel records revealed no documented verification of E1's skills and knowledge. 2. A review of E3's personnel records revealed no documented verification of E3's skills and knowledge. 3. A review of E4's personnel records revealed no documented verification of E4's skills and knowledge. 3. In an interview, E1 acknowledged E1's, E3's, and E4's personnel records did not contain documented verification of skills and knowledge before E1, E3, and E4 provided physical health services on behalf of the facility.

Based on documentation review, observation, and interview for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the license issued by the Department revealed the facility was licensed at the directed care level. 2. During an environmental inspection of the facility, the Compliance Officer observed the door to the backyard patio of the home to have a door alarm; however, it was not working and did not alert employees of the egress of a resident from the facility. 3. During an interview, E1 reported that the battery to the back door alarm was dead. 4. During an interview, E1 acknowledged the back door of the facility provided access to the outside and did not control or alert employees of the egress of a resident from the facility.

Based on observation, record review, and interview; the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, and documented in the resident's medical record for one of three residents receiving medication administration. Findings include: 1. The Compliance Officer observed an empty bottle of Ciprofloxacin HCL 500 mg in R3' s medication storage bin with a fill date of January 18, 2025 and with instructions to "take 1 tablet by mouth twice daily for 7 days." 2. A review of R3's medical record revealed a service plan for personal care services which reported that R3 received medication administration. 3. A review of R3's medical record revealed no medication order for Ciprofloxacin HCL 500 mg. 4. A review of R3's medication administration record (MAR) revealed no documentation of Ciprofloxacin HCL 500 mg being administered to R3 in the month of January 2025. 5. In an interview, E1 reported that Ciprofloxacin HCL 500 mg was administered to R3 from January 18-24, 2025; however, E1 forgot to add this medication to R3's MAR and did not have a medication order available for review. 6. In an interview, E1 acknowledged a medication administered to a resident was not administered in compliance with a medication order, and documented in the resident's medical record.

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 a risk to the physical health and safety of residents with access to the unsecured medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a closet door at the front of the home which stored resident medications; however, the door was unlocked at the time of the inspection. 2. In an interview, E1 acknowledged the aforementioned medications were stored in a closet used for medication storage, but the unit was not locked at the time of inspection.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed the facility's disaster plan was reviewed on October 28, 2021. However, no additional documentation of a review was available. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. A review of the facility's employee disaster disaster drills revealed disaster drills conducted on the following dates and times: -December 2, 2024 with no time documented -June 3, 2024 with no time documented -December 2, 2023 at 11:30 am -June 1, 2023 with no time documented 2. In an interview, E1 reported having a 24 hour personnel shift and mistakenly believed disaster drills needed to be conducted once every six months. 3. In an interview, E1 acknowledged a disaster drill for employees was not conducted and documented on each shift at least once every three months.

Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB. Findings include: 1. A review of R1's and R4's medical records revealed no documentation of a baseline screening which consisted of assessing R1's and R4's risks of prior exposure to infectious TB and determining if R1 and R4 had signs or symptoms of TB. 2. A review of E3's and E4's personnel records revealed no documentation of freedom from infectious tuberculosis by way of required two step TB skin tests or one TB blood test. 3. In an interview, E1 acknowledged baseline screening conducted by a qualified individual consistent with R9-10-113(A)(2)(a)(i-ii) was not available in R1's and R4's medical records upon review. 4. In an interview, E1 acknowledged E3's and E4's personnel records did not include freedom from infectious TB by way of required two step TB skin tests or one blood test.

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 one of four personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E3's personnel record revealed no documentation of completed training on recognizing the signs and symptoms of TB was available for review. 2. In an interview, E1 acknowledged E3's personnel record did not include documentation of initial training on recognizing the signs and symptoms of TB.