Splendido at Rancho Vistoso

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95° F and 120° F in the areas of a facility used by residents. The deficient practice posed a health and safety risk to the residents. Findings include: 1. During a tour of the facility with E1, the Compliance Officer observed the hot water temperature in a resident’s bathroom measured 125° F. 2. In an interview, E1 acknowledged that the hot water temperature was not maintained between 95° F and 120° F in the areas of a facility used by residents.

Based on record review, documentation review, observation, and interview, the manager failed to ensure before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults for two of four caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of policy and procedure titled "Employee Orientation, Development, and Competencies" revealed 6.1 Nursing employees and certified nursing assistants are required to be certified in cardiopulmonary resuscitation (CPR) and automatic external defibrillator (AED) use". 6.1.1 CPR/AED training and certification is provided via the American Heart Association or American Red Cross standards by a certified provider. All rules and regulations related to the provision of this service by the provider are adhered to. 6.1.2 Only staff that is certified in CPR/AED training should perform this act". 2. A review of E2's personnel record revealed E2 was hired as a caregiver in June 2021. The Compliance Officer observed in E2's personnel record the following: A review of a document titled "Lifeline Training Resources Adult/Infant Child CPR & First Aid, 03/28/2023 - 03/28/2025". 3. An online search of Lifeline Training Resources revealed this course is an online course only for CPR and First Aid. This course does not provide the standards associated with the American Heart Association or the American Red Cross as per the facilities policy and procedures for CPR, which could have posed a risk if E2 was unable to meet a resident's needs during an emergency. 4. A review of E3's personnel record revealed E3 was hired as a caregiver in August 2021. The Compliance Officer observed in E3's personnel record the following: A review of a document titled "National CPR Foundation CPR/Automated External Defibrillator (AED)/First Aid training" certification. The course was taken on May 15, 2023. 5. An online search of the National CPR Foundation revealed this is an online course. This course does not provide the standards associated with the American Heart Association or the American Red Cross as per the facilities policy and procedures for CPR, which could have posed a risk if E3 was unable to meet a resident's needs during an emergency. 6. In an interview, E1 and E7 reported being unaware E2, and E3's CPR documentation was an on-line course that does not provide the standards associated with the American Heart Association or the American Red Cross as per the facilities policy and procedures for CPR. This is a repeat citation form the compliance inspection conducted on April 4, 2023.

Based on record review, documentation review, observation, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411, for one of six personnel records sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population and the Department received false or misleading information. Findings include: 1. A.R.S. \'a7 36-411 states, "... 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 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." 2. A review of E2's personnel record revealed E2 was hired as a caregiver in June 2021. The Compliance Officer observed a copy of a document titled "State Of Arizona Department Of Public Safety" this document had E2's name on it. The number on the document was 2A01298229. The Compliance Officer observed in some areas of this document the font had changed and looked to be different from other areas on the document. 3. A review of the website from the Arizona Department of Public Safety revealed the fingerprint card number had expired on August 4, 2023. The Compliance Officer observed the issued date was August 4, 2017, with an expiration date of August 4, 2023, and the card had been renewed two other times since 2004. The document in E2's personnel record had an issue date of August 4, 2018, and an expired date of August 4, 2024. - No documentation was provided to show E2 had a valid fingerprint clearance card. 4. In an interview, E1 and E7 reported being unaware E2 did not have a valid fingerprint clearance card, the card had been altered from it's original state, and the Department was provided false or misleading information..