Spring Days Adult Care Home, LLC

Based on record review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E1's personnel record revealed no documentation indicating E1 completed fall prevention and fall recovery training. 2. Review of E2's personnel record revealed no documentation indicating E2 completed fall prevention and fall recovery training. 3. Review of E3's personnel record revealed no documentation indicating E3 completed fall prevention and fall recovery training. 4. Review of E4's personnel record revealed no documentation indicating E4 completed fall prevention and fall recovery training 5. In an interview, E2 reported being unable to locate the fall prevention, and fall recovery training. E2 acknowledged documentation was not available showing E1, E2, E3, and E4 had completed a training program for fall prevention and fall recovery.

Based on observation, record review, documentation review, and interview, the manager failed to ensure policies and procedures were implemented, to protect the health and safety of a resident that except as provided in subsection (M), cover cardiopulmonary resuscitation training for applicable employees and volunteers, including, the method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation, the qualifications for an individual to provide cardiopulmonary resuscitation training, the time-frame for renewal of cardiopulmonary resuscitation training, and the documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training, for one of four employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Upon arrival the Compliance Officer observed E4 cleaning up the kitchen from lunch. The Compliance Officer asked E2 if E4 was a caregiver. E2 stated " our housekeeper". 2. A review of the facility's "Policy and Procedures Manual" with a last reviewed date of June 1, 2021, revealed a policy titled "Support Staff". This policy stated "Support Staff are individuals that may provide ancillary services other than medical services, nursing services or health-related services provided to a resident. These services may include housekeeping, cooking, maintenance, activities, and cosmetology services. .... c. Has valid and current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults". 3. A review of E4's personnel record revealed E4 did not have first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults. 4. In an interview, E2 reported being unaware that the facility's policy's and procedures required E4 to have aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults.

Based on documentation reviewed and interview, the manager failed to establish and document a policy and procedure as part of the policies and procedure required in R9-10-803(C)(1)(h) to ensure the manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. Findings include: 1. A review of caregiver schedules revealed no manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. 2. A review of the facility's "Policy and Procedures Manual" with a last reviewed date of June 1, 2021, revealed the facility had not established, documented, and implemented as needed a policy and procedure regarding back-up staffing to provide assisted living services to a resident. 3. In an interview, E2 acknowledged the policy and procedure manual provided for review did not include a plan to ensure the manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. Technical assistance was provided during the on-site compliance inspection conducted on March 28, 2022.

Based on record review, documentation review, and interview, the manager failed to ensure a resident's written service plan when initially developed and when updated was signed and dated by the resident or resident's representative, for one of three residents sampled. Findings include: 1. A review of R3's medical record revealed two service plans, one dated March 7, 2023, and one dated June 9, 2023, for directed care services. The service plans were signed and dated by the nurse on March 7, 2023, and June 9, 2023, and the manager on March 7, 2023, and June 9, 2023, however, both service plans were not signed or dated by the resident's legal representative, which was required. 2. In an interview, E2 acknowledged the two service plans provided for R3, had not been signed, or dated by the resident's representative when the service plan was updated.

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 a disaster plan in an emergency. Findings include: 1. A review of the facility's staffing schedule revealed three shifts: - 8:00 am to 6:00 pm (First Shift), - 3:00 pm to 10:00 pm (Second Shift), and - 10:00 pm to 8:00 am (Third shift). 2. A review of documentation titled, "Disaster Drill" revealed the following information: - December 21, 2022, (First Shift), - December 21, 2022, combined for (Second and Third shifts), - June 23, 2022 (First Shift), and - June 23, 2022, (Second shift). There was no additional documentation of evidence to indicate a disaster drill was conducted on each shift at least once every three months and documented. 3. In an interview, E2 reported being unable to locate the other documents, due to E1 being out of town. E2 acknowledged disaster drills for employees were not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the manager failed to ensure pets or animals allowed in the facility were licensed consistent with local ordinances. Findings include: 1. A review of the facility's pet records for D1, and D2, revealed no current documentation the pets had licensure with Pima County. 2. In an interview, E2 acknowledged there was no documentation of licensure available to review for D1, and D2 from Pima County. Technical assistance was provided during the March 28, 2022 compliance inspection.