Summit Senior Living LLC

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. Findings include: 1. Review of the record for E1 (hired October 21, 2021), failed to reveal documentation of fall prevention and fall recovery training. 2. During an interview, E2 indicated that training for fall prevention and fall recovery had not been administered to all staff. This is a repeat deficiency from the compliance inspection conducted on September 22, 2022.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority that includes an identification of each concern about the delivery of services related to resident care, any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care and any changes made or action taken as a result of the identification of a concern about the delivery of services related to resident care. 2. Review of the reports submitted to the governing authority revealed that the reports failed to include an identification of concerns or include any recommendation for changes. 3. During an interview, E2 acknowledged that the required documentation was not included in the reports.

Based on record review and interview, the manager failed to ensure that two of two sample resident records contained documentation of notification to the resident of the availability of the vaccination for pneumonia. Findings include: 1. The record belonging to R1 contained no documentation indicating that the resident had been notified of the availability of the pneumonia vaccination on a yearly basis. No additional documentation indicating when the resident had been offered, refused or received the vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required. 2. The record belonging to R3 contained no documentation indicating that the resident had been notified of the availability of the pneumonia vaccination on a yearly basis. No additional documentation indicating when the resident had been offered, refused or received the vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required. 3. During an interview, E2 acknowledged that the required documentation was not available for review.

Based on record review and interview for one of one sample directed care resident record, the manager failed to obtain documentation at least once every six months throughout the duration of the resident's condition, from the resident's medical practitioner, indicating that the resident's needs were being met by the facility, as per their scope of services. Findings include: 1. During an interview, E2 indicated that R3 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 2. Review of the resident's record revealed that the last statement from the medical practitioner that the resident's needs were being met as per the facility's scope of services, was dated December 1, 2021. Based on the resident's date of acceptance this documentation was required. 3. During an interview, E2 acknowledged that the required documentation was not in the resident's record.

Based on observation, documentation review and interview, the licensee implemented a modification, prior to approval or amended of the license issued by the Department. Findings include: 1. Observation of the middle, back of the home located adjacent to the television area, revealed that the area had been modified into two resident bedrooms. 2. Review of Department records revealed a floor plan indicating the area had been one large bedroom. No documentation of a request for a modification of the health care institution was found in the record. 3. During an interview, E2 stated, "We changed that area into two bedrooms in September 2022. The first resident moved in this past February".