The Frontier House

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained documentation of notification to the resident of the availability of vaccination for pneumonia. Findings include: 1. The record belonging to R3 contained no documentation indicating that the resident had been notified of the availability of the pneumonia 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. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill was created and included an identification of residents who were not evacuated. Findings include: 1. Review of 12 months of facility evacuation drill documentation revealed that the documentation failed to include an identification of residents who were not evacuated. 2. During an interview, E1 stated, "We do have some residents who do not evacuate." 3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities. Findings include: 1. Review of facility policies and procedures failed to reveal documentation indicating that the health care institution had established and documented tuberculosis infection control policies and procedures that included subsections a. through f. of this rule. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on record review and interview the manager failed to ensure that one of three sample resident records contained documentation reflecting that a resident had a written service plan that was completed no later than 14 calendar days after the resident's date of acceptance. Findings include: 1. The record for R2 failed to reveal a completed service plan based on the resident's date of acceptance. 2. During an interview, E1 stated, "We did one, I can't find that." 3. During an interview, E1 acknowledged the required documentation was not available for review.

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 facility documentation failed to reveal that the health care institution had developed a fall prevention and recovery training program policy and procedure as required in A.R.S. \'a7 36-420.01. 2. Review of the record for E1 (hired July 1, 2010), failed to reveal documentation that fall prevention and fall recovery training had been administered. 3. Review of the record for E2 (hired January 1, 2023), failed to reveal documentation that fall prevention and fall recovery training had been administered. 4. Review of the record for E3 (hired November 1, 2012), failed to reveal documentation that fall prevention and fall recovery training had been administered. 5. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been developed and administered to all staff. This is a repeat deficiency from the compliance inspection conducted on January 25, 2023.

Based on record review and interview, the manager failed to ensure that one of three sample personnel records included documentation that a copy of the employee's current fingerprint clearance card had been obtained and verified with the Department of Public Safety (DPS), or an application for a fingerprint clearance card completed, within 20 working days of employment. Findings include: 1. The record for E2 (start date January 1, 2023) contained no documentation reflecting that the employee had a valid fingerprint clearance card or had submitted an application for fingerprint clearance to the DPS. 2. During an interview, E1 stated, "I thought we did that but, I can't find the documentation." 3. During an interview with the DPS it was determined that DPS had no record of an application or a fingerprint clearance card on file for E2. 4. During an interview, E1 acknowledged that the required documentation was not available for review.

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 contained a record of incident report occurrences but failed to include an identification of concerns or include any recommendation for changes. 3. During an interview, E1 acknowledged that the required documentation was not included in the reports.

Based on record review and interview, the manager failed to ensure that one of one of one sample personnel records contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113. Findings include: 1. The record for E2 (Caregiver, hired January 1, 2023) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. 2. During an interview, E1 acknowledged that the employee worked more than eight hours per week and the documentation did not reflect that the employee records contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.

Based on record review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. Review of the record for E1 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 2. Review of the record for E2 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 3. Review of the record for E3 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 4. During an interview, E1 acknowledge that the required documentation was not available.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review.