The Inn at the Fountains

Based on document review, 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 for one of four personnel sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of facility documentation revealed a fall prevention and fall recovery program had been updated and implemented on May 9, 2023. The program stated, "All Associates will complete one hour of competency training in fall prevention and fall recovery upon hire and annually thereafter." 2. A review of facility "Learning Experience/In-Service" documentation revealed a document titled "AZ Fall Prevention & Fall Recovery" which documented an in-service training of facility employees. The document contained a list of names of all facility staff who attended the one fall prevention and fall recovery training, however E6's name was not included. 3. A review of E6's (hire date April 17, 2023) personnel record revealed E6 completed orientation, however, evidence of documentation of E6's completion of initial fall prevention and fall recovery training was available for review. 4. During an interview, E1 acknowledged there was no documentation indicating E6 had completed an initial training program for fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident covering cardiopulmonary resuscitation (CPR) training. The deficient practice posed a health and safety risk if the employee did not know how to properly administer CPR. Findings include: 1. A review of the facilities policies and procedures (reviewed January 30, 2023) revealed a policy titled "Administering CPR, First Aid, Fall Prevention Training, Fall Recovery Training AZ only, in accordance with A.R.S. 46-420." The policy stated: "Caregivers will be required to submit new training documentation prior to the expiration date..." 2. A review of E3's personnel record revealed E3 was hired as a caregiver. Further review revealed a copy of E3's CPR and Basic First Aid certification card, however the card indicated an expiration date of "May 25, 2023." 3. During an interview, E1 acknowledged that E3's personnel record did not include evidence of current CPR and First Aid training.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include the amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication, for four of eight residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan updated June 8, 2023 for personal care services. The service plan included assistance with laundry. However, the service plan did not include the frequency at which the laundry service would be provided to R1. 2. A review of R2's medical record revealed a service plan updated January 25, 2023 for personal care services. The service plan included assistance with bathing and laundry. However, the service plan did not include the frequency at which the bathing or laundry service would be provided to R2. 3. A review of R3's medical record revealed a service plan updated June 1, 2023 for personal care services. The service plan included assistance with bathing. However, the service plan did not include the frequency at which the bathing service would be provided to R3. 4. A review of R5's medical record revealed a service plan updated June 8, 2023 for personal care services. The service plan included assistance with laundry. However, the service plan did not include the frequency at which the laundry service would be provided to R5. 5. In an interview, E1 acknowledged R1's, R2's, R3's and R5's service plans did not include the frequency of assisted living services being provided to each resident.

Based on observation, interview and documentation review the manager failed to ensure the service plans for two of two residents sampled who stored medication in their residential unit included how the medication was stored and controlled. Findings include: 1. During a tour of the facility the Compliance Officer observed two medication organizers filled with various medications, and two bottles of prescription medication sitting on a small table in R2's residential unit. The Compliance Officer also observed a medication organizer marked "PM" sitting on the counter in R2's bathroom, and a medication organizer marked "AM" inside the medicine cabinet in R2's bathroom. The Compliance Officer observed medication organizers filled with various medications sitting on a table inside R5's residential unit. 2. In an interview, E1 confirmed R2 and R6 self-administered medication, and R2 and R5 would store medications in R2's and R5's residential unit. 3. A review of R2's medical record revealed a service plan updated January 25, 2023, for personal care. The service plan included a sections for "Oral Medications" and "Non-Oral Medications" which indicated R2 would receive "Support provided by an OUTSIDE Provider." However, the service plan did not state if R2 would be storing medications in R2's room or how the medication would be stored and controlled. 4. A review of R5's medical record revealed a service plan updated June 8, 2023, for personal care. The service plan did not include whether the resident would receive assistance in the self-administration of medication or medication administration. The service plan did not state if R6 would be storing medications in R5's room or how the medication would be stored and controlled. 5. In an interview, E1 acknowledged the service plans for R2 and R5, who self-administered and stored medication, did not include how the medication would be stored and controlled.