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Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed to include initial training and continued competency training. Findings include: 1. A review of the facility documentation revealed an undated document titled "Fall Reduction Program." However, the training policy and procedure did not include the initial training and continued competency training requirement. 2. A review of E1's personnel record revealed initial training in fall prevention and fall recovery. 3. A review of E2's personnel record revealed initial training in fall prevention and fall recovery. 4. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program did not include the initial training and continued competency training requirement. This is a repeat deficiency from the compliance inspection conducted on September 6, 2022.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C)(2), for two of two employees sampled. The deficient practice posed a risk if employees were a danger to a vulnerable population. Findings include: A.R.S. \'a7 36-411(C) Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card. 1. A review of E1's personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 2. A review of E2's personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 3. A review of facility documentation revealed a policy and procedure titled "FINGERPRINT" (dated in January 2023). The procedure stated "For individuals with a Fingerprint Card ...phone the Department of Public Safety to verify if the card holder has a valid Level 1 Clearance ..." 4. In an interview, E1 acknowledged the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C)(2) for E1 and E2.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: R9-10-113(A)(2)(a)(i)(ii)(iii): ..."a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1) ..." 1. A review of R2's (admitted in 2023) medical record revealed a negative TB skin test. However, a baseline screening was not available for review. 2. In an interview, E1 acknowledged R2 had not provided freedom from infectious TB as specified in R9-10-113. Technical assistance was provided on this Rule during the compliance inspection conducted on September 6, 2022.

Based on observation, documentation review, and interview, the manager failed to ensure one cat was vaccinated against rabies. Findings include: 1. The Compliance Officer observed four cats, O1, O2, O3 and O4, in the facility during the inspection. 2. A review of facility documentation revealed O1's rabies vaccine expired on November 24, 2021. 3. In an interview, E1 reported O1 did not have current rabies vaccination. Technical assistance was provided on this Rule during the compliance inspection conducted on September 6, 2022.

Based on documentation review and interview, the health care institution's chief administrative officer failed to ensure the health care institution established, documented, and implemented tuberculosis infection control activities consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "INFECTION CONTROL" (dated in January 2023). The procedure revealed non-compliance with R9-10-113.A.1. 2. In an interview, E1 reported E1 reported the facility had not established, documented and implemented tuberculosis infection control activities as specified in R9-10-113.A.1. Technical assistance was provided on this Rule during the compliance inspection conducted on September 6, 2022.

Based on documentation review and interview the health care institution's chief administrative officer failed to ensure establish, document and implement tuberculosis infection control activities to include annual training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "INFECTION CONTROL" (dated in January 2023). The procedure revealed non-compliance with R9-10-113.A.2.c. 2. In an interview, E1 acknowledged E2's personnel record had not included documentation of TB training and education. E1 reported the facility had not established, documented and implemented tuberculosis infection control activities as specified in R9-10-113.A.2.c. Technical assistance was provided on this Rule during the compliance inspection conducted on September 6, 2022.