Tj's Assisted Living Facility LLC

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of three caregivers. 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, E2 introduced self as a caregiver, and the Compliance Officer observed E2 providing services to the residents. The services were assisting with meals, assisting with medication, and assisting in transportation from the walker to the sofa. 2. A review of E2's personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on April 4, 2024. There was no other current documentation of CPR training available for review that included a demonstration of E2's ability to perform CPR. 3. A search on the National CPR Foundation website FAQ's page revealed a section regarding hands-on training. That stated, "No, we do not offer hands-on training. If your employer has requested you to receive hands-on training or a skills check, please visit CPRNearMe.com." 4. A documentation review revealed the employee schedule, dated November 2025, showed E2 had been working in November 2025. 5. In an interview, E1 stated that E2 covered the day shift and the night shift. 6. In an interview, E1 reported that E1 was unaware that online classes were not acceptable. 7. In an interview, E1 and E2 acknowledged that E2 did not have CPR training that included a demonstration of the individual's ability to perform CPR. 8. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview the health care institution failed to 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 E2 (hired December 2, 2017), failed to reveal documentation of fall prevention and fall recovery training. 2. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been administered to all staff.

Based on record review and interview, the manager failed to ensure that resident records contained a standardized emergency responder patient information form. Findings include: 1. The record for R1 failed to contain the completed emergency responder patient information documentation. 2. The record for R2 failed to contain the completed emergency responder patient information documentation. 3. The record for R3 failed to contain the completed emergency responder patient information documentation. 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 ensure that policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. Review of the facility policy and procedure manual revealed documentation indicating that the manual had last been reviewed on October 7, 2020. No additional documentation indicating that the policies and procedures had been reviewed at least once every three years was available for review. 2. During an interview, E1 acknowledged 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 per the frequency established in the plan. Findings include: 1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority "annually". 2. No reports were available for review. 3. During an interview, E1 stated, "I haven't done that."

Based on documentation review and interview, the manager failed to ensure that documentation is maintained after the last date on the documentation of the caregivers working each day. Findings Include: 1. The record of employee work schedules for March and April, 2024 indicated that E3 worked each day from 1p to 5p. 2. During an interview, E1 stated, "She hasn't been working since her fingerprint certification expired. I've been covering the shift. I didn't change the schedule." 3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure that records for individuals who are 12 years of age or older, residing in an assisted living home, who were not a resident, a manager, a caregiver, or an assistant caregiver, contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113. Findings include: 1. The record for O1 did not contain documentation of freedom from TB. 2. The record for O2 did not contain documentation of freedom from TB. 3. During an interview, E1 indicated that O1 and O2 had been residing in the facility since August 2024. 4. During an interview, E1 acknowledged that the required documentation was not available.

Based on record review and interview, the manager failed to ensure that resident records had service plans that were reviewed and updated at least once every three months for a resident receiving directed care services. Findings include: 1. The record for R1 contained service plan updates reflecting the following dates: February 27, 2024 and September 20, 2023. No additional service plan updates were available for review. 2. During an interview, E1 acknowledged that service plan documentation did not reflect that updates were conducted at least once every three months.

Based on record review and interview for two of two sample directed care resident records, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident remain in the facility and a signed and dated statement from a 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, E1 indicated that R1 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 2. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the resident's medical practitioner indicating that the resident's needs were being met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required. 3. During an interview, E1 indicated that R3 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 4. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the resident's medical practitioner indicating that the resident's needs were being met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required. 5. During an interview, E1 acknowledged that the required documentation was not in the resident's record.

Based on documentation review and interview, the manager failed to ensure that policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. Review of the facility medication administration policies and procedures failed to reveal documentation indicating that the policies had been reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 2. During an interview, E1 stated "I had that."

Based on observation and interview the manager failed to ensure that when medications were stored by the facility, the medications were stored in a locked area. Findings include: 1. Observation of the unlocked kitchen refrigerator revealed the following medications on a shelf inside the door: two bottles of Haloperidol, One bottle of Hyocyamine, two boxes of Lorazepam, three boxes of Morphine Sulfate, one box of Trulicity. 2. During an interview, E1 acknowledged the medications were not stored in a locked area.

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months. Findings include: 1. Review of facility disaster plan review documentation indicated that the last review was conducted on March 15, 2021. 2. During an interview, E1 acknowledged that the documentation failed to reflect that a review had been conducted at least once every 12 months.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. Facility disaster drill documentation revealed that the last disaster drill was conducted on December 15, 2023. No other disaster drill documentation was available for review. 2. During an interview, E1 acknowledged that documentation failed to reflect that employee drills were conducted on each shift, at least once every three months.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. Evacuation drill documentation indicated that the last evacuation drill for employees and residents had been conducted on December 15, 2023. No additional evacuation drill documentation was available for review. 2. During an interview, E1 acknowledged the documentation failed to indicate that evacuation drills for employees and residents had been conducted at least once every six months.

Based on observation and interview, the manager failed to ensure that a smoke detector was tested at least once a month. Findings include: 1. Twelve months of smoke detector test documentation was requested. No smoke detector test documention was available for February and March, 2024. 2. During an interview, E1 stated "I don't have that."

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 include 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 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. 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.