Valencia Care Homes

Based on a documentation review and interview, the manger failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. In record review, the facility had no documentation to indicate E6 (hired March 23, 2023, as a caregiver) received training on fall prevention and fall recovery. 2. During an interview, E1 and E2 reported E6 worked the night shift alone. 3. During an interview, E2 acknowledged the personnel record for E6 did not include the required training.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for one of five individuals sampled who was working as a caregiver. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. A review of E4's personnel record revealed E4 was hired as a caregiver on December 18, 2023. The record included a caregiver training certificate from Arizona Assisted Living Caregiver and Manager Training Programs, LLC., ALTP 0150, dated January 25, 2013. 2. A review of the NCIA verification of caregiver training portal revealed the training program was in operation from May 11, 2009 through July 31, 2012, which made E4's certificate invalid. 3. In an interview, E2 reported E4 worked as a caregiver three night shifts per week, alone, while employed at the facility, and acknowledged documentation was not available that showed E4 completed a caregiver training program approved by the Department or the NCIA Board.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures, for one of five sampled caregivers. The deficient practice posed a risk if the employees did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of the facility's policies and procedures revealed a policy that stated "The hiring person or manager will ensure, check and document that each caregiver or assistant caregiver providing physical health services or behavioral care services have the required skills and knowledge before providing any service." 2. The Compliance Officers observed E3 working at the facility. 3. A review of E3's personnel record revealed a hire date of May 28, 2024. E3's record revealed no documentation of verifying E3's skills and knowledge. 4. In an interview, E2 acknowledged documentation was not available showing E3's skills and knowledge were verified and documented.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of five personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: 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, 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)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCW's (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E6's personnel record revealed a hire date of March 23, 2023. The personnel record did not include documentation of freedom from TB. 4. During an interview, E2 acknowledged E6 did not provide documentation of freedom from infectious TB as specified in R9-10-113. Technical assistance was provided on this Rule during the compliance inspection conducted August 15, 2023.

Based on record review, documentation review, and interview, for one of five caregivers reviewed, the manager failed to ensure a caregiver provided documentation of cardiopulmonary resuscitation training (CPR) certification specific to adults which included a demonstration. The deficient practice posed a health and safety risk to residents if caregivers did not have CPR training which included a demonstration of the employee's ability to perform CPR. Findings include: 1. In record review, E4's personnel record revealed a hire date of December 18, 2023, as a caregiver. The record included documentation of a CPR certification, dated September 11, 2022, from National CPR Foundation, which was an online training program, and did not include a demonstration. 2. In an interview, E2 reported E4 worked the night shift alone, at the facility, three days a week. 3. In documentation review, a facility policy, titled, "First Aid and CPR Training...," documented, "... 2. Method and content of CPR training which includes the ability to perform and demonstrate cardiopulmonary resuscitation... " 4. In an interview, E2 acknowledged E4 did not have current documentation of CPR training, that included a demonstration of the individual's ability to perform CPR.

Based on interview and record review, for one of five employees reviewed, the manager failed to have a personnel record for an employee, as required by this Article. The deficient practice posed a risk to resident health and safety if the facility did not obtain documentation showing an employee met the requirements to provide services for the residents. Findings include: 1. In an interview, E2 reported E5 worked as a caregiver at the facility for approximately "two weeks to a month," (hire date unknown) and worked the night shift alone. 2. In record review, the facility did not have a personnel record for E5. 3. During an interview, E1 and E2 acknowledged having no personnel record for E5.

Based on documentation review, record review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), when there is a change in the manager. Findings include: 1. In record review, E1 was the facility manager. 2. A review of Department documentation revealed O1 was the manager. The Department was not notified of the change in the manager. 3. During an interview, E1 reported [E1] was the manager effective May 1, 2023.

Based on observation, and interview, the manager failed to ensure soiled linen and soiled clothing stored by the facility were stored in closed containers. Findings include: 1. During an environmental inspection, the surveyor observed a container in the laundry room which was uncovered and filled with soiled linens. 2. During an interview, E1 and E2 acknowledged the soiled linen and clothing stored by the facility was not stored in a closed container.