Valley Vista Assisted Living, LLC

Based on documentation review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility and as specified in R9-10-113, for two of two employees sampled. 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: c. Annually providing training and education related to recognizing signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution.” 2. A review of E1's and E2's personnel records revealed no documentation of annual TB training for 2025. E1 and E2’s last documented TB training was dated November 6, 2024. 3. In an exit interview, the findings were reviewed with E1. E1 acknowledged E1 and E2’s personnel records did not provide documentation in compliance with R9-10-113.

Based on record review, documentation review, and interview, the manager failed to ensure, for two of two sampled employees, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E1's and E2's personnel records revealed CPR and First Aid training certifications dated April 18, 2022 with a marked expiration of April 18, 2024. However, current documentation of First Aid training and CPR training was not available for review. 2. In an interview, E1 acknowledged E1's and E2's personnel records did not include documentation of current First Aid and CPR training certification.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for two of two residents reviewed. R9-10-815(C)(1) states, "In addition to the requirements in R9-10=808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: (1) The requirements in R9-10-814(F)(1) through (3). Findings include: 1. A review of R1's medical record revealed a service plan, dated April 15, 2024, for personal care services. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. A review of R2's medical record revealed a service plan, dated March 2, 2024, for directed care services. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 3. In an interview, E1 acknowledged R1's and R2's services plan did not include a description of the skin maintenance each resident required to prevent and treat bruises, injuries, pressure sores, and infections.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. On May 7, 2024 at 10:30 AM, The Compliance Officer requested the facility's annual disaster plan review and provided E1 a list of the documents being requested, to include the annual disaster plan review document. However, documentation of a disaster plan review was not available. 2. In an interview, E1 acknowledged the annual disaster plan review had not been provided for review. E1 reported the review had been misplaced and E1 was not able to locate it during the on-site inspection.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for two of two employee records sampled. Findings include: 1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of E1's personnel record revealed a fingerprint clearance card which expired on April 11, 2023. 3. In an interview, E1 acknowledged the personnel record provided for E1 did not include documentation of compliance with A.R.S. \'a7 36-411. E1 reported E1 forgot the card expired this year and had not yet applied for renewal.

Based on documentation review, record review, and interview, the manager failed to ensure a policy and procedure was implemented to protect the health and safety of a resident that covered cardiopulmonary resuscitation (CPR) training for applicable employees including the method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's ability to perform CPR, and including the documentation that verifies that the employee has received CPR training, for two of two personnel records sampled. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "CPR AND FIRST AID Policy AND PROCEDURES". The policy stated: "...B. This assisted living facility requires a caregiver who provides direct care to residents to obtain and provide documentation of cardiopulmonary resuscitation training specific to adults, which includes a demonstration of the caregiver's ability to perform cardiopulmonary resuscitation ... C. Upon employment all caregivers will be required to provide current training in CPR and First Aid ... E ... Caregiver's will be required to submit new training documentation one month prior to the expiration date ..." 2. A review of E1's personal record revealed no documentation of current CPR Training. The record included an "American Heart Association Basic Life Support BLS Provider (CPR and AED)" certification card, with an issue date of March 29, 2019, and a renewal date of March 2021, and documentation of CPR training issued on March 30, 2021, by "NationalCPRFoundation," an online-only CPR training program. 3. A review of E3's personal record revealed no documentation of current CPR Training. 4. In an interview, E1 acknowledged E1's and E3's personnel records did not include current documentation of CPR training.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures covering first aid training were implemented, for two of two personnel records sampled. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "CPR AND FIRST AID Policy AND PROCEDURES". The policy stated: " ... C. Upon employment all caregivers will be required to provide current training in CPR and First Aid ... E ... Caregiver's will be required to submit new training documentation one month prior to the expiration date ..." 2. A review of E1's personal record revealed no documentation of current first aid training. The record included documentation of first aid training issued on March 30, 2021, by "NationalCPRFoundation," and expired on March 30, 2023. 3. A review of E3's personal record revealed no documentation of current first aid training. 4. In an interview, E1 acknowledged E1's and E3's personnel records did not include current documentation of first aid training.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of two personnel records sampled. Findings include: 1. A review of facility's staffing schedule, for April 2023, revealed E3 worked as an assistant caregiver on April 11, 18, and 25, 2023 from 7:30 AM to 2:30 PM and on April 5, 6, 7, 8, 12, 13, 14, 15, 19, 20, 21, 22, 26, 27, 28, and 29, 2023 from 2 PM to 9 PM. 2. A review of E3's personnel records revealed no documentation of verification of E3's skills and knowledge. 3. In an interview, E1 acknowledged E3's personnel record did not include documentation of verification of E3's skills and knowledge.

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record contained documentation indicating a caregiver or assistant caregiver received orientation before providing assisted living services to a resident, for one of two personnel records sampled. Findings include: 1. A review of E3's personnel record revealed no documentation to indicate E3 received orientation prior to providing physical health services. 2. A review of facility's staffing schedule, for April 2023, revealed E3 worked as an assistant caregiver on April 11, 18, and 25, 2023 from 7:30 AM to 2:30 PM and on April 5, 6, 7, 8, 12, 13, 14, 15, 19, 20, 21, 22, 26, 27, 28, and 29, 2023 from 2 PM to 9 PM. 3. In an interview, E1 acknowledged E3's personnel record did not include documentation of orientation before E3 provided physical health services.

Based on document review, observation, and interview, the manager failed to ensure a facility authorized to provide directed care services had a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed when exiting from a back door leading to the secured backyard, no alarm sounded to alert employees of the egress of a resident from the facility. 3. In an interview E1 acknowledged the side door did not have a door alarm, to alert employees of the egress of a resident from the facility.