Venus Assisted Living Home

Based on interview and documentation review, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder (EMS). The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. In an interview, E1 reported R1 had an accident, emergency, or injury on January 14, 2026, that resulted in facility personnel contacting EMS on behalf of R1. 2. In an interview, when the Compliance Officer requested a copy of the documentation given to EMS in compliance with this statute, E1 revealed "not available at this time." When the Compliance Officer asked if facility personnel gave EMS a document in compliance with this statute, E1 stated, “No.”

Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for two of three personnel sampled. The deficient practice posed a potential TB exposure 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel. The webpage states, "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing." 3. A review of E2 and E3's personnel records revealed only one TB test, risk assessment, and signs and symptoms screening. 4. In an interview, E1 and E2 acknowledged that E2 and E3 did not have a second TB test. 5. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on September 28, 2023.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner or a registered nurse. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed there was no documentation dated within 90 days of their acceptance date, which included whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner or registered nurse. Based on R1's acceptance date, this documentation was required. 2. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A review of department documentation revealed an intake report dated January 14, 2026, which revealed that 911 was called. 2. A review of R1's record revealed no documentation showing the date and time of the incident; the names of the individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future. 3. In an interview, E1 acknowledged that E1 and E2 did not include documentation showing the date and time of the incident; the names of the individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future. 4.In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager 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. Review of facility documentation revealed a policy and procedure titled "Fall Prevention" reviewed and signed by E1 August 5, 2023. This policy stated "...All employees upon hire will take part in an in-service training program regarding Fall Prevention and Fall recovery, which will include initial training and continued competency at least every 12 months..." 2. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of January 12, 2008. The personnel record revealed documentation of fall prevention training dated November 18, 2021. However, current documentation was not available indicating E1 completed fall prevention and fall recovery training. 3. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of February 3, 2021. The personnel record revealed documentation of fall prevention training dated November 16, 2021. However, current documentation was not available indicating E2 completed fall prevention and fall recovery training. 4. Review of E3's personnel record revealed E3 worked as an assistant caregiver and had a hire date of September 17, 2023. The personnel record did not include documentation showing E3 completed fall prevention and fall recovery training. 5. In an interview, E1 acknowledged documentation was not available showing E1, E2, and E3 had completed initial training and continued competency training for fall prevention and fall recovery.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of three employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution..." 2. Review of E3's personnel record revealed E3 worked as an assistant caregiver and had a hire date of September 17, 2023. The personnel record revealed a fingerprint clearance card issued on July 20, 2023. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution. 3. Review of the Department of Public Safety (DPS) fingerprint clearance card database on September 28, 2023, revealed E3's fingerprint clearance card was valid. 4. In an interview, E1 acknowledged documentation was not available showing E3's work references were obtained upon hire at the facility.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the facility quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Quality Management Program Including Incident Reports" reviewed and signed by E1 August 5, 2023. This policy stated "..The manager will review all residents' narrative notes, unusual occurrence reports, complaints in regards to the residents' care, the facility manager's reports and caregivers' communication logs, will document the collection of data on a monthly basis on the Quality Management Monthly Reporting form..." 2. Review of facility documentation revealed no documentation of a quality management report. 3. In an interview, E1 reported E1 could not locate the quality management documentation.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of three caregivers. The deficient practice posed a potential TB exposure 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. Review of E2's personnel record revealed no documentation of freedom from infectious TB. Based on E2's hire date, this documentation was required. 3. Review of E3's personnel record revealed no documentation of freedom from infectious TB, a risk assessment of prior exposure to infectious TB, or a determination if E3 had signs or symptoms of TB. Based on E3's hire date, this documentation was required. 4. In an interview, E1 acknowledged E2 and E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113. 5. Technical assistance was provided on this Rule during the compliance inspection conducted November 15, 2022.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of three caregivers. The deficient practice posed a risk if the employees were unable to meet resident's needs. Findings include: 1. Review of E3's personnel record revealed E3 worked as an assistant caregiver and had a hire date of September 17, 2023. The personnel record revealed no documentation showing E3 received orientation specific to the duties to be performed. 2. Review of the facility's policy and procedure revealed a policy titled "Orientation and In-Service Training" reviewed and signed by E1 August 5, 2023. This policy stated "New employee orientation is required to be completed by all new employees and volunteers before providing assisted living services to the residents ..." 3. In an interview, E1 acknowledged E3 had not received orientation specific to the duties to be performed.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record included the correct strength for a medication administered to one of two residents reviewed. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated August 9, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated September 18, 2023. This medication order stated "Reduce Escitalopram 20mg 1 tab - to 1/2 tab daily x 1 week then 1/2 tab every other day x 1 week then stop". 3. Review of R1's medical record revealed a September 2023 medication administration record (MAR). This MAR stated "Escitalopram 75mg 1/2 tab PO QD" and indicated one half tab was administered at 8am September 19th - 25th and 27th. 4. During a review of R1's medications, Escitalopram 20mg was observed. 5. In an interview, E1 reported Escitalopram 20mg one half tab was administered per the medication order and acknowledged R1's MAR did not include the correct strength of the administered medication.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. Review of R2's medical record revealed no documentation showing the pneumonia vaccination was offered or received. Based on R2's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R2's medical record did not include current documentation showing the pneumonia vaccination was offered or received.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon the onset of the condition and every six months thereafter, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R1's medical record revealed a written determination from R1's medical practitioner signed and dated October 28, 2022. However, documentation was not available stating R1's needs could be met by the facility and R1's needs were within the facility's scope of services, upon the onset of the condition and every six months thereafter. 2. In an interview, E1 reported R1 was unable to ambulate even with assistance for approximately one month and acknowledged R1's medical practitioner did not provide a written determination upon the onset of the condition and every six months thereafter.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "Disaster plan, Relocation, Records, Medication, Food and Water." Documentation was available in the policy and procedure that showed the disaster plan was last reviewed August 3, 2022. 2. In an interview, E1 acknowledged the facility's disaster plan was not reviewed within the last 12 months.

Based on documentation review, record review, and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities as specified in R9-10-113. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility's documentation revealed no policy and procedure that covered TB infection control activities. 2. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of January 12, 2008. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of February 3, 2021. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 4. Review of E3's personnel record revealed E3 worked as an assistant caregiver and had a hire date of September 17, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 5. Review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 6. In an interview, E1 acknowledged the facility had not established, documented, and implemented a TB infection control program as specified in R9-10-113. 7. Technical assistance was provided on this Rule during the compliance inspection conducted November 15, 2022.