Whispering Wind Assisted Living, LLC

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for staff regarding fall prevention and fall recovery that included continued competency training, for two of five personnel sampled. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed a fall prevention and fall recovery training program was available. 2. A review of E1's personnel record revealed continued competency training in fall prevention and fall recovery for August 2022. However, no documentation of continued competency training in fall prevention and fall recovery was available after August 2022. 3. A review of E5's personnel records revealed continued competency training in fall prevention and fall recovery for September 2022. However, no documentation of continued competency training in fall prevention and fall recovery was available after September 2022. 4. In an interview, E2 and E3 acknowledged the facility was not in compliance with A.R.S. \'a7 36-420.01

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented that covered in-service education, for two of five personnel sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Orientation and In-service Training," the policy stated "On or before each year anniversary of starting employment, all employees and volunteers providing assisted living services to a resident will be oriented for at least 12 hours of continuing education. Such training will be documented in the personnel record of the employee or volunteer record." 2. A review of E1's personnel record revealed E1 worked as a caregiver and had a hire date of January 01, 2019. E1's personnel record showed that in July 2022, E1 completed 12 hours of in-service education. However, documentation was not available that showed E1 completed 12 hours of continuing education from January 2023 to January 2024, as required by the facility's policies and procedures. 3. A review of E5's personnel record revealed E5 worked as a caregiver and had a hire date of April 11, 2022. E5's personnel record shows that in February 2023, E5 completed 12 hours of in-service education. However, documentation was not available that showed E5 completed 12 hours of continuing education from April 2023 to April 2024, as required by the facility's policies and procedures. 4. In an interview, E2 and E3 acknowledged E1's and E5's personnel record did not include documentation of completing 12 hours of in-service education annually, as required by the facility's policies and procedures.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. The Compliance Officer requested to review the facility's quality management report and supporting documentation for the report. However, a quality management report was not available for review. 2. In an interview, E2 reported that the facility had not completed the quality management reports and was unable to provide them for review during the inspection

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training, before providing assisted living services, for two of five personnel sampled. 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 the facility's policies and procedures revealed a policy titled "CPR Training," the policy stated "1. All employees and volunteers' staff must be CPR certified before beginning employment at the Facility, and must maintain CPR certification throughout their employment at the Facility. 6. Time frame for renewal will be two (2) years from the date of issue." 2. A review of E1's personnel record revealed E1 worked as a manager. The personnel record revealed a first aid and CPR card with an expiration date of August 28, 2024. There was no other current documentation of first aid and CPR training in E1's personnel record. 3. A review of E2's personnel record revealed E2 worked as a caregiver. The personnel record revealed a first aid and CPR card with an expiration date of August 28, 2024. There was no other current documentation of first aid and CPR training in E2's personnel record. 4. A review of the October 2024 personnel schedule revealed the following: - E1 worked the 7:00PM - 7:00AM shift October 1st to 4th, and 6th to the 11th. - E2 worked the 7:00AM - 7:00PM shift October 1st, 3rd to the 8th, 10th and 11th. 5. In an interview, E2 and E3 acknowledged E1 and E2 did not have current documentation of first aid and CPR training.

Based on documentation review and interview, the manager failed to ensure a pest control program compliant with Arizona Administrative Code (A.A.C.) R3-8-201(C)(4) was implemented and documented. Findings include: 1. A.A.C. R3-8-201(C)(4) states: "4. An individual may not provide pest management services at a...health care institution...unless the individual is a certified applicator in the certification category for which services are being provided." 2. A review of facility documentation failed to reveal evidence of a pest control program compliant with A.A.C. R3-8-201(C)(4). 3. In an interview, E2 reported the facility did not have a pest control program and E1 sprayed for pests in the facility. E2 acknowledged the facility did not utilize a pest control program compliant with A.A.C. R3-8-201(C)(4).

Based on documentation review, observation, and interview, the licensee implemented a modification of the facility, without an approval or amended license issued by the Department. The deficient practice posed a risk as the Department was unable to assess and approve the modification, as the facility did not submit an updated floor plan, and documentation of compliance with local building and zoning codes. Findings include: 1. A review of Department floor plans for AL10998H showed one 7-bedroom house on the property. The Department had no record of the licensee submitting a request for approval for a modification to the physical plant regarding the addition of a guest house to the property. The floor plan did not indicate the new construction. 2. During the environmental tour, the Compliance Officer observed a guest house on the back of the property. 3. In an interview, E2 and E3 reported being unaware approval was required from the Department for a modification to the facility and the construction began December, 2023. E2 and E3 acknowledged modifications were made to the facility, and to the floor plan, without Department approval.

Based on record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution implemented 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, for two of five personnel sampled. Findings include: 1. A review of E1's personnel record revealed documentation of training and education related to recognizing the signs and symptoms of TB dated August 29, 2022. However, no documentation of annual training and education related to recognizing the signs and symptoms of TB was available after August 2022. 2. A review of E2's personnel record revealed documentation of training and education related to recognizing the signs and symptoms of TB dated August 28, 2022. However, no documentation of annual training and education related to recognizing the signs and symptoms of TB was available after August 2022. 3. In an interview, E2 and E3 acknowledged E1's and E2's documentation of annual training and education related to recognizing the signs and symptoms of TB at least once every 12 months was not available for review.