Winston Park L L C

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. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility documentation did not reveal documentation that the facility developed or administered a training program for all staff regarding fall prevention and fall recovery. 2. Review of E1's and E2's personnel records did not reveal documentation of fall prevention and fall recovery training. 3. In an interview, E1 acknowledged the health care institution had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. Findings include: 1. A.R.S. \'a7 46-454(A) stated "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.110 stated "Immediate" means without delay. 3. Review of facility incident reports revealed a document titled "Report of Suspected Abuse, Neglect, or Exploitation" dated March 4, 2024. This document reported an incident where a CNA providing hospice service at the facility injured R5's fingers and shouted at R5. 4. In an interview, E1 reported an internal investigation was conducted, however the incident was not reported to adult protective services (APS) or the police. E1 acknowledged the suspected abuse was not reported according to A.R.S. \'a7 46-454.

Based on record review and interview, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of two caregivers reviewed. The deficient practice posed a health and safety risk to the residents if the employees were not trained. Findings include: 1. Review of E2's personnel record revealed E2's position was listed as caregiver and had a hire date of Janaury 3, 2024. 2. Review of E2's personnel record revealed no documentation of completing a caregiver training program approved by the NCIA Board. In addition, E2's record did not include documentation showing an administrator's license, a nursing license, or employment as a caregiver prior to November 1, 1998. Therefore, E2 was not qualified to be left alone with the residents based on the lack of caregiver training. 3. In an interview, E1 reported that E2 was a caregiver at the facility, and provided assisted living services to residents without the supervision of a manager or caregiver. E1 reported that E2 had a Certified Nursing Assistant (CNA) license, and thought that was a valid substitute for a caregiver training program approved by the Department or NCIA board. E1 acknowledged that E2 did not provide documentation of completing a caregiver training program approved by the Department or NCIA board.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of four residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R3's (admitted in 2023) medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E1 acknowledged R3 did not provide documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. The deficient practice posed a health and safety risk to the residents if a fire extinguisher was needed and did not work properly. Findings include: 1. During the facility tour with E1, the Compliance Officer observed a rechargeable fire extinguisher. This fire extinguisher had a service tag attached dated February 2023. 2. In an interview, E1 acknowledged the rechargeable fire extinguisher was not serviced at least once every 12 months.

Based on observation and interview, the manager failed to ensure a resident bathroom contained a slip-resistant surface in the shower. Findings include: 1. During the facility tour with E1, the Compliance Officer observed the two resident bathrooms that contained showers. However, the showers did not contain a slip-resistant surface. 2. In an interview, E1 acknowledged the showers did not contain a slip-resistant surface.