Abuelos at Edgewood Place

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled residents. R9-10-113(A)(2)(a)(i-ii) 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…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 [and] ii. Determining if the individual has signs or symptoms of tuberculosis.” Findings include: 1. A review of R2's medical record revealed R2 was admitted to the facility more than seven days before the date of the inspection. However, the review revealed documentation of baseline screening to include assessing risks of prior exposure to infectious tuberculosis and determining if R2 had signs or symptoms of TB was not available for review. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's complete medical record was maintained according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of two sampled residents. Findings include: 1. During the on-site inspection, the Compliance Officer requested to review R1, a former resident's, complete medical record. However, R1's completed service plan, current at the time of R1's discharge, was not provided for review. A portion of the requested service plan was provided, however, the provided service plan was incomplete. 2. In an interview, E1 reported R1's complete medical record had been placed in several manilla folders and stored at the time of R1's discharge, however, E1 acknowledged the completed, current service plan which had been in place at the time of R1's discharge had not been located or provided during the on-site inspection. 3. In an interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's medical record contained an accurate medication order for each medication that was administered to a resident, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a list of medication orders, signed by a medical practitioner and dated October 14, 2025. This list included the following order: "Senna 8.6mg, PO BID Constipation." 2. A review of R2's medical record revealed a list of medication orders, signed by a medical practitioner and dated September 24, 2025. This list included the following order: "Senna Lax 8.6 Mg Tablet Oral, 8.6 mg, Every 2 hours as needed- take only as needed, Constipation, Take 1 tab (8.6 mg) by mouth twice daily as needed for constipation. May increase up to 12 tabs in a 24 hours period." 3. A review of R2's medical record revealed a Medication Administration Record (MAR) dated October 2025. The MAR indicated Senna had not been administered to R2 during the month of October 2025. The MAR did not document the switch from "as needed" Senna to "scheduled" Senna on October 14, 2025. 4. In an interview with E1, E1 reported they had not noticed the error in the October 14, 2025 medication order recapitulation for R2. E1 reported they would immediately contact R2's medical practitioner to obtain a corrected order showing Senna was to be administered only as needed. 5. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to designate, in writing, a caregiver who was present on the facility's premises and accountable for the facility when the manager was not present. Findings include: 1. A documentation review of the facility work schedule revealed E3 had worked alone at the facility during the month of September 2024. 2. A documentation review of the facility's written designations revealed E3 was not designated to be accountable for the facility when the manager was not present. 3. In an interview, E1 acknowledged E3 had not been designated to be accountable for the facility when the manager was not present.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(G), for one of two employees sampled. A.R.S. \'a7 36-411(G) 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.." Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Upon Employment," which stated, "Volunteers who are unsupervised with residents, and all caregiver, assistant caregivers, manager or anyone who is unsupervised with residents must maintain fingerprint clearance in accordance with ARS 36-411.A-J. If employee's fingerprints were more than two years old at time of hire then employee must renew them 30 days prior to their expiration. Fingerprints will be verified online and the verification will be placed in the employee file." 2. The Compliance Officer observed E2 working in the facility as a caregiver during the on-site inspection. 3. A review of E2's personnel record revealed E2 had been hired as a caregiver in February of 2024. 4. A review of E2's personnel record revealed E2 had an expired fingerprint clearance card issued on October 2, 2018, with a marked expiration of October 2, 2024. 5. Online verification of E2's fingerprint clearance card status revealed a pending application for a fingerprint clearance card, submitted to the Department of Public Safety on September 19, 2024. 6. In an interview, E1 acknowledged E2 did not have a valid fingerprint clearance card at the time of the on-site inspection.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training for applicable employees to include the method and content of cardiopulmonary resuscitation training, to include a demonstration of the employee's ability to perform cardiopulmonary resuscitation, to include the qualifications for an individual to provide CPR training, and to include the time frame for renewal of CPR training, for one of two caregivers sampled. The deficient practice posed a risk if the 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, "Upon Employment (803.C.1.b/806.C.1.c.iii/803.C.1.d-e/)," which stated, "5) Employee must maintain current CPR and First Aid certification that must be obtained within 30 days of expirations. a) CPR training must meet either American Heart Association, American Red Cross, or National Safety Council and include hands on demonstration and be taught by an instructor who's been certified by previous mentioned organizations." 2. A review of E2's personnel record revealed E2 had been hired in February of 2024 as a caregiver. 3. A review of E2's personnel record revealed a CPR and First Aid training certification card from "NationalCPRFoundation," an online only provider for which the training had not included a hands on demonstration of E2's ability to perform CPR and for which the instructor's credentials had not been verified to have been issued by American Heart Association, American Red Cross, or National Safety Council. 4. In an interview, E1 acknowledged the manager failed to implement the facility's CPR training policy and acknowledged E2's CPR training had not included a demonstration of E2's ability to perform CPR.

Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one 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: 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 HCWs (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 E2's personnel record revealed E2 had been hired as a caregiver in February of 2024. E2's personnel record included a two-step skin test. However, E2's personnel record did not include a baseline screening questionnaire. 4. In an interview, E1 acknowledged the personnel file provided for E2 had not included documentation of evidence of freedom from infectious TB as required by R9-10-113.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the 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 physician, registered nurse practitioner, registered nurse, or physician assistant for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a physician's determination for admission for R1 was not available for review. 2. In an interview, E1 acknowledged R1's initial admission determination had not been provided for review.

Based on record review, documentation review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for two of two residents sampled who received directed care services. Findings include: 1. A review of R1's medical record revealed a service plan, updated June 11, 2024, for directed care services. However, the service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. A review of R2's medical record revealed a service plan, updated July 9, 2024, for directed care services. However, the service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 3. In an interview, E1 acknowledged R1's and R2's service plans did not include each resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed a fire extinguisher mounted in the dining area. The fire extinguisher had inspection tag dated July 2023, more than one year prior to the on-site inspection. 2. In an interview, E1 acknowledged the fire extinguisher service tag indicated the fire extinguisher had not been serviced at least once every 12 months.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Fall prevention," and a policy titled, "Fall Assessment." However, the policies did not include fall recovery procedures, and did not state the timing and frequency with which staff would receive the training, or how the training would be documented. 2. A review of E2's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 3. A review of E3's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 4. In an interview, E1 and E2 acknowledged the facility's policy did not include fall recovery procedures and E2's and E3's personnel records did not include documentation of completion of fall prevention and fall recovery training.

Based on record review, documentation review, observation, and interview, the manager failed to ensure for one of two personnel members sampled, before providing assisted living services to a resident, a caregiver provided current documentation of first aid training certification. Findings include: 1. A review of E2's personnel record revealed E2 was hired as a caregiver in June of 2021. 2. A review of the facility work schedule revealed E2 worked on the 7 a.m. to 7 p.m. shift on July 10, July 11, July 14, July 15, July 21, July 22, July 28, and July 29, 2023. 3. The Compliance Officer observed E2 was working at the facility during the on-site inspection. 4. A review of E2's personnel file revealed First Aid training certification was not available for review. 5. In an interview, E2 reported E2 had taken a "combo" cardio-pulmonary resuscitation (CPR) and first aid training course, but had not realized the certification issued to E2 by the school included only CPR training. E2 attempted to contact the school but was only able to leave a message. E2 described the training had included instruction on using an Epi-pen and had included the first aid component, however, E2 was not able to provide documentation of first aid training certification during the on-site inspection. 6. In an interview, E1 and E2 acknowledged E2's personnel file did not contain documentation of current first aid training certification.

Based on documentation review, observation, and interview, the manager failed to ensure, for 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, the means of exiting controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A documentation review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed a side door in the officer area adjacent to the dining room. The side door was not equipped with a door alarm, and did not require a key or code to open. The side door opened to a fenced cement patio with gates leading into the backyard of the facility. 3. In an interview, E1 and E2 acknowledged there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort which did not control or alert employees of the egress of the resident.