Adora Assisted Living LLC

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for one of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 2. A review of E2's personnel record revealed E2 completed training on recognizing the signs and symptoms of TB on June 23, 2024. However, based on E2's date of hire, documentation of annual training was required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two personnel sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states, "Each residential care institution, nursing care institution and home health agency 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, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card." 2. A review of E2's personnel record revealed documentation of the facility's good faith efforts to contact E2's previous employers in 2020. However, based on E2's date of hire, these efforts were not current to E2's date of hire at the facility. 3. A review of the E2's personnel record revealed documentation of a valid fingerprint clearance card (FPCC). However, the status of E2's FPCC was verified in 2023. However, based on E2's date of hire, these efforts were not current to E2's date of hire at the facility. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two personnel sampled. The deficient practice posed a potential illness 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. 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 two negative TB skin tests that were more than 12 months old; however, no additional documentation of freedom from infectious TB was available for review. Based on E2’s date of hire, this documentation was required. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a caregiver provided a resident with the assisted living services in the resident’s service plan, for one of two residents sampled. The deficient practice posed a risk as the service plan to direct services was not followed. Findings include: 1. A review of R2's service plan, dated November 9, 2025, revealed that R2 required a partial bath five times a week. 2. A review of R2's activities of daily living documentation for January 2026 revealed R2 received a partial bath on the following days: January 2, 2026; January 7, 2026; and January 9, 2026. However, partial baths were not provided to R2 five times a week, as required. 3. In an interview, E3 reported R2 received a partial bath as needed, rather than five times a week. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that a resident’s medical record contained documentation of medication administered to the resident that included the date and time of administration, for two of two residents sampled. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. A review of R1’s medical record revealed a signed medication list, dated December 17, 2025, which included the following medications: Apixaban 5 milligram (mg), 1 tablet by mouth (po) every 12 hours; Carvedilol 12.5 mg, 1 tablet po twice a day (bid); and Losartan 50 mg, 1 tablet po bid. 2. A review of R1's medication administration record (MAR) for January 2026 indicated R1 was administered the aforementioned medications at 5:00 PM, January 1, 2026 - present. 3. The Compliance Officers observed the following medications prefilled in R1's medication organizer in the 8:00 PM slot: Apixaban 5 mg; Carvedilol 12.5 mg; and Losartan 50 mg. 4. In an interview, E3 reported the aforementioned medications were given at 8:00 PM, rather than 5:00 PM, as documented. 5. A review of R2's medical record revealed a signed medication order, dated December 29, 2025, which included Risperidone 1 mg, 1 tablet po three times a day (tid). 6. A review of R2's MAR for January 2026 indicated R2 was administered Risperidone 1 mg, at 8:00 AM, 12:00 PM, and 5:00 PM, January 1, 2026 - present. 7. The Compliance Officers observed Risperidone 1 mg prefilled in R2's medication organizer in the 2:00 PM slot. 8. In an interview, E3 reported R2 was administered Risperidone 1 mg at 2:00 PM, rather than 12:00 PM, as documented. 9. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a signed medication list, dated December 17, 2025, which included the following medications: Trazodone 50 milligrams (mg), 0.5 tablet by mouth (po) at bedtime (qhs); and Docusate Sodium 100 mg, 2 capsules po twice a day (bid) as needed (prn). 2. A review of R1's medication administration record (MAR) for January 2026 revealed R1 was administered Trazodone 50 mg, 0.5 tablet po qhs, January 1, 2026 - present. 3. The Compliance Officers observed 1 tablet of Trazodone 50 mg prefilled in R1's medication organizer in the 8:00 PM slot. 4. In an interview, E3 reported R1 was administered 1 tablet of Trazodone 50 mg, rather than 0.5 tablet, as ordered. 5. A review of R1's MAR for January 2026 revealed R1 was administered Docusate Sodium 100 mg, 1 capsule po bid prn on January 1, 2026, at 8:00 AM. However, documentation of additional administrations was not available for review. 6. The Compliance Officers observed 1 tablet of Docusate Sodium 100 mg prefilled in R1's medication organizer in the 8:00 PM slot. 7. In an interview, E3 reported Docusate Sodium 100 mg was administered as scheduled at 8:00 PM rather than prn, as ordered. 8. A review of R2's medical record revealed a signed medication list, dated December 29, 2025, which included the following medications: Trazodone 100 mg, 1 tablet po qhs prn; and Senna 8.6 mg, 2 tablets po twice a day (bid). 9. A review of R2's MAR for January 2026 revealed R2 was administered Trazodone 100 mg, 1 tablet po qhs at 8:00 PM, January 1, 2026 - present. 10. In an interview, E3 reported R2 was administered Trazodone 100 mg schedule at 8:00 PM, rather than prn, as ordered. 11. A review of R2's MAR for January 2026 revealed R2 was administered Senna 8.6 mg, 2 tablets po at 8:00 AM and 8:00 PM, January 1, 2026 - present. 12. The Compliance Officers did not observe Senna 8.6 mg 2 tablets prefilled in R2's medication organizer. 13. In an interview, E3 reported R2 was administered Senna 8.6 mg prn, rather than scheduled bid, as ordered. 14. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

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 risk to the physical health and safety of the residents. Findings include: 1. During an environmental inspection, the Compliance Officers observed a fire extinguisher mounted in the kitchen with a service tag dated 2024. 2. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of the residents. Findings include: 1. During an environmental inspection, the Compliance Officers observed a tall floor lamp plugged into an electrical outlet and placed inside the far end of a resident’s shower area. 2. A review of the facility’s policies and procedures revealed a policy titled, “38. Environmental Safety, “ which stated, “Policy Statements: R9-10-719 states: A. A manager shall ensure that: 1. The premises and equipment are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury.” Additionally, “Procedures: B. A manager shall ensure that: b. All employees will constantly be watchful of any condition or situation that may cause a resident or other individual to suffer physical injury and report such a condition to the manager or correct the issue themselves.” 3. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, interview, and documentation review, the manager failed to ensure a resident’s sleeping area was not used as a passageway to a common area, another sleeping area, or common bathroom. The deficient practice posed a potential privacy rights violation to the resident. Findings include: 1. During an environmental inspection, the Compliance Officers observed a caregiver's room inside the walk-in closet area of a resident’s private room. The caregiver room could only be accessed through the resident’s room and bathroom. The room was equipped with a mattress, pillows, and bedding, as well as personal items. 2. During an interview, E2 reported the caregivers used the caregiver room to take naps. 3. A review of Department records revealed the facility was not licensed before October 1, 2013. 4. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, interview, and documentation review, a person maintained a health care institution and provided services outside the scope of what was allowed in an Assisted Living facility. A resident who required tracheostomy care/services was accepted at the facility without the facility having Hospice or Home Health services involved, which is prohibited, and is declared a nuisance inimical to the public health and safety, per A.R.S. \'a7 36-430. Findings include: 1. In observation, the Compliance Officer observed R1 at the facility had a tracheostomy, and tracheostomy care and services were provided by the caregivers. R1 also received tube feeding, was confined to a bed or chair and unable to walk, and had a Foley catheter. 2. During an interview, E1 reported [E1] was a Registered Nurse and E1 and the caregivers provided tracheostomy services for the resident. 3. In documentation review, the facility's policies and procedures included a "Scope of Practice of Assisted Living Facility," which documented, "Our facility is a licensed/certified to provide the following which defines our "Scope of Practice... (Check all that apply)..." No categories on the document were checked, and the Scope of Practice did not indicate the facility's scope of services. 4. During an interview, the findings were reviewed with E1, who acknowledged the facility accepted a resident who required services outside the scope of what was allowed in an assisted living facility, and did not have Hospice or Home Health services involved, which was prohibited.

Based on observation, record review, and interview, for one of one caregiver reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services according to policies and procedures. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents. Findings include: 1. On arrival, the Compliance Officer (CO) observed E2 was completing an employment application at the kitchen table. 2. In observation, the CO observed R1 in bed, and had a tracheostomy, received tube feeding, was confined to a bed or chair and unable to walk, and had a Foley catheter. 3. During an interview, E2 reported E2 worked alone at the facility (as the only caregiver) for a period of time on September 4, 2024, when E1 was not at the facility. E1 reported two Home Health workers were at the facility with E2. The Home Health workers reported they were at the facility to provide education for the staff and not assigned to provide services for R1. 4. In record review, E2's personnel record (hired as a caregiver on September 1, 2024), did not include documentation E2's skills and knowledge were verified and documented. 5. During an interview, E1 acknowledged that before providing services a manager was required to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services for residents and acknowledged this was not completed, as required

Based on observation, interview, and record review, for one of one caregiver reviewed, the manager failed to ensure a caregiver received orientation specific to the duties to be performed by the caregiver. The deficient practice posed a health and safety risk to residents if a caregiver was not oriented, as required. Findings include: 1. On arrival, the Compliance Officer (CO) observed E2 was completing an employment application at the kitchen table. 2. In observation, the CO observed R1 in bed, with a tracheostomy, received tube feeding, was confined to a bed or chair and unable to walk, and had a Foley catheter. 3. During an interview, E2 reported E2 worked alone at the facility (as the only caregiver) for a period of time on September 4, 2024, when E1 was not at the facility. E1 reported two Home Health workers were at the facility with E2. The Home Health workers reported they were at the facility to provide education for the staff and not assigned to provide services for R1. 4. In record review, E2's personnel record (hired as a caregiver on September 1, 2024), did not include documentation E2 received orientation. 5. During an interview, E1 acknowledged that before providing services, a manager was required to ensure a caregiver received orientation specific to the duties to be performed by the caregiver, and acknowledged this was not completed, as required