An Enchanted Assisted Living LLC

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for two of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The webpage stated: "The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting." 2. A review of facility documentation revealed a policy and procedure (P&P) titled “Infection Control, Contagious Diseases including COVID (upper respiratory illness) Tuberculosis (TB) Control and Screening.” The P&P stated: “3. For Tuberculosis: f. All individuals employed by the facility or providing volunteer services for the facility will be required to complete Tuberculosis (TB) Training and Education related to recognizing the signs and symptoms of tuberculosis upon higher and annually thereafter.” 3. A review of E1’s and E2’s personnel records revealed E1 was hired as the manager and E2 was hired as a caregiver and assistant manager. The review revealed documentation of training and education related to recognizing the signs and symptoms of TB dated May 7, 2025, after E1 and E2 began providing services at the assisted living facility. 4. A review of facility documentation revealed a personnel schedule which indicated E1 and E2 worked before May 7, 2025. 5. A review of R2’s medical record revealed documentation of assisted living services (ADL) provided to R2 and a medication administration record (MAR), both dated May 2025. The ADL revealed E1 and E2 provided services before May 7, 2025. The MAR revealed E2 administered medication before May 7, 2025. 6. In an interview, when the Compliance Officer asked whether E1 and E2 received the training upon hire and had documentation of such training, E2 stated, “No.” Technical assistance was provided on this rule during the compliance inspection conducted on August 11, 2023.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for one of two sampled employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(3) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459.” 2. A review of E2's personnel record revealed E2 was hired after January 1, 2025. The review revealed a printout from the Adult Protective Services (APS) registry dated May 6, 2025, after E2 was hired. 3. A review of facility documentation revealed a personnel schedule which indicated E2 worked before May 6, 2025. 4. A review of R2’s medical record revealed documentation of assisted living services (ADL) provided to R2 and a medication administration record (MAR), both dated May 2025. The ADL and MAR revealed E2 provided services before May 6, 2025. 5. In an interview, when the Compliance Officer asked whether E2 had any documentation demonstrating a facility representative checked the APS registry for E2 before May 6, 2025, E2 stated, “No.” This is a repeat citation from the compliance inspection conducted on August 11, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the individual provided physical health services, for one of two sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Employees and Volunteer Qualifications.” The P&P stated: “The hiring individual will check and document qualification, skills and knowledge for each employee and volunteer to ensure they meet the criteria and are able to perform the job duties before starting to provide assisted living services to the residents. Documentation of such check is going to be kept in the employees’ records upon hiring (‘Employee Orientation’ and ‘Employee Qualifications and Skills’).” 2. A review of E2's personnel record revealed E2 was hired as a caregiver. The review revealed a document titled “EMPLOYEE QUALIFICATIONS AND SKILLS.” However, the document revealed the manager did not verify E2’s skills and knowledge until May 2, 2025. 3. A review of facility documentation revealed a personnel schedule which indicated E2 worked before May 2, 2025. 4. A review of R2’s medical record revealed documentation of assisted living services (ADL) provided to R2 and a medication administration record (MAR), both dated May 2025. The ADL and MAR revealed E2 provided services before May 2, 2025. 5. In an interview, when the Compliance Officer asked whether E2 had any documentation demonstrating the manager verified E2’s skills and knowledge before E2 began providing services, E2 stated, “No.”

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(iii) 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…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: iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 2. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)." 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 4. A review of E2's personnel record revealed E2 was hired as a caregiver. The review revealed one TST dated as read before E2 began providing services at the facility and one TST dated as read after E2 began providing services at the facility. 5. A review of facility documentation revealed a personnel schedule which indicated E2 worked before the date the second TST was read. 6. A review of R2’s medical record revealed documentation of assisted living services (ADL) provided to R2 and a medication administration record (MAR), both dated May 2025. The ADL and MAR revealed E2 provided services before the date the second TST was read. 7. In an interview, when the Compliance Officer asked whether E2 had any documentation demonstrating E2 had a second negative TST before providing services at the facility, E2 stated, “No.” Technical assistance was pr

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. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. 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." 2. A review of facility documentation revealed a policy and procedure (P&P) titled “Infection Control, Contagious Diseases including COVID (upper respiratory illness) Tuberculosis (TB) Control and Screening.” The P&P stated: “3. For Tuberculosis: a. Before admission or on the day of admission all residents will be required to complete TB screening and a risk assessment.” 3. 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 no documentation assessing risks of prior exposure to infectious tuberculosis and determining if R2 had signs or symptoms of TB. 4. In an interview, E1 and E2 reported not having R2’s assessment and screening. Technical assistance was provided on this rule during the compliance inspection conducted on August 11, 2023.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record for two of two sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. 1. A review of R1's and R2’s medical records revealed current service plans. The service plans stated: “Nails checked daily and trimmed as needed.” The review further revealed documentation of assisted living services (ADLs) provided to R1 and R2 dated January 2026 which included a place to document nail care. However, the ADLs revealed no documentation demonstrating R1 and R2 received nail care, other than January 2, 2026, for R2.. 2. In an interview, E2 reported caregivers checked R1’s and R2’s nails daily. However, E2 reported the facility did not document checking nails. Technical assistance was provided on this rule during the compliance inspection conducted on August 11, 2023.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the strength and dosage of administration, for one of two sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R2’s medical record revealed a medication administration record (MAR) dated January 2026. The MAR revealed documentation demonstrating R2 received “Lisinopril 10mg 1 tab POQD (OR 20mg ½ tab)” and “Metoprolol SUCC. ER 25mg 1 tab POQD” daily. 2. The Compliance Officer observed R2’s medication bottles and R2’s medication organizer. However, the Compliance Officer observed one tablet of lisinopril 20 mg and one half tablet of metoprolol 25 mg (i.e. 12.5 mg) in each of the the “MORN” slots of R2’s medication organizer. 3. In an interview, E2 reported caregivers had been administering 1 tablet of lisinopril 20 mg and one half tablet of metoprolol 12.5 mg and not what was documented on the MAR. E2 reported the strength and dosage for R2’s lisinopril and metoprolol on the January 2026 MAR were incorrect.

Based on documentation review, record review, interview, and observation, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two sampled residents. 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 facility documentation revealed a policy and procedure (P&P) titled “Medications Including Opioids, Narcotics and Schedule 2.” The P&P stated, “All medications or treatments are administered to the Resident only in compliance with the Doctors Order and instructions from a Physician or Medical Practitioner.” The P&P continued, “The Caregiver to administer medication to a Resident is to follow the 6 ‘R’ rule [including] right dose.” 2. A review of R2's medical record revealed a current service plan which indicated R2 received assistance in the self-administration of medication. 3. In an interview, E1 and E2 reported the service plan was incorrect. E1 and E2 reported R2 received medication administration. 4. A review of R2’s medical record revealed medication orders for the following medications: - “ALPRAZOLAM 0.25 MG TABLET…ONE TABLET BY MOUTH DAILTY AT BEDTIME” dated May 23, 2025; - “DC [Discontinue] Lisinopril 20 mg daily” dated July 24, 2025; - “Lisinopril 10 mg; Take one tab by mouth daily” dated July 24, 2025; and - “Metoprolol Succ. 25 mg; Take one tab by mouth daily, Hold for systolic BP less than 100” dated July 24, 2025. The review further revealed a medication administration record (MAR) dated January 2026 and a series of “VITAL STATISTICS FLOWSHEET[S]” dated July 2025 through December 2025. The documents revealed the following: - No documentation demonstrating R2 received R2’s alprazolam in January 2026; - Documentation demonstrating R2 received R2’s lisinopril 10 mg daily in January 2026; - Documentation demonstrating R2 received R2’s metoprolol 25 mg daily in January 2026; and - No documentation demonstrating facility personnel checked R2’s systolic blood pressure since December 15, 2025, before administering R2’s metoprolol. 5. In an interview, E2 reported E2 had an order to discontinue R2’s alprazolam. E2 reported caregivers checked R2’s blood pressure two to three times a week and not daily before administering R2’s metoprolol as ordered. When the Compliance Officer asked when caregivers last checked R2’s blood pressure, E2 reported caregivers last checked R2’s blood pressure on December 15, 2025. 6. A review of R2’s medical record revealed two discontinue orders for R2’s alprazolam. However, one was written on May 19, 2025, before the currently effective order was written, and the other was for a separate “AS NEEDED” order and was not signed by a medical practitioner. 7. The Compliance Officer observed R2’s medication bottles and R2’s medication organizer. However, the Compliance Officer observed the following: - No medication bottles of alprazolam and no alprazolam i

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for three of three employees. 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 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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work... 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, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card..." 2. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of May 1, 2023. The personnel record revealed a fingerprint card issued on June 11, 2021. 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 E1's fitness to work in a residential care institution. 3. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of May 1, 2023. The personnel record revealed a fingerprint card issued on July 15, 2022. 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 E2's fitness to work in a residential care institution. 4. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of May 1, 2023. The personnel record revealed a fingerprint card issued April 7, 2023. However, the record did not contain documentation showing the card was verified with the Department of Public Safety (DPS) . 5. Review of the DPS fingerprint clearance card database on August 11, 2023, revealed E1's, E2's, and E3's fingerprint clearance cards were valid. 6. In an interview, E1 acknowledged documentation was not available showing E1's and E2's work references were obtained and E3's fingerprint card was verified with DPS upon hire.

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 two of three caregivers. The deficient practice posed a risk if the employees were unable to meet resident's needs. Findings include: 1. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of May 1, 2023. The personnel record revealed no documentation showing E1 had received orientation specific to the duties to be performed. 2. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of May 1, 2023. The personnel record revealed no documentation showing E2 had received orientation specific to the duties to be performed. 3. Review of the facility's policy and procedure revealed a policy titled "Orientation and In-Service Training" that stated "New employee orientation is required to be completed by all new employees and volunteers before starting to provide assisted living services to the residents ..." 4. In an interview, E1 acknowledged documentation was not available showing E1 and E2 received orientation specific to the duties to be performed.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 21, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated August 9, 2023. This medication order stated "Senna Plus 8.6mg/50mg PO two times daily PRN". 3. Review of R1's medical record revealed an August 2023 medication administration record (MAR). This MAR stated "Senna Plus 8.6mg/50mg PO two tabs daily as needed" however did not indicate Senna Plus was administered August 1st - present. 4. During an observation of R1's medications, Senna Plus 8.6mg/50mg was observed and one tab was observed prefilled in the "Morn" slot of R1's medication organizer. 5. In an interview, E1 reported one tab of Senna Plus was currently administered daily and acknowledged R1's medical record did not include documentation the medication was administered.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed Lantus, Lorazepam, and ABH 1/25/1 gel unlocked in a box in the kitchen refrigerator. This box had a locking device, however the device was not locked. 2. During an observation, E1 was the only employee at the facility when the Compliance Officer arrived and was not accessing the medications at the time of arrival. 3. In an interview, E1 acknowledged medications were stored unlocked.