Arizona's Golden Heart II

Based on record review and interview, the manager failed to ensure, before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement that included the manager's signature and date signed, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a residency agreement. However, the residency agreement was not signed by a manager. Based on the R1's date of admission, the residency agreement was required to be signed. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A.R.S. § 36-420.04.A.1-9 states, “Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: (...).” 2. A review of R1’s and R2’s medical records revealed no standardized form to provide to emergency responders. 3. In an interview, E2 acknowledged that a standardized form for emergency responders was not completed for R1 and R2. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities, including annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of the facility’s documentation revealed that no risk assessment for infectious tuberculosis (TB) was documented or available at the time of the inspection. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered infection control. The deficient practice posed a risk as the established and documented policies and procedures were not followed. Findings include: 1. The Compliance Officers arrived approximately 10:32 am. E1 answered the door wearing surgical gloves. E1 led the Compliance Officers to the dining room table. E1 walked to the kitchen wearing the surgical gloves while looking for E1’s phone. 2. E2 arrived approximately 10:45 am. 3. During an environmental tour of the facility with E2, the Compliance Officers observed E1 still wearing surgical gloves. 4. A review of the facility’s policies and procedures revealed a policy titled “Gloving.” The policy stated, “Gloving is an important procedure for the prevention of infections. [...] Wear a pair of gloves for no longer than 20-30 minutes. Wash hands after removing gloves according to the “Hand washing” Policy and Procedure.” 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedure manual revealed a review page. However, the page was not signed or dated. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that the assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Upon arrival at the facility, E1 was alone with five residents. 2. During an environmental tour of the facility with E2, the Compliance Officers observed R3 in R3’s bedroom. R3 was sitting on top of the Hoyer lift sling. The Hoyer lift was sitting behind R3 in the room. 3. In an interview, R3 reported that R3 uses the Hoyer lift due to medical reasons. 4. A review of E1’s personnel record revealed a “Caregiver Skills Training Record” dated September 30, 2025. However, the Hoyer Lift was not checked off. 5. In an interview, E2 acknowledged that Hoyer Lift was not checked off. 6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of the four employees sampled. The deficient practice posed a potential TB exposure 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) test is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1's personnel record revealed E1’s hire date of September 27, 2025. In addition, the following was revealed: No documentation of TB risk assessment. No documentation of TB signs and screening. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of two residents reviewed. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed. Findings include: 1. A review of R2's medical record revealed a service plan dated April 12, 2025. The service plan indicated R2 received personal care services. The service plan indicated R2 was independent of Oral Care and Comb Hair, and required moderate assistance with dressing. 2. A review of R2’s medical record revealed Activities of Daily Living documentation. This documentation revealed R2 experienced a change in condition and was “total care” for dressing in the am and pm, oral care, and assistance with hair maintenance. However, a service plan update was not completed. 3. In an interview, E2 acknowledged that R2’s service plan was not updated. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure a medical record was maintained for one of two residents in the facility. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. During an environmental inspection, the Compliance Officers observed R2 lying in bed. E2 reported that R2 had been a resident for a long time. 2. A review of R2’s medical record revealed the following: A Tuberculous (TB) test and screening. All other documentation stated another facility’s name. 3. In an interview, E2 reported that R2 moved into a sister facility before licensing. Once the facility was licensed, R2 moved to the community. E2 reported that E2 transferred R3’s file to the facility without changing the documentation. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.