Ashbrook Home Care LLC

Based on record review and interview, the manager failed to ensure that there was a document for Emergency responders that met the requirements for A.R.S. 36-420.04.A.1-9. Findings include: 1. A review of R1's medical records revealed a form used for Emergency responders, however, the form did not contain an area for the reason the emergency responder was notified, the name and address for the pharmacy, or the facility information. 2. In an interview, E2 acknowledged that the form used for Emergency responders did not have all the required information per A.R.S. 36-420.04.A.1-9.

Based on record review, document review, and interview, the manager failed to ensure that the health care institution provided training and education, annually, related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution and annually assessing the health care institution's risk for exposure to infectious tuberculosis. Findings include: 1. A review of E1's, E2's and E3's employee records revealed No documentation related to annual training for the signs and symptoms or tuberculosis, at the time of the inspection. 2. A review of facility documents revealed No documentation for the annual assessment of the facility's risk for exposure to infectious tuberculosis, at the time of the inspection. 3. In an interview E1 and E2 acknowledged that the manager failed to ensure there was training for signs and symptoms of tuberculosis for staff or volunteers and there was not an annual facility assessment to identify the facility's risk of exposure to infectious tuberculosis.

Based on record review and interview, the manager failed to ensure compliance with A.R.S. 36-411. Findings include: 1 . A review of E1's, E2's and E3's employee records revealed no APS check for E1, E2 or E3. 2 . In an interview, E2 acknowledged that the manager failed to ensure compliance with A.R.S. 36-411.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was documented in the resident's medical record. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. The Compliance Officer arrived at the facility at 10:43 AM. 2 . A review of R1's medication administration record (MAR) revealed that the following medications were not signed off as administered for June 26, 2025, for the morning medications: Boost 1 1/2 carton Three times a day (TID) Acetaminophen 325 milligrams (mg) 2 tablets (tabs) TID Quetiapine 25 mg 1 tab Twice a Day (BID) Sertraline 50 mg 1 tab daily Duloxetine 30 mg 1 tab daily Senna 50 mg 1 tab BID 3 . In an interview, E2 acknowledged that E2 had not signed off the medications for June 26, 2025, however E2 reported that medications were passed.

Based on observation and interview, the manager failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months and had a tag attached to the fire extinguisher that specified the date of the last servicing and the identification of the person who serviced the fire extinguisher. Findings include: 1 . During the facility tour, the Compliance Officer observed a fire extinguisher, however the tag read August 2022/2023 as the last inspection date. 2 . In an interview, E2 acknowledged that the fire extinguisher had not been serviced in the last 12 months.

Based on observation and interview the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed a broken window in a resident room. 2. In an interview, E2 acknowledged that 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.

Based on observation and interview the manager failed to ensure that oxygen container were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During a tour of the facility, the Compliance Officer observed two oxygen tanks, in a resident's room that were not secured in a upright position. 2. In an interview, E2 acknowledged that the manager failed to ensure that oxygen tanks were secured in an upright position. This is a repeat citation from the onsite compliance inspection conducted on July 27, 2023.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation in compliance with R9-10-806(C)(1)(a-c.i-iii), for one of two volunteers sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of E3's personnel record revealed the following documentation: -Current cardiopulmonary resuscitation training and first aid training; and -Current documentation of freedom from infectious tuberculosis. However, documentation of compliance with R9-10-806.C.1.a.b.c.ix. was not provided for review. 2. In an interview, E2 reported E3's personnel record was located at another facility. E2 acknowledged documentation of E3's compliance with R9-10-806.C.1.a.b.c.ix. was not provided for review.

Based on observation and interview, the manager failed to ensure a current drug reference guide was available for use by personnel members. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed the facility's drug reference guide was "Nursing 2020 DRUG HANDBOOK." 2. An Internet search revealed the current version of this drug reference guide was "Nursing 2024 DRUG HANDBOOK." 3. In an interview, E2 acknowledged the facility's drug reference guide was not current.

Based on observation and interview, the manager failed to ensure a current toxicology reference guide was available for use by personnel members. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department. request. Findings include: 1. The Compliance Officer observed a posting on the wall stated "TOXICOLOGY http://toxnet.nlm.nih.gov." 2. A review of the http://toxnet.nlm.nih.gov revealed the website was no longer valid. 3. In an interview, E2 reported to be unaware the above mentioned toxicology reference website was no longer valid. E2 acknowledged a current toxicology reference guide was not available for review.

Based on record review, documentation review, and interview, the manager failed to ensure documentation required by Article 8 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. A review of E1's personnel record revealed documentation of cardiopulmonary resusitation (CPR) and first aid training from "EMS Safety," issued December 28, 2020 and with an expiration date of December 28, 2022. However, current documentation of CPR and first aid training was not available for review. 2. The Compliance Officer requested to review E5's personnel record to include documentation of CPR and first aid training. However, the requested documentation was not provided. 3. A review of E3's personnel record revealed the following documentation: -Current cardiopulmonary resuscitation training and first aid training; and -Current documentation of freedom from infectious tuberculosis. However, documentation of compliance with R9-10-806.C.1.a.b.c.ix. was not provided for review. 4. The Compliance Officer requested to review E5's personnel record. However, a personnel record was not provided for review. 5. A review of R3's medical record revealed a service plan dated in November 2022 for personal care services. However, the service plan was not signed and dated by R3 and the manager. 6. A review of R1's medical record revealed a document (dated April 2023) titled "ACTIVITIES OF DAILY LIVING FLOWSHEET." The document revealed "Complete Bath 2 x week/PRN" was provided on the following dates: -April 1, 2023; -April 9, 2023; -April 15, 2023; However, documentation to reveal R1 received a complete bath 2 times a week was not available for review. 7. A review of R2's medical record revealed a document titled, "DETERMINATION FOR ADMISSION." However, the documentation did not include the level of care R2 was expected to receive and whether R2 required continuous medical services, intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 8. A review of R2's medical record revealed a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10) was not available for review. 9. A review of R2's medication administration record (MAR) dated April 2023 revealed R2 received medication administration of the following medication on April 1-30, 2023: -Glipizide ER 10mg tab; -Tamsulosin HCL 0.4mg cap; -Pravastatin Sodium 80mg tab; -Allopurinol 100mg tab; -Losartan Potassium 50mg tab; -Amiodarone 200mg tab; -Isosorbide MN 20mg tab; -Trazadone 50mg tab; and -Ketoconazole 2% shampoo. However, medication orders for the above mentioned medications were not available for review. 10. The Compliance Officer observed the facility's drug reference guide was "Nursing 2020 DRUG HANDBOO

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training and first aid training, for one of two caregivers sampled and one of two volunteers sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of E1's (hired in 2020) personnel record revealed documentation of CPR and first aid training from "EMS Safety", issued December 28, 2020 and with an expiration date of December 28, 2022. However, current documentation of CPR and first aid training was not available for review. 2. In an interview, E1 reported E1 had not renewed E1's CPR and first aid training. 3. The Compliance Officer requested to review E5's personnel record to include documentation of CPR and first aid training. However, the requested documentation was not provided. 4. In an interview, E2 reported E1 renewed E1's CPR and first aid training, however the requested documentation was not provided for review. E2 acknowledged E1's and E5's CPR training was not available for review.

Based on observation and interview, the manager failed to ensure a personnel record for an employee or volunteer was maintained throughout the individual's period of providing services in or for the assisted living facility, for one of two volunteers sampled. The deficient practice posed a risk as required information could not be verified for E5, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed E1 and E5 working on the premises upon arrival at 11 AM. 2. The Compliance Officer observed E5 cleaning the facility and providing services to a resident. 3. In an interview, E1 stated E5 came to the facility as a "reliever" (May 3, 2023). 4. The Compliance Officer requested to review E5's personnel record. However, a personnel record was not provided for review. 5. In an interview, E2 stated E5 was hired as a "volunteer" and acknowledged a personnel record was not maintained throughout the E5's period of providing services.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative and the manager, when initially developed for one of two residents sampled who received personnel care services. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R3's medical record revealed a service plan dated in November 2022. However, the service plan was not signed and dated by R3 and the manager. 2. In an interview, E2 acknowledged the service plan for R3 had not been signed and dated by R3 and the manager.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of three residents sampled. The deficient practice posed a risk as a resident did not receive the expected service, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed a current service plan for directed care services dated in March 2023. The plan revealed R1 was to receive the following service: -"Complete Bath 2 X week/PRN" 2. A review of R1's medical record revealed a document (dated April 2023) titled "ACTIVITIES OF DAILY LIVING FLOWSHEET." The document revealed the above mentioned service indicated on R1's service plan was provided on the following dates: -April 1, 2023; -April 9, 2023; -April 15, 2023; However, documentation to reveal R1 received a complete bath 2 times a week was not available for review. 3. In an interview, E2 acknowledged R1 had not received the assisted living service documented in R1's service plan.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's needs required in R9-10-807(B), for one of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R2's medical record revealed a document titled, "DETERMINATION FOR ADMISSION." However, the documentation did not include the level of care R2 was expected to receive and whether R2 required continuous medical services, intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 2. In an interview, E2 reported E2 gave a copy of the document to R2's doctor to fill out and had not received the document from R2's doctor. E2 acknowledged R2's medical records did not contain the required documentation. This is a repeat deficiency from the onsite compliance inspection conducted on May 26, 2022.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's signed residency agreement and any amendments, for one of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R2's medical record revealed a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10) was not available for review. 2. In an interview, E2 reported R2's residency agreements was completed, however, the agreement was not at the assisted living facility. E2 acknowledged R2's medical record did not contain a signed residency agreement.

Based on observation, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of three residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed the following medication bottles belonging to R2: -Glipizide ER 10mg tab; -Ketoconazole 2% shampoo; -Amiodarone 200mg tab; -Tamsulosin HCL 0.4mg cap; -Isosorbide MN 20mg tab; -Allopurinol 100mg tab; -Pravastatin Sodium 80mg tab; -Losartan Potassium 50mg tab; and -Trazadone 50mg tab. 2. A review of R2's medication administration record (MAR) dated April 2023 revealed R2 received medication administration of the following medication on April 1-30, 2023: -Glipizide ER 10mg tab; -Tamsulosin HCL 0.4mg cap; -Pravastatin Sodium 80mg tab; -Allopurinol 100mg tab; -Losartan Potassium 50mg tab; -Amiodarone 200mg tab; -Isosorbide MN 20mg tab; -Trazadone 50mg tab; and -Ketoconazole 2% shampoo. However, medication orders for the above mentioned medications were not available for review. 3. In an interview, E2 reported E2 was having issues retrieving R2's medication orders from R2's prescribing doctor. E2 acknowledged R2 received medication administration without medication orders.

Based on observation and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed a posting on the wall of a disaster plan, dated May 15, 2020. 2. The Compliance Officer requested to review the facility's annual disaster plan review. However, the facility's annual disaster plan review was not provided for review. 3. In an interview, E2 reported the disaster plan was reviewed at least once every 12 months, however, E2 reported the requested documentation was not located at the facility. This is a repeat deficiency from the onsite compliance inspection conducted on May 26, 2022.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement a disaster plan, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of Department documentation revealed the facility's perpetual license was effective on June 11, 2020. 2. A review of facility documentation revealed a staffing schedule, dated May 2023. The schedule revealed the facility maintained two shifts, 7 AM-7 PM and 7 PM-7 AM. 3. A review of facility documentation revealed disaster drills were completed on the following dates and times: -January 4, 2022 at 10AM; and -June 15, 2022 at 10AM. However, additional documentation of disaster drills for employees conducted on each shift at least once every three months was not available for review. 4. In an interview, E2 reported disaster drills for employees were completed on each shift at least once every three months, however, E2 reported the requested documentation was not available at the facility. Technical assistance was provided on this Rule during the onsite compliance inspection conducted on May 26, 2022.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement a disaster plan, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of Department documentation revealed the facility's perpetual license was effective on June 11, 2020. 2. A review of facility documentation revealed an evacuation drill for employees and residents was completed on June 15, 2022 at 10 AM. However, additional documentation of evacuation drills for employees and residents conducted at least once every six months was not available for review. 3. In an interview, E2 reported evacuation drills for employees and residents were conducted at least once every six months, however, E2 reported the requested documentation was not available at the facility.

Based on observation and interview, the manager failed to ensure oxygen containers were secured. The deficient practice posed a potential explosion or leak of a compressed gas, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. The Compliance Officer observed one oxygen container stored upright, but unsecured, in R2's bedroom. 2. In an interview, E2 acknowledged there was an unsecured oxygen container in R2's bedroom.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a health and safety risk to residents, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. The Compliance Officer observed five ambulatory residents on the premises. 2. The Compliance Officer observed the following poisonous or toxic materials in the unlocked laundry room: -Clorox Cleaner + Bleach; -Lysol Power Bathroom Foamer; -Windex; -Two bottles of Lysol Power Cleaning Gel; -Pine-Sol; -Fabuloso; and -Clorox Bleach. 3. In an interview, E2 acknowledged the poisonous or toxic materials were left unlocked and were accessible to residents.