Ashlee Care

Based on record review and interview, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder (EMS). The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of the facility’s documentation revealed Report of Unusual Occurrence. The following was revealed: On September 24, 2025, at 11:40 am, “R2 was reaching into laundry basket and fell out of wheelchair. Called 911. Ambulance to R2 to Banner.” On January 26, 2024, at 7:16 am, “R4 fell in living room. R4 said his knee hurts. Call 911.” 2. A review of the facility’s documentation revealed a document titled “Report of Unusual Occurrence.” The documentation revealed the following: No copies of the packet were given to Emergency Services (EMS) for the incident on September 24, 2025, for R2. No copies of the packet were given to Emergency Services (EMS) for the incident on January 26, 2024, for R4. 3. In an interview, E1 and E2 acknowledged that R2 and R4 did not have an EMS packet. 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 of an assisted living home failed to maintain a standardized form for each resident to be provided at the time an emergency responder is contacted. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R1’s, R2’s, R3’s, and R4’s medical records revealed no standardized form to be provided at the time an emergency responder is contacted. 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 health care institution 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 risk. Findings include: 1. A review of the facility’s documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis. 2. In an interview, E1 acknowledged that the annual assessment of the facility's TB risk assessment was not completed. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 4. Technical assistance was provided on this Rule during the inspection conducted on June 2, 2022.

Based on record review, documentation review, and interview, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered, and the effect of the opioid administered, for one of four residents receiving an opioid. Findings include: 1. A review of R3's medical record revealed a current service plan for personal care services. R3's service plan revealed that R3 received medication administration. 2. A review of R3's medical record revealed a medication order (dated October 13, 2025). The medication order stated, "Tramadol 50 mg take one tablet by mouth TID." 3. A review of R3's medical record revealed a medication administration record (MAR) for October 2025. “Tramadol HCL 50 mg one tablet by mouth TID” was documented as administered every day in October 2025. However, documentation of the identification of R3's need for the opioid before the opioid was administered, and the effect of the opioid administered, was not available. 4. A review of R3's medical record revealed a medication administration record (MAR) for November 2025. “Tramadol HCL 50 mg one tablet by mouth TID” was documented as administered on November 1, 2025, to November 3, 2025. However, documentation of the identification of R3's need for the opioid before the opioid was administered, and the effect of the opioid administered, was not available. 5. A review of R3's medical record revealed no documentation of an end-of-life condition or an active malignancy. 6. In an interview, E2 acknowledged that there was no documentation of the need for the opioid before the opioid was administered, and the effect of the opioid administered. 7. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, observation, 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 three of the three 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. The Compliance Officer observed E2 and E3 providing services to the resident during the inspection. 4. A review of the facility’s scheduled work hours revealed the following: E2 was listed to work every day in September, October, and November. E3 was listed to work Monday to Friday in September, October, and November. 5. A review of E2's personnel record revealed E2’s hire date of February 1, 2024. In addition, the following was revealed: No documentation of TB risk assessment. An “Tuberculosis Symptom Screen Annual Questionnaire” dated February 6, 2025. 6. A review of E3's personnel record revealed E3’s hire date of April 25, 2025. In addition, the following was revealed: No documentation of TB risk assessment. An “Tuberculosis Symptom Screen Annual Questionnaire” dated April 8, 2025. 7. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 8. Technical assistance was provided on this Rule during the inspection conducted on June 2, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure that 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 R9-10-113, for one of four residents sampled. The deficient practice posed a 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. A review of R1's medical record revealed no documentation of an assessment of the resident's risk of exposure to infectious TB and signs and symptoms of infectious TB. Based on the acceptance date, this documentation was required. 3. A review of the facility's policies and procedures revealed a policy titled “Tuberculosis (TB) Testing.” The policy stated, “ The TB test/screening must be BOTH administered AND read prior to the individual being accepted as a resident or as [...]. TB test/screening can be administered up to 7 days after administration.” 4. In an interview, E1 acknowledged that R1 did not have documentation of an assessment of the residents' risk of exposure to infectious TB and signs and symptoms of infectious TB. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 6. Technical assistance was provided on this Rule during the inspection conducted on June 2, 2022.

Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of a medication administered to a resident that included the date and time of administration; the name, strength, dosage, and route of administration; the name and signature of the individual administering the medication; and an unexpected reaction a resident had to the medication, for two of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed a current written service plan dated June 10, 2025. This service plan indicated R1 received medication administration. 2. A review of R1's medical record revealed medication orders signed and dated by a medical practitioner on June 10, 2025, for the following: “Famotidine 40 mg 1 Tab PO BID.” 3. A review of R1’s October and November 2025 medication administration records (MARs) revealed “Famotidine 40 mg 1 Tab PO BID” was not listed. 4. The Compliance Officers observed the following medication bottles: “Famotidine 40 mg.” 5. In an interview, E2 acknowledged that the MAR was missing “Famotidine 40 mg 1 Tab PO BID.” In addition, E2 reported that R1 received the “Famotidine 40 mg.” 6. 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 that when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for three of four residents. The deficient practice posed a health and safety risk. Findings include: 1. A review of the facility’s documentation revealed a document titled “Report of Unusual Occurrence.” The documentation revealed the following: On September 24, 2025, R2 had an incident in which emergency services were called. On January 26, 2024, R4 had an incident in which emergency services were called. Documentation was not available showing any action taken to prevent the incident from occurring in the future 2. In an interview, E1 acknowledged that the documentation was missing any action taken to prevent the incident from occurring in the future. 3. 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 the facility's policy and procedure and a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807.G.2, for two of two residents accepted by the assisted living home. Findings include: 1. A review of Department documentation revealed the facility was licensed as an assisted living facility. 2. A review of R1's and R2's medical record revealed a residency agreement. The respective residency agreements stated the manager may terminate the agreement with 14 days notice "b. Under any conditions in subsection (C)* (A.R.S. 36-401(C)); or ..." 3. Arizona Revised Statute (A.R.S.) 36-401(C) reads, "Nursing care services may be provided by the adult foster care licensee if the licensee is a nurse who is licensed pursuant to title 32, chapter 15 and the services are limited to those allowed pursuant to law. The licensee shall keep a record of nursing services rendered." 4. In an interview, E1 acknowledged R1's and R2's residency agreement did not include the correct provisions for an assisted living facility to terminate residency with a fourteen day notice. Technical assistance regarding this requirement was provided during an on-site compliance inspection conducted on June 6, 2022.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan updated December 16, 2023 for personal care services including medication administration. 2. A review of R1's medical record revealed a document titled "Doctor's Orders," listing medications prescribed to R1. The document was dated December 28, 2023, however the document was signed by a registered nurse and not a medical practitioner. 3. In an interview, E1 acknowledged R1's medical record did not contain a medication order from a medical practitioner for each medication administered to the resident.

Based on documentation review, observation, and interview, the manager failed to ensure the 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, 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 review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the facility tour with E1, the compliance officer observed the door leading out to the backyard. The outside area, in the backyard, allowed residents to be a least 30 feet away from the facility. The door leading out to the backyard was equipped with a device intended to employees to the egress of a resident to the outside area, however the device was not working and did not sound an alert when the compliance officer opened the door. 3. During an interview, E1 acknowledged there was a means of exiting the facility which allowed residents to be at least 30 feet away from the facility, which did not control or alert employees of the egress of a resident. This is a repeat citation from an on-site compliance inspection conducted on June 2, 2022.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered by an individual under the direction of a medical practitioner, and in compliance with a medication order for two of two residents records sampled. Findings include: 1. A review of R1's and R2's medical record revealed a document titled "Authorization to Administer Medication." The document identified the facility Manager as the only employee authorized to administer medications to R1 and R2. 2. A review of R1's and R2's medication administration record (MAR) dated January 2024 revealed documentation indicating R1's and R2's medications had been administered by caregivers other than the facility's manager. 3. A review of R1's medical record revealed a document titled "Doctor's Orders," listing medications prescribed to R1. The document was dated December 28, 2023, however the document was signed by a registered nurse and not a medical practitioner. 4. In an interview, E1 acknowledged medication was not administered by an authorized individual and not in compliance with a medication order.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. A review of facility documentation revealed an annual disaster plan review dated November 30, 2022. However, evidence of a disaster plan review within the previous 12 months was not available for review. 2. In an interview, E1 acknowledged a current disaster plan review was not provided for review. Technical assistance regarding this requirement was provided during an on-site compliance inspection conducted on June 6, 2022.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. The Compliance Officer observed the hot water temperature measured at 134.9 \'b0F in a shared bathroom. 2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95 \'b0F and 120 \'b0F.