Citrus Manor Assisted Living, LLC

Based on documentation review, record review, and interview, the manager failed to ensure compliance with A.R.S. § 36-411 based on one of three records sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 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..." 2. A review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of May 9, 2025. The personnel record revealed a fingerprint clearance card with an expiration date of October 22, 2025. 3. A review of the Department of Public Safety (DPS) fingerprint clearance card database revealed no information was found or yielded in the search. 4. A review of the facility's March 2026 work schedule revealed E3 was scheduled to work during the month of March. 5. In an interview, O1 made call attempts and spoke with E1 and E3 to obtain a valid fingerprint clearance card for E3 with no information being provided to the Compliance Officer before the inspection concluded. 6. In an exit interview, findings were reviewed with O1 and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk as the resident's whereabouts were unknown. Findings included: 1. A review of Department records revealed [R2] was found wandering the streets. Someone found [R2] took [R2] to the Fire Department. [R2] was taken back to the facility. The facility was unaware of [R2] leaving the facility. 2. A review of R2's medical record revealed an "Unusual Occurrence Report" dated February 23, 2026 at 10:04 am. The report stated "Resident eloped from facility..called 911..." 3. A review of R2's medical record revealed documentation showing R2 had a diagnosis of "Alzheimer's Disease". Additionally, R2's medical record revealed a service plan dated January 21, 2026, that stated "Wandering at times" and "Cognitive Skills for Daily Decision Making - Severely impaired". 4. In an exit interview, E1 acknowledged R2 eloped from the facility, and no additional information was provided.

Based on record review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. Review of E1's personnel record revealed that there was no annual continuing education training for recognizing the signs and symptoms of TB. 2. Review of E2's personnel record revealed that there was no annual continuing education training for recognizing the signs and symptoms of TB. 3. In an exit interview, the findings were discussed with E2 and no additional information was provided. 4. Technical assistance was provided on this Rule during the inspection conducted on August 3, 2022, and this is a repeat deficiency from the inspection conducted on September 5, 2023.

Based on documentation review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and administered. Findings include: 1. A review of facility documentation revealed a policy and procedure for fall prevention and fall recovery was not available for review. 2. A review of facility documentation revealed a training program for fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged the facility failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training. Technical assistance was provided on this Rule during the compliance inspection completed on August 3, 2022.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for two of two residents sampled who received personal care services. The deficient practice posed a risk as a service plan did not reinforces and clarifies services to be provided to a resident. Findings include: 1. A review of R1's (accepted in 2023) medical record revealed a service plan dated in February 2023 for personal care services. However, documentation to demonstrate R1's service plan was reviewed and updated at least once every six months was not available for review. 2. A review of R2's (accepted in 2019) medical record revealed a service plan dated in January 2023 for personal care services. However, documentation to demonstrate R2's service plan was reviewed and updated at least once every six months was not available for review. 3. In an interview, E1 acknowledged the service plans for R1 and R2 were not updated. This is a repeat deficiency from the compliance inspection conducted on August 3, 2022.

Based on documentation review and interview, the manager failed to ensure a disaster plan review required in (A)(2) was documented to include the time of the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. Findings include: 1. A review of facility documentation revealed a disaster plan review dated in December 2022. However, the disaster plan review did not include documentation of the time of the disaster plan review; a critique of the disaster plan review; and if applicable recommendations for improvement. 2. In an interview, E1 acknowledged the disaster plan review did not include documentation of the time of the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. Technical assistance was provided on this Rule during the compliance inspection completed on August 3, 2022.

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution established, documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of facility documentation revealed documentation of tuberculosis infection activities required in R9-10-113.A.2.a-f were not available for review. 2. A review of R1's medical revealed revealed a baseline 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 was not available for review. Based on R1's date of admission, the documentation was required. 3. A review of E1's, E2's, and E3's personnel records revealed documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 4. A review of facility documentation revealed documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis was not available for review. 5. In an interview, E1 reported the health care institution had not established, documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Technical assistance was provided on this Rule during the compliance inspection completed on August 3, 2022.