Cogir of Morrison Ranch

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver who was expected to have more than eight hours per week of direct interaction with residents, 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 for one of 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E2's personnel record revealed no documentation of a TB skin test. Additionally, there was no documentation of assessing risks of prior exposure to infectious TB or documentation of determining if E2 had signs or symptoms of TB. Based on E2's date of hire, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure a manager provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for two of three employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2’s personnel record revealed that documentation was not available showing E2 had current CPR and first aid. 2. A review of E3’s personnel record revealed a CPR card from the American Red Cross dated as issued on February 5, 2024. This card expired as of February 2026. 3. A review of the facility’s policies and procedures revealed a document titled, "Staffing and Training Requirements" that included the following verbiage: "Renewal of Training 1. All employees and volunteers required to maintain CPR Certification must renew their certification at least every two 2) years or more frequently if specified by the certifying organization. 2. Employees whose certification has expired must not perform duties requiring CPR competency until recertification is completed." 4. A review of the facility's documentation revealed a staff schedule for February and March, which showed E2 and E3 worked multiple shifts at the facility during this time. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for two of three employees sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A review of A.R.S. § 36-411 states "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. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A review of E2 and E3's personnel records revealed no documentation that E2 and E3 were not on the adult protective services registry. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the governing authority failed to ensure that the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a health and safety risk to the resident. Findings include: 1. A review of R1's medical record revealed a service plan dated March 5, 2026, that indicated R1 received personal care services. 2. In an interview, E1 reported that E2 was a maintenance worker at the facility and was not a certified caregiver. Despite this, E1 reported E2 had unsupervised access to R1's bedroom and could enter at any time without any documented reason or work orders requested. E1 reported that E2 entered R1's bedroom 49 times between February and March 2026, according to the tracking system connected to E2's key fob. E1 reported there were no documented reasons or work orders associated with these visits. 3. In an interview, E1 reported E2 inappropriately touched R1 multiple times during these visits. This was also confirmed in an interview with R1 by the Compliance Officer. 4. A review of facility documentation revealed a documented report dated March 20, 2026, following the related incident with R1, detailing the events. The report included the following verbiage: "A report was received...alleging an inappropriate relationship between [R1] and an employee. The primary care provider has been notified and is scheduled to evaluate the resident on March 26, 2026." 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.