Hacienda Del Rey

Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis (TB), on or before the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of nine personnel sampled. 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. R9-10-113.B.1.b states: For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: If the individual had a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, compliance with subsection (A)(2)(b)." 3. R9-10-113.A.2.b states: "If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201:. Referring the individual for assessment or treatment; and annually obtaining documentation of the individual ' s freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101." 4. A review of E8's personnel record revealed E8 had been hired as a caregiver in April 15, 2020. E8's personnel record included documentation of a positive PPD from October 2022, an X-ray and doctor's statement, dated October 11, 2022, stating E8 had, "no evidence of acute cardiopulmonary disease, communicable disease or active tuberculosis." However, E8's personnel record did not include further annual documentation of E8's freedom from symptoms of infectious tuberculosis. 5. In an interview, E1 acknowledged the personnel record provided for E8 had not included documentation of evidence of freedom from infectious TB as required by R9-10-113.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. § 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. During the environmental tour, the Compliance Officer observed a laptop in each building of the facility used for medication administration documentation. During the tour of Casita 4, Casita 5, and Casita 9 the Compliance Officer observed the laptops were open and unlocked. Further observation of the laptops revealed the medical records of the residents in each building were readily accessible. 3. In an interview, E1 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of nine residents sampled who received medication administration. Findings include: 1. A review of R8's medical record revealed a Directed service plan from July 2025 which reported R8 was to receive medication administration services. 2. A review of R8's medical record revealed a medication order from August 2025 for the following medication: Oxycodone HCL 20milligram (MG) Tabs - Give one tab by mouth(PO) every 4 hours (Q4 hours) scheduled for chronic pain. 3. A review of R8's medical record revealed a Medication Administration Record (MAR) for October 2025. The MAR indicated the following: Oxycodone HCL 20milligram (MG) Tabs had not been administered on October 4, 2025 at 12:00AM. 7. In an interview, E1 acknowledged the medications administered to R8 was not documented in R8's medical record.

Based on documentation review, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. Findings include: 1. A review of E2's personnel record revealed a job title of assistant caregiver. 2. A review of facility disciplinary action documentation, dated December 8 , 2024, revealed a narrative that stated, "During the investigation of the incident, [E2] admitted to providing care to residents without a Certified Caregiver present to which ED reminded [E2] that [E2] had been instructed not to provide care without the supervision of another caregiver." 3. A review of E4's personnel record revealed did not include documentation of a completed caregiver training course. 4. A review of the facility's personnel schedule revealed E4 was scheduled to work independently, in House Six, on the following dates from 10:00 PM - 6:00 AM: - November 18, 2024 - November 20, 2024; - November 24, 2024 - November 27, 2024; - December 1, 2024 - December 4, 2024; - December 8, 2024 - December 11, 2024; and - December 15, 2024. 5. In an interview, E1 reported the facility terminated E2 as a result of the violation of facility policies. E1 also reported E4 was taken off the schedule, on December 16, 2024, immediately following the completion of a personnel record audit, revealing E4's lack of caregiver certification. E1 acknowledged that an assistant caregiver did not interact with residents under the supervision of a manager or caregiver.