Heritage Oaks Assisted Living LLC

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis (TB) infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of E1’s and E4’s personnel records revealed annual training and education related to recognizing the signs and symptoms of TB, to include initial training per R9-10-113.A.1, was not available for review. 2. A review of R1’s medical record revealed documentation of baseline screening to include a risk assessment, symptom screening, and a negative TB test, dated within seven days after R1’s date of acceptance, was not available for review. 3. A review of R2’s medical record revealed a negative TB test dated 19 days prior to R2’s date of admission. However, documentation of a complete baseline screening to include a risk assessment and symptom screen were not available for review. 4. In an interview, E1 and E2 acknowledged the health care institution had not documented and implemented tuberculosis infection control activities as required in R9-10-113.A.2.a-f. Technical assistance was provided for this rule during the on-site compliance and complaint inspection conducted on January 3, 2024.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for four of four personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. A.R.S. § 36-411 states: "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 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

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that 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 facility's license revealed the facility was licensed to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed an exit door from the kitchen had a door alarm magnet, but was missing the door alarm entirely. The Compliance Officer observed when the door was opened, an alarm did not sound. 3. During an environmental tour of the facility, the Compliance Officer observed an exit door from the living room had a door alarm, but was missing the magnet. The Compliance Officer observed when the door was opened, an alarm did not sound. 4. In an interview, E1 and E2 acknowledged the facility provided directed care services, and did not have a means to control or alert employees of the egress of a resident from the facility on all exits.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a mediation order, for one of two sampled residents. Findings include: A review of R2's medical record revealed a service plan, dated November 11, 2024, for personal care services including medication administration. A review of R2's medical record revealed a Medication Administration Record (MAR) dated March 2025. For the medication, "Memantine HCI Oral Tablet 5 MG, Give 5 mg by mouth at bedtime for dementia," the MAR indicated the following: On March 20, 2025, the medication had not been administered due to, "Medication not Available"; On March 21, 2025, the medication had not been administered due to, "Medication not Available"; On March 22, 2025, the medication had not been administered due to, "Medication not Available"; On March 23, 2025, the medication had not been administered due to, "Medication not Available"; On March 24, 2025, the medication had not been administered due to, "Medication not Available"; On March 25, 2025, the medication had not been administered due to, "Medication not Available"; On March 26, 2025, the medication had not been administered due to, "Medication not Available"; On March 27, 2025, the medication had not been administered due to, "Medication not Available"; On March 28, 2025, the medication had not been administered due to, "Medication not Available"; On March 29, 2025, the medication had been marked as administered; On March 30, 2025, the medication had not been administered due to, "Medication not Available"; and On March 31, 2025, the medication had not been administered due to, "Medication not Available". A review of R2's medical record revealed an order from a medical practitioner ordering the medication to be held until filled, discontinued, or changed was not available for review. A review of R2's medical record revealed a termination notice stating the facility was not able to meet R2's needs for ordered medication was not available for review. In an interview, E1 acknowledged the medication had not been administered on March 29, 2025 as it was not yet available on that date. In an interview, E1 and E2 acknowledged R2 had not been administered Memantine between March 20 and March 31 due to the medication not being available.

Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of four personnel sampled. Findings include: 1. A review of E3's personnel record revealed documentation of completed initial training on fall prevention and fall recovery was not available for review. 2. In an interview, E1 and E2 acknowledged the personnel record provided for E3’s had not included documentation of initial training in fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated August 16, 2023, for personal care services. The service plan stated the following service would be provided to R2: - "Constipation: 1) Monitor bowel movements daily. 2) Include high fiber foods, such as beans, whole grains, fresh fruit and vegetables in diet daily. 3) Offer fluids in between meals 4) Give PRN medication, as ordered, for constipation if no bowel movement. 4) If [R2] has any of the following call Doctor: distended abdomen, abdominal pain, vomiting or no bowel movement for 3 days." 2. A review of R2's electronic medical record revealed a, "Care Tracking Sheet," dated December 2023, which documented the services provided to R2. However, documentation of bowel movements were not available for review. 3. A review of facility documentation revealed a log titled, "BM Tracking Sheet," which documented the bowel movements and assistance provided to all residents at the facility between December 9, 2023 and January 1, 2024. However, documentation of R2's bowel movements were not available for review. 4. In an interview, E2 reported the service plan for R2 may need to be updated because R2 was independent of toileting and could report bowel movements to staff if required but did not regularly receive assistance with toileting. E1 and E2 acknowledged documentation of services provided to R2 did not include documentation of bowel movements as required by R2's service plan. Technical assistance for this rule was provided during the onsite compliance inspection conducted on January 30, 2023.