Intouch at Belmont

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for one of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.” The webpage stated: “The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting…Initial TB training should be provided before the HCW starts working.” 2. A review of facility documentation revealed a series of personnel schedules which indicated E4 worked on a regular basis between July 2024 and May 2025. 3. A review of E4's personnel record revealed E4 was hired as a caregiver in July 2024. However, the review revealed E4 did not receive training and education related to recognizing the signs and symptoms of TB until May 4, 2025. 4. In an interview, E2 acknowledged E4 did not receive training and education related to recognizing the signs and symptoms of TB upon hire. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on June 12, 2023.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for one of three sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(1-2) states: "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.” 2. A review of E5's personnel record revealed E5 was hired as an assistant caregiver. The review revealed an “Employment Application Form” which indicated E5 had prior employment. The form contained a place to document contact with E5’s previous employer. However, the form and further review of E5’s personnel record revealed no documentation demonstrating facility personnel contacted E5’s previous employer. The review further revealed E5 had a fingerprint clearance card (FCC). However, the review revealed no documentation demonstrating facility personnel verified E5’s FCC. 3. A review of the Department of Public Safety (DPS) website revealed E5's FCC was valid. 4. In an interview, E3 reported E3 had contacted E5’s previous employer but had not documented the contact. E3 further revealed E3 did not verify E5’s FCC after E5 applied for one. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on June 12, 2023.

Based on documentation review, 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 date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for two of three sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(iii) 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…and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 2. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. 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: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC).” 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 4. A review of E4’s personnel record revealed E4 was hired as a caregiver. The review revealed a negative TST result dated as read on July 4, 2024, before E4 began providing services. The review revealed a second negative TST, dated as read on March 3, 2025, after E4 began providing services. 5. A review of E5’s personnel record revealed E5 was hired as an assistant caregiver. However, the review revealed no negative TSTs or other test(s) recommended by the CDC. 6. A review of facility documentation revealed a series of personnel schedules which indicated E4 and E5 worked without evidence of freedom from infectious TB. 7. In a series of interviews, E2 asked the Compliance Officer if E5 needed a two-step TST. When the Compliance Officer asked if E5 had ever received a test for TB, E5 stated, “No.” 8. In a separ

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established and documented that included the frequency of assisted living services and ancillary services being provided to the resident, for two of two sampled residents. Findings include: 1. A review of R1's and R2’s medical records revealed current service plans. The service plans indicated R1 and R2 were to receive assistance with ambulation, dressing, oral care, personal hygiene, toileting, and transferring. However, the service plans did not include the frequencies of these services. 2. In an interview, E2 reported the service plans did not include frequencies for all services. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on June 12, 2023.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area inaccessible to residents. The deficient practice posed a risk to residents with access to the poisonous or toxic materials. Findings include: 1. The Compliance Officer observed a magnet key on one of the refrigerators in the kitchen and two magnet keys on the microwave in the kitchen in plain sight. The Compliance Officer observed a cabinet under the sink in the kitchen. Using the magnet key from the refrigerator, the Compliance Officer was able to open the cabinet under the sink. Inside the cabinet, the Compliance Officer observed a variety of poisonous or toxic materials, including dishwasher tablets, Fabuloso, oven and grill cleaner, stainless steel cleaner, and three unlabeled bottles containing what appeared to be cleaning agents, among others. 2. In an interview, the Compliance Officer reminded E2 poisonous or toxic materials could not be accessible to residents, which included leaving the key accessible. When the Compliance Officer asked what the unlabeled bottles contained, E2 stated, “Disinfectant.” E4 then reported the bottles contained Fabuloso mixed with water. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on June 12, 2023.

Based on observation and interview, the manager failed to ensure garbage and refuse were removed from the premises at least once a week. Findings include: 1. On the side of the house, the Compliance Officer observed broken furniture and equipment. 2. In an interview, E2 reported the facility was throwing away the broken items and was waiting for the city to pick up the items during bulk trash day. 3. In a separate interview, E3 reported the broken items had been on the side of the house for approximately three weeks. E3 reported bulk trash day was at the end of July. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on June 12, 2023.