Oak Haven Assisted Living

Based on record review, documentation review and interview, the manager failed to ensure that a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. § 36-411, for one of two sampled employees The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A review of E3's personnel record revealed documentation of a valid fingerprint clearance card was not available for review. However, based on E3's date of hire, a fingerprint card or documentation of a active application for a fingerprint clearance card was required. 2. During the on-site inspection, E1 contacted E3 and requested documentation from E3, however, documentation showing E3 had a fingerprint clearance card or had submitted an application for a fingerprint clearance card was not provided during the on-site inspection. E1 reported E3 had been hired in August but after one day E1 realized E3 did not have a caregiver certificate. E1 reported E3 had just gotten a caregiver certificate on September 24, 2025 and started working at the facility at that time. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review, record review, interview, and observation, the manager failed to ensure a 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 one of two sampled employees. Findings include: 1. R9-10-113(A)(2)(a)(i-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, 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)(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 the facility work schedule revealed E3 had worked as a caregiver from 6 AM to 6 PM on September 27, September 28, October 1, and October 4, 2025 5. A review of E3’s personnel record revealed E3 was hired in August of 2025. However, documentation of baseline screening for TB was not available for review. 6. In an interview, E1 reported E3 had an order for a blood test for TB, however, E1 reported the results from that test were not available at the time of the on-site inspection. 7. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of two caregivers reviewed. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3's personnel record revealed E3 worked as a caregiver and was hired in August 2025. However, documentation of first aid and CPR training was not available for review. 2. During the on-site inspection, E1 contacted E3 and requested E3's CPR and First Aid certification. E1 reported E3 stated E3's former employer had that documentation, but that their human resources person was not available on the day of the inspection so it could not be provided. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.