Red Mountain Senior Home #1 INC

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for three of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's, E2's, and E3's personnel records revealed documentation of initial training and education related to recognizing the signs and symptoms of TB. However, documentation of annual training and education related to recognizing the signs and symptoms of TB, which is required at least once every 12 months, was not available for review. 1. In an interview, E1 acknowledged that E1's, E2’s, and E3’s documentation of annual training and education related to recognizing the signs and symptoms of TB at least once every 12 months was not available for review.

Based on the record review and interview, the manager failed to ensure an employee provided documentation 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 R9-10-113, for two of three caregivers reviewed. The deficient practice posed a potential risk of TB exposure to residents. Findings include: 1. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test healthcare personnel upon hire (pre-placement), two-step testing should be used." 2. A review of E2's personnel record revealed documentation of a negative TB skin test dated February 12, 2025. However, there was no documentation of a second TB skin test. 3. A review of E3's personnel record revealed documentation of a negative TB skin test dated February 20, 2025. However, there was no documentation of a second TB skin test. 4. In an interview, E1 acknowledged E2 and E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility. This is a repeat deficiency from a compliance and complaint inspection conducted on September 7, 2023

Based on observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings include: 1. A review of Department documentation revealed E7 was the facility manager. 2. The Compliance Officer observed E1's managers license posted on the premises. 3. A review of E1's personnel record revealed E1 was hired as the facility's manager on April 1, 2023. 4. A review of Department documentation revealed the governing authority failed to notify the Department when E1 became the facility's manager. 5. In a joint interview, E5 and E6 acknowledged the facility did notify the Department when E1 became the facility's manager.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for one of two assistant caregivers sampled. The deficient practice posed a risk if E4 was unable to meet a resident's needs. Findings include: 1. A review of the facility documentation revealed a policy titled "Employees and Volunteers Qualifications" (dated in July 2023). The policy stated " ...Employment requirements: ...13. Verification of skills and knowledge documentation before providing any assisted living services to the residents." 2. A review of E4's (hired in 2023) personnel record revealed documentation of E4's verified skills and knowledge was not available for review. 3. A review of facility documentation revealed a staffing schedule dated January 2023 through August 2023. The staffing schedule revealed E4 was scheduled to work on Monday's from 7AM-1PM, Friday's from 7AM-2PM, and Saturday's from 7AM-1PM and 4PM-7PM. 4. In a joint interview, E5 and E6 acknowledged E4's skills and knowledge were not verified and documented prior to E4 providing physical health services and according to the facility's policies and procedures.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for two of four employees sampled. The deficient practice posed a potential tuberculosis exposure risk to residents. Findings include: R9-10-113(A)(2)(a)(i)(ii)(iii): ..."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, baseline 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) ..." 1. A review of the facility documentation revealed a policy and procedure titled "Tuberculosis (TB) Control - Tuberculosis Screening" (dated in July 2023). The policy and procedure stated " ...3. Baseline Screening will be provided will be required of all new facility personnel and new residents. 5. In some situations, a two-step tuberculin skin test will be required ..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1's (hired in 2023) personnel record revealed documentation of a baseline screening was not available for review. 4. A review of E4's (hired in 2023) personnel record revealed documentation of a Mantoux tuberculin skin test dated April 1, 2023. However, a second Mantoux tuberculin skin test was not available for review. 5. In a joint interview, E5 and E6 acknowledged E1's and E4's did not provide evidence of freedom from infectious tuberculosis as specified in R9-10-113. Technical assistance was provided on this Rule during the compliance inspection completed on September 30, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for one of two assistant caregivers sampled; and orientation and in-service education, for one of one manager sampled. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Orientation and In-Service Training" (dated in July 2023). The policy and procedure stated "...New employee orientation is required to be completed by all new employees and volunteers ...Fall Prevention and Recovery Training is required upon hire and at least every 12 months..Tuberculosis (TB) Training and Education will be provided upon hire and at least every 12 months ..." 2. A review of E1's (hired in 2023) personnel record revealed orientation, initial training in fall prevention and fall recovery, and initial TB training and education was not available for review. 3. A review of E4's (hired in 2023) personnel record revealed orientation was not available for review. 4. In a joint interview, E5 and E6 acknowledged E1 personnel records had not contained orientation, initial training in fall prevention and fall recovery, and initial TB training and education; and E4's personnel record had not contained orientation. This is a repeat deficiency from the compliance inspection conducted on September 30, 2022.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of three current residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: R9-10-113(A)(2)(a)(i)(ii)(iii): ..."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, baseline 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) ..." 1. A review of the facility documentation revealed a policy and procedure titled "Tuberculosis (TB) Control - Tuberculosis Screening" (dated in July 2023). The policy and procedure stated " ...3. Baseline Screening will be provided will be required of all new facility personnel and new residents." 2. A review of the the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of R2's (admitted in 2023) medical record revealed a TB test. However, a baseline screening was not available for review. 4. A review of R3's (admitted in 2023) medical record revealed a TB test. However, a baseline screening was not available for review. 5. In a joint interview, E5 and E6 acknowledged R2 and R3 had not provided freedom from infectious TB as specified in R9-10-113. Technical assistance was provided on this Rule during the compliance inspection completed on September 30, 2022.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the manager, for two of three current residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R2's (admitted in 2023) medical record revealed a written service plan dated in August 2023 for directed care services. However, the service plan was not signed and dated by the manager. 2. A review of R3's (admitted in 2023) medical record revealed a written service plan dated in August 2023 for directed care services. However, the service plan was not signed and dated by the manager. 3. In a joint interview, E5 and E6 acknowledged R2's and R3's service plans were not signed and dated by the manager.