Saguaro Ranch Luxury Assisted Living, LLC

Based on observation, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), for two of two caregivers or assistant caregivers sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed E3 and E4 working and interacting with residents in their respective capacities as caregiver or assistant caregiver. 2. A review of E3's personnel record revealed evidence of one negative Tuberculin Skin Test, which was administered within twelve months of E3's date of hire. However, evidence of a second negative tuberculin skin test, a negative blood test or a signs and symptoms and risk assessment, authenticated by an occupational health reviewer was unavailable for review. 3. A review of E4's personnel record revealed evidence of one negative Tuberculin Skin Test, which was administered within twelve months of E4's date of hire. However, evidence of a second negative tuberculin skin test, a negative blood test or a signs and symptoms and risk assessment, authenticated by an occupational health reviewer was unavailable for review. 4. In an interview, E1 acknowledged E3's and E4's personnel records did not contain documentation of evidence of freedom from infectious TB.

Based on record review and interview, the manager failed to ensure assistance in the self-administration of medication provided to a resident was documented in the resident's medical record, for two of two residents sampled who received personal care services. The deficient practice posed a risk as a directed care resident did not receive medication administration. Findings include: 1. A review of R1's medical record revealed R1 received assistance in the self-administration of medication. 2. A review of R1's medical revealed an order dated March 18, 2024 for "Voltaren 1% topical gel applied...tid @ 8a, 12p 6p for leg pain." 3. A review of R1's medication administration record (MAR), dated April 2024, revealed caregivers' initials to indicate caregivers had provided assistance in the self-administration of Voltaren as follows: "Noon and 5PM," on every day in April. However, the MAR indicated assistance with medication administration was provided at "9PM" on April 1, 3-8, 12-15, 19-22 and 26-29. Evidence assistance in the self-administration of the medication on April 2, 9-11, 16-18, 23-25 or 30, 2024 was unavailable for review. 4. A review of R2's medical record revealed R2 received assistance in the self-administration of medication. 5. A review of R2's medical revealed an order dated February 21, 2024 for "Voltaren 1% topical BID 9AM/5PM," "Aspercreme w/ Lidocaine 4% QD 9AM On/ 9PM OFF," and "Artificial Tears 1 Drop/eye BID 9AM/5PM." 6. A review of R2's medication administration record (MAR), dated April 2024, revealed caregivers' initials to indicate caregivers had provided assistance in the self-administration of medication as follows: Voltaren "9AM," on every day in April. However, evidence assistance with medication administration was provided at "9PM" on April 1, 8, 11, 15, 16 or 234, 2024 was unavailable for review; Aspercreme w/Lidocaine "9AM," on every day in April. However, evidence assistance with medication administration was provided at "9PM" on April 1, 8, 11, 15, 16 or 234, 2024 was unavailable for review; and Artificial Tears on every day in April. However, evidence assistance with medication administration was provided at "9PM" on April 1, 8-11, 16, 17 or 24, 2024 was unavailable for review. 7. In an interview, E1 acknowledged assistance in the self-administration of medication provided to a resident was not documented in R1's or R2's medical record for April 2024.

Based on documentation review and interview, the manager failed to ensure policies and procedures were available to employees and volunteers of the assisted living facility. Findings include: 1. During the on-site inspection, the Compliance Officer requested to review the facility's policies and procedures. However, the policies and procedures were not provided for review. 3. In an interview, E1 advised the policies and procedures were typically available electronically, however E1 was not able to locate them. E1 and E2 acknowledged the policies and procedures were not available to employees and volunteers of the assisted living facility.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request or prior to the exit interview. Findings include: 1. On January 19, 2024, the Compliance Officer requested the following documents during the on-site inspection: - Policies and Procedures - Quality Management Program - Personnel file for E3. However, this documentation was not provided. 2. In an interview, E1 acknowledged this information was not provided to the Compliance Officer. E1 reported the policies and procedures likely contained the Quality Management program, however E1 was unable to locate the policies and procedures. E1 and E3 acknowledged E3 did not have a personnel record.

Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained, for one of one personnel records sampled. Findings include: 1. The Compliance Officer observed E3 was working at facility. The Compliance Officer requested to review E3's personnel record. 2. In an interview, E3 reported they did not have a personnel record. E3 advised they had been working at the facility as the "Director," with a date of hire "June 2023." E3 advised their duties included administrative duties, assisting in resident admissions, marketing, updating employee records and terminating employees. 3. In an interview, E1 agreed E3's personnel file was not established.