Sorrento Assisted Living

Based on record review and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide to the emergency responders a written document that included all information required in A.R.S. § 36-420.04, for two of three residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R2’s medical record revealed a standardized form missing the name, address, and telephone number of the resident's current pharmacy, and the name and contact information for the resident's primary care physician. 2. A review of R3’s medical record revealed a standardized form missing the name, address, and telephone number of the resident's current pharmacy, and the name and contact information for the resident's primary care physician. 3. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on record review, documentation review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution for three of three employees sampled and annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of E1's personnel record revealed E1’s hire date of December 29, 2025. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 2. A review of E2's personnel record revealed E2’s hire date of December 23, 2025. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 3. A review of E3's personnel record revealed E3’s hire date of January 2, 2024. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 4. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment. 5. In an interview, E3 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted, nor was the employee's annual training. 6. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedures revealed a page titled "Policies and Procedures Manual Review Statement". However, the page was not signed and dated. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program, which included a method to collect data to evaluate services provided to residents. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Quality Management Program.” The policy stated, “Sorrento Assisted Living Home has implemented a quality management program. Sorrento Assisted Living Home will review and evaluate the effectiveness of the quality management program at least once every 12 months." 2. A review of the facility’s quality management documentation revealed no documentation of completion for 2024 or 2025. 3. In an interview, E3 acknowledged that a plan was not documented or implemented for an ongoing quality management program. 4. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 5. This is a repeat citation from the compliance and complaint inspection conducted on July 30, 2024.

Based on documentation review and interview, the manager failed to ensure the report required in subsection (2) was maintained for at least 12 months after the date the report was submitted to the governing authority. Findings include: 1. A review of the facility’s documentation revealed that reports for the Quality Management Program were not maintained for at least 12 months, as the facility did not have a Quality Management Program in place. 2. A review of the facility’s policies and procedures revealed a policy titled “Quality Management Program.” The policy stated, “The report and supporting documentation submitted to the governing authority will be maintained with the facility’s administrative records and 12 months after the date the report is submitted to the governing authority." 3. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. A review of Department documentation revealed the facility was licensed at the directed care level. 2. A.R.S. § 36-401.A.42. defines "Supervision" as directly overseeing and inspecting the act of accomplishing a function or activity. 3. Upon arrival at the facility, the Compliance Officer was greeted by E2. E2 was alone in the house with eight residents in the living room. The backdoor was closed. E1 was sitting on the patio on the phone with E1’s back to the back door. 4. A review of E2’s personnel record revealed that E2 was an assistant caregiver. 5. During an interview, E3 reported that E2 was an assistant caregiver. E1 was the certified caregiver. 6. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistance caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. Upon arrival to the facility, E2 greeted the Compliance Officer. During the inspection, the Compliance Officers observed E1 and E2 on shift and interacting with residents. E3 approximately arrived to the facility at 10:30 am. 2. In an interview, E3 reported that E3 and E4 come every morning and evening to administer medications. 3. A review of the facility's employee work schedule revealed the following: A schedule for January 2026 that included the names of employees working each day, with no record of hours worked by each. The employee work schedule revealed E3 and E4 were not scheduled to work on January 6-8, 2026, January 14, 2026, January 20-21, 2026, and January 27, 2026. No further documentation of the caregivers scheduled to work and hours worked by each was available for Compliance Officer review. A schedule for December 2025 that included the names of employees working each day, with no record of hours worked by each. The employee work schedule revealed E3 and E4 were not scheduled to work on December 8-9, 2025, December 11, 2025, December 15, 2025, December 18, 2025, and December 22 - 23, 2025. No further documentation of the caregivers scheduled to work and hours worked by each was available for Compliance Officer review. 4. In an interview, E3 acknowledged that the employee work schedule did not include documentation of the caregivers who worked each day, and the hours worked by each. 5. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 6. This is a repeat citation from compliance and complaint inspection on July 30, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for three of three employees sampled. The deficient practice posed a potential TB exposure risk to residents.  Findings include:  1. R9-10-113.A 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, 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, 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. 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) or Interferon Gamma Release Assay (IGRA) test is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1's personnel record revealed E1’s hire date of December 29, 2025. There was no documentation of TB signs and symptom screening. 4. A review of E2's personnel record revealed E2’s hire date of December 23, 2025. There was no documentation of TB risk assessment screening. 5. A review of E3's personnel record revealed E3’s hire date of January 1, 2024. There was no documentation of TB risk assessment screening. 6. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 7. This is a repeat citation from the abbreviated inspection on August 15, 2023, and the compliance and complaint inspection on July 30, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one of three residents sampled. The deficient practice posed a TB exposure risk to residents.  Findings include: 1. R9-10-113.A 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, 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, 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. A review of R3's medical record revealed documentation of TB signs and sympotoms screening. However, there was no documentation of assessing risks of prior exposure to infectious TB. Based on R3's admission date, this documentation was required. 3. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of a resident, an individual submitted documentation that was dated within 90 calendar days before the resident was accepted by an assisted living facility and if an individual was requesting or was expected to receive supervisory care services, personal care services, or directed care services it included whether the individual required continuous medical services, continuous or intermittent nursing services, restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for three of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1’s medical record revealed documentation with the required elements dated within 90 days of R1's acceptance; however, the documentation was not signed by a medical practitioner or registered nurse as required. 2. A review of R2’s medical record revealed documentation with the required elements dated within 90 days of R2's acceptance; however, the documentation was not signed by a medical practitioner or registered nurse as required. 3. A review of R3’s medical record revealed documentation with the required elements dated within 90 days of R3's acceptance; however, the documentation was not signed by a medical practitioner or registered nurse as required. 4. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan included documentation of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of the three residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. A review of R1’s medical record revealed a current service plan dated June 1, 2025. However, the service plan did not list R1’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 3. This is a repeat citation from the abbreviated inspection conducted on August 15, 2023.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that documented the level of service the resident was expected to receive for one of three applicable residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R3’s medical record revealed the following: A current service plan dated August 9, 2025. The service plan did not include the level of service R3 received. A service plan dated February 9, 2025. The service plan did not include the level of service R3 received. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 3. This is a repeat citation from the abbreviated inspection conducted on August 15, 2023, and the compliance and complaint inspection conducted on July 30, 2024.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, and was reviewed and updated at least once every six months for a resident receiving personal care services, for two of three residents sampled. Findings include: 1. A review of R1’s service plan, dated June 1, 2025, indicated R1 required personal care services. However, documentation of a service plan review or update within the last six months was not available. 2. A review of R2’s service plan, dated June 29, 2025, indicated R2 required personal care services. However, documentation of a service plan review or update within the last six months was not available. 3. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, and when initially developed, was signed and dated by the resident or the resident’s representative, for one of three 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 R3's medical record revealed a service plan dated August 9, 2025. However, the resident or the resident's representative did not sign and date the service plan. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. § 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. The Compliance Officer (CO) observed a closet with unlocked sliding doors in the dining room. On one side of the closet, the CO observed binders with the residents' names on them. On the other side of the closet, the CO observed “Onetouch Delica Plus Lancets 33G” with a prescription label attached. 3. A review of the facility’s policies and procedures revealed a policy titled “Resident Records.” The policy stated, “A resident’s medical record is protected from loss, damage, or unauthorized use.” 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of assisted living services provided to the resident for three of three residents sampled. The deficient practice posed a risk if the services provided could not be verified. Findings include: 1. A review of R1's medical record revealed the following: A current service plan dated June 1, 2025. The service plan reported R1 received assistance with activities of daily living (ADLs), including shower and bed bath; shampoo 2x/week; oral care daily; nail care as needed; comb hair daily; dressing; room maintenance; bowel total incontinence; incontinent check every 3-4 hours; medication administration; monitor skin integrity daily; offers sufficient fluids at least 6-8 glasses a day; offers adequate nutritional intake; offers resident to eat meals, snacks, and drink fluids daily. Electronic “Tasks & ADL’s” documentation revealed no assisted living services were documented as provided on the following days: January 2, 2026, to January 9, 2026; December 18, 2025; and December 20, 2025, to December 30, 2025. 2. A review of R2's medical record revealed the following: A current service plan dated June 29, 2025. The service plan stated R1 received assistance with activities of daily living (ADLs), including shower 2x/week; shampoo 2x/ week; nail care as needed; shave as needed; comb hair daily; dressing; room maintenance; bowel total incontinence; medication administration; monitor skin integrity daily; offers sufficient fluids at least 6-8 glasses a day; offers adequate nutritional intake; offers resident to eat meals, snacks, and drink fluids daily. Electronic “Tasks & ADL’s” documentation revealed no assisted living services were documented as provided on the following days: January 2, 2026, to January 13, 2026; December 1, 2025 to December 5, 2025; December 8, 2025 to December 12, 2025; December 14, 2025, to December 18, 2025, and December 20, 2025, to December 30, 2025. 3. A review of R3's medical record revealed the following: A current service plan dated August 9, 2025. The service plan stated R1 received assistance with activities of daily living (ADLs), including shower; shampoo 2x/ week; nail care as needed; shave as needed; dressing; room maintenance; bowel total incontinence; medication administration; monitor skin integrity daily; turn resident every 2-3 hours if immobile to prevent skin breakdown; offers sufficient fluids at least 6-8 glasses a day; offers adequate nutritional intake; offers resident to eat meals, snacks, and drink fluids daily. Electronic “Tasks & ADL’s” documentation revealed no assisted living services were documented as being provided on the following days: January 3, 2026, to January 13, 2026; December 1, 2025, to December 18, 2025; and December 20, 2025, to December 31, 2025. 4. In an interview, E3 acknowledged that assisted living services provided to the residents were not being documented. 5. In an

Based on record review and interview, the manager accepted and retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2), for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical record revealed the following: A current written service plan dated June 29, 2025. The service plan indicated that R2 was wheelchair/chairbound and bedbound. A document titled “Approval of Continued Residency” was blank. No documentation indicating R2's medical practitioner examined R2 upon acceptance and every six months thereafter, signed and dated a determination that stated R2's needs could be met by the facility, and reviewed that the facility's scope of services was available. 2. A review of R3's medical record revealed the following: A current written service plan dated August 9, 2025. The service plan indicated that R3 was wheelchair/chairbound and bedbound. A document titled “Approval of Continued Residency,” dated April 15, 2025. No documentation indicating R3's medical practitioner examined R3 every six months thereafter, signed and dated a determination that stated R3's needs could be met by the facility, and reviewed that the facility's scope of services was available. 3. In an interview, E3 acknowledged that R2 and R3 were non-ambulatory and did not have the required documentation. 4. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed that the facility provided medication administration services. 2. A review of facility policies and procedures revealed a policy titled “Medication policies.” However, the medication policies and procedures were not reviewed, signed, and dated by a medical practitioner, registered nurse, or pharmacist. 3. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one of three residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R3’s medical record revealed a signed medication list, dated December 10, 2025, which included “Midodrine HCl Tablet 2.5 mg - Take 1 tablet oral three times daily.” 2. A review of R3’s medication administration record (MAR) for January 2026 revealed that “Midodrine HCl Tablet 2.5 mg” was listed as needed (PRN). However, the medication order indicated that R3 was to receive “Midodrine HCl Tablet 2.5 mg” three times a day. 3. A review of R3’s medication administration record (MAR) for December 2025 revealed that “Midodrine HCl Tablet 2.5 mg” was listed (PRN). However, the medication order indicated that R3 was to receive “Midodrine HCl Tablet 2.5 mg” three times a day. 4. In an interview, E3 acknowledged that R3 was not being administered “Midodrine HCl Tablet 2.5 mg” three times a day. 5. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 6. This is a repeat citation from the compliance and complaint inspection on July 30, 2024.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's disaster plan revealed that no disaster plan review was conducted in 2024 or 2025. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 3. Technical assistance was provided on this rule during the compliance and complaint inspection conducted on July 30, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure that the premises and equipment used at the facility were cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a risk to the physical health and safety of the residents. Findings include: 1. During the environmental inspection with E2, the Compliance Officers smelled a strong urine odor. Upon entry to the bathroom by the front door, the Compliance Officers observed the floor covered in urine. 2. In an interview, E2 reported that a resident is incontinent and frequently urinates on the floor. 3. A review of the facility’s policies and procedures revealed a policy titled “Environmental Safety.” The policy stated “The assisted living manager shall ensure that the premises and equipment are cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection.” 4. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 5. This is a repeat citation from the compliance and complaint inspection conducted on July 30, 2024.

Based on observation and interview, the manager failed to ensure that there were paper towels in a dispenser or a mechanical air hand dryer in the residents' bathroom. The deficient practice posed an infection control risk. Findings include: 1 . During the environmental inspection with E2, the Compliance Officer observed no paper towels in a dispenser or a mechanical air hand dryer in the resident bathroom by the front door. 2. During the environmental inspection with E2, the Compliance Officer observed no paper towels in a dispenser or a mechanical air hand dryer in the resident bathroom by the laundry room. 3. In an interview, E2 acknowledged that there were no paper towels in a dispenser or a mechanical air hand dryer in the resident bathroom by the front door or laundry room. 4. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 5. This is a repeat citation from the compliance and complaint inspection on July 30, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure that a resident's bedroom was not used as a passageway to a common area or another sleeping area. The deficient practice posed a potential privacy rights violation to the resident. Findings include: 1. During the environmental inspection with E2, the Compliance Officer observed a door in the living room. E2 stated the door was locked. 2. During the environmental inspection with E2, the Compliance Officer observed the master bedroom, bathroom, and closet occupied by two residents. The Compliance Officer observed a bed, clothing, shoes, and personal belongings in the master closet. 3. In an interview, E1 and E2 reported that E2 slept in the master bedroom closet. 4. In an interview, E3 acknowledged that E2 slept in the master bedroom closet. 5. During the inspection, the Compliance Officer observed E2 entering the master bedroom to get to the master closet. 6. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 7. This is a repeat citation from the abbreviated inspection on August 15, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed an policy titled, "Fall Prevention and Recovery." The policy stated, "Sorrento Assisted Living, as a licensed healthcare institution, has developed and administers a training program for all caregiving staff regarding fall prevention and fall recovery. The training program requires initial training and continued competency on an annual basis in fall prevention and fall recovery." 2. A review of E2's personnel record revealed no documentation of Fall Prevention and Fall Recovery training. 3. In an interview, E1 acknowledged documentation of Fall Prevention and Fall Recovery training was not available for review.

Based on documentation review and interview, the manager failed to ensure that a plan was documented and implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Quality Management Program." The policy stated, "Sorrento Assisted Living Home has implemented a quality management program. Sorrento Assisted Living Home will review and evaluate the effectiveness of the quality management program at least once every 12 months." 2. During the on-site compliance and complaint inspection, the Compliance Officers requested the facility's quality management documentation at 10:00 AM. No documentation was provided for Compliance Officer review. 3. In an interview, E1 acknowledged a plan was not documented or implemented for an ongoing quality management program.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistance caregivers working each day, included the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. During the on-site compliance and complaint inspection, the Compliance Officers observed E3 on-shift and interacting with residents. 2. A review of the facility's employee work schedule revealed a schedule for July 2024, that included the names of employees working each day, with no record of hours worked by each. The employee work schedule, did not contain documentation that E3 was scheduled to work on July 30, 2024. No further documentation of the caregivers scheduled to work, and hours worked by each was available for Compliance Officer review. 3. In an interview, E1 acknowledged the employee work schedule did not include documentation of the caregivers who worked each day, and the hours worked by each.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for three of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A 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, 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, 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E1's personnel record revealed a hire date of January 20, 2024. 4. A review of E1's personnel record revealed a negative TB skin test that was less than 12 months old and no additional documentation of freedom from infectious TB was available for review. 5. A review of E2's personnel record revealed a hire date of June 17, 2024. 6. A review of E2's personnel record revealed a negative TB skin test that was less than 12 months old and no additional documentation of freedom from infectious TB was available for review. 7. A review of E3's personnel record revealed a hire date of July 11, 2024. 8. A review of E3's personnel record revealed a negative TB skin test that was less than 12 months old and no additional documentation of freedom from infectious TB was available for review. 9. In an interview, E1 reported E1 was unaware of the new TB policies as specified in R9-10-113. E1 acknowledged E1, E2, and E3 did not provided evidence of freedom from infectious TB as specified in R9-10-113. This is a repeat citation from the abbreviated inspection conducted on August 15, 2023.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that included the level of service the resident was expected to receive for one of three residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a current service plan, dated February 23, 2024. The written service plan did not include documentation of the level of service the resident was expected to receive. 2. In an interview, E1 acknowledged the service plan did not include the level of service the resident was expected to receive. This is a repeat citation from the abbreviated inspection conducted on August 15, 2023.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated at least once every three months for a resident receiving directed care services for one of one resident sampled. Findings include: 1. A review of R1's medical record revealed R1 received directed care services. 2. A review of R1's medical record revealed a service plan dated February 23, 2024. No further documentation of a current, updated service plan was available for Compliance Officer review. 3. In an interview, E1 acknowledged R1's medical record did not include a written service plan updated at least once every three months.

Based on record review and interview, the manager failed to ensure that a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1 for one of three residents sampled. The deficient practice posed a risk as the Department was unable to verify services were provided to residents. Findings include: 1. A.R.S. Title 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical record as follows... If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider." 2. The Compliance Officers requested to review R3's medical record. However portions of R3's medical record were unable for Compliance Officer review. R3's medical record did not contain the following required documentation per R9-10-811.C: - The date of termination of residency; - Documentation of assisted living services provided to the resident; - Documentation of medication administered to the resident; and - Documentation of any actions taken to control the resident's sudden, intense, or out-of-control behavior. 3. In an interview, E1 reported being unaware of the requirements to maintain a resident's medical record per A.R.S. Title 12, Chapter 13, Article 7.1. E1 acknowledged R3's medical record was not maintained according to A.R.S. Title 12, Chapter 13, Article 7.1.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of assisted living services provided to the resident for three of three residents sampled. The deficient practice posed a risk if services provided could not be verified. Findings include: 1. A review of R1's service plan revealed R1 received the following assisted living services: - Monitor skin integrity daily; - Incontinence check every 3 hours; - Medication administration; - Offers sufficient fluids at least 6-8 glasses a day; and - Offers adequate nutritional intake, offers resident to eat meals, snacks, and drink fluids daily. 2. A review of R2's service plan revealed R2 received the following assisted living services: - Shower, twice a week; - Shampoo, twice a week; - Check nails after each complete bath and clean as needed; - Comb hair daily; - Shave as needed; - Full assistance with dressing; - Full assistance with room maintenance; - Transfer assistance with one caregiver; - Medication administration; - Offers sufficient fluids at least 6-8 glasses a day; - Blood pressure checks daily; - Pulse checks daily; - Temperature checks daily; and - Weight checks daily. 3. A review of R3's service plan revealed R3 received the following assisted living services: - Shower, twice a week; - Shampoo, twice a week; - Oral care reminders; - Check nails daily and clean as needed - Trim finger nails as needed; - Comb hair daily; - Full assistance with room maintenance; - Reminders of toileting; - Incontinent check as needed; - Medication administration; and - Offers sufficient fluids at least 6-8 glasses a day. 4. A review of R1's, R2's, and R3's medical records revealed no documentation of the assisted living services provided to the residents. 5. In an interview, E1 reported documentation of services was done digitally, but no documentation was provided for Compliance Officer review. E1 acknowledged R1's, R2's and R3's medical records did not contain documentation of assisted living services provided to the residents.

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident for one of three residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication list dated April 29, 2024 signed by an RN for: - Losartan 50 milligrams (mg), one tablet per mouth (po) daily (qd); - Furosemide 40 mg, 1 tablet po qd; - Duloxetine 60 mg, 1 capsule po qd; - Prednisone 10 mg, 1 tablet po; and - Sertraline HCl 100 mg, 1 tablet po at bedtime (qhs). However the medication list was not signed by a medical practitioner as required. 3. A review of R1's medication administration record (MAR) for July 2024 revealed the administration of the following medications: - Losartan 50 mg, 1 tablet po qd and indicated 1 tablet was administered at 8:00AM July 1 - present; - Furosemide 40 mg, 1 tablet po qd and indicated 1 tablet was administered at 8:00AM July 1 - present; - Duloxetine 60 mg, 1 capsule po qd and indicated 1 tablet was administered at 8:00AM July 1 - present; - Prednisolone 5 mg, 2 tablets po qd indicated 2 tablets were administered at 8:00AM July 1 - present; - Sertraline HCl 100 mg, 1 tablet po at qhs and indicated 1 tablet was administered at 8:00PM July 1 - present. 4. The Compliance Officers observed the following medications stored by the facility for administration to R1: - Losartan 50 milligrams (mg); - Furosemide 40 mg; - Duloxetine 60 mg; - Prednisolone 10 mg; and - Sertraline HCl 100 mg. 5. In an interview, E1 acknowledged R1's medical record did not contain a medication order from a medical practitioner for each medication that was administered to the resident.

Based on record review, observation and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order for one of three residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed R2 received medication administration. 2. A review of R2's medical record revealed a signed medication order dated May 30, 2024 for Lisinopril 10 milligrams (mg), 1 tablet per mouth (po), every day (qd), hold if Systolic Blood Pressure (SBP) is less than 130 millimeters of mercury (mmHg) and Amlodipine Besylate 10 mg, 1 tablet po qd. 3. E1 reported R2's systolic blood pressure (SBP) measured below 130 mmHg on July 30, 2024 with a reading of 115/89 mmHg. 4. A review of R2's medication administration record (MAR) for July 2024 revealed R2 received Lisinopril 10 mg, 1 tablet po qd and indicated one tablet was administered at 8:00AM July 30, 2024. 5. The Compliance Officers observed one Amlodipine Besylate 10 mg tablet remaining in the AM slot for July 30, 2024 of R2's medication organizer after administration of 8:00AM medications. 6. In an interview, E2 reported holding Amlodipine Besylate rather than Lisinopril on July 30, 2024. E1 acknowledged R2 did not receive Amlodipine Besylate 10 mg and Lisinopril 10 mg in compliance with a medication order. 7. A review of R2's medical record revealed a signed medication order dated May 30, 2024 for Trazodone 50 mg, 1 tablet po at bedtime (qhs) as needed (PRN). 8. The Compliance Officers observed one tablet of Trazodone 50 mg in R2's medication organizer prefilled in the PM slot for the dates July 30 - August 4, 2024. 9. In an interview, E2 reported R2 was administered one tablet of Trazodone 50 mg nightly. E1 acknowledged R2 was not administered Trazodone 50 mg in compliance with a medication order.

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was documented in the resident's medical record for two of three residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's and R2's medical records revealed R1 and R2 received medication administration. 2. A review of R1's medical record revealed an unsigned medication list dated July 30, 2024, including the following medications: - Advair Diskus 250 - 50 MCG/ACT, 1 inhalation twice a day (bid); - Oxycodone HCl 10 milligrams (mg), 1 tablet by mouth (po) every evening (qhs); and - Oxycodone-Acetaminophen 10-325 mg, 1 tablet po q6h and needed (PRN). 3. A review of R1's medical record revealed a signed medication order (dated July 20, 2024) for Nystatin 5 mL, 5 mL po swish and swallow q6h for 10 days. 4, A review of R1's medication administration record (MAR) for July 2024 revealed no documentation of the following medications: - Advair Diskus 250 - 50 MCG/ACT; - Nystatin 5 mL; and - Oxycodone HCl 10 milligrams (mg). 5. In an interview, E1 acknowledged documentation of medication administration for the aforementioned medications to R1 was not recorded in R1's MAR. 6. A review of R1's MAR for July 2024 revealed no administration of Oxycodone-Acetaminophen 10-325 mg from July 1 - present. 7. The Compliance Officers observed E2 administer Oxycodone-Acetaminophen 10-325 mg to R1. E2 reported R1 has received Oxycodone-Acetaminophen 10-325 mg in the month of July, but no documentation of administration was available for review. 8. In an interview, E1 acknowledged R1's MAR did not accurately document medication administered to R1. 9. A review of R2's medical record revealed signed medication orders dated May 30, 2024 for the following medications: - Trazodone 50 mg, 1 tablet po qhs PRN; - Sennosides (Senna) 8.6 mg 1 tablet po twice a day (bid); and - Lisinopril 10 mg, 1 tablet po qd with a hold order if systolic blood pressure is less than 130 mmHg. 10. A review of R2's medical record revealed a discontinue (d/c) order for Senna 8.6 mg dated July 9, 2024. 11. A review of R2's MAR for July 2024 revealed documentation of administration of Senna 8.6 mg 1 tablet per moth (po) twice a day (bid) and and indicated 1 tablet was administered at 8:00AM and 8:00PM July 1 - present. 12. The Compliance Officers did not observe Senna 8.6 mg stored by the facility, or in R2's medication organizer. E2 reported R2 was not administered Senna 8.6 mg following the d/c order July 9, 2024. 13. A review of R2's MAR for July 2024 revealed no documentation of Trazodone 50 mg 1 tablet po at bedtime (qhs) and indicated R2 did not receive administration of Trazodone from July 1 - present. 14. The Compliance Officers observed 1 tablet of Trazodone 50 mg stored in R2's medication organizer prefilled in the PM slot for July 30 - August 4, 2024. E2 repo

Based on documentation review, record review, interview, and observation, the manager failed to ensure that a caregiver immediately reports a medication error to the medical practitioner who ordered the medication. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Errors." The policy stated, "The manager or caregiver will immediately report a medication error to the medical practitioner who ordered the medication ...The manager or caregiver will also report the error immediately to the Emergency Contact." 2. A review of R2's medical record revealed a signed medication order for Lisinopril 10 milligrams (mg), dated May 30, 2024, 1 tablet by mouth (po), every day (qd), hold if Systolic Blood Pressure (SBP) is less than 130 millimeters of mercury (mmHg). 3. E1 reported R2's systolic blood pressure (SBP) measured below 130 mmHg on July 30, 2024 with a reading of 115/89 mmHg. 4. A review of R2's medication administration record (MAR) for July 2024 revealed R2 received Lisinopril 10 mg, 1 tablet po qd and indicated one tab was administered at 8:00AM July 30, 2024. 5. In an interview, E1 acknowledged R2 was not administered Lisinopril, as it should have been held, in compliance with a medication order on July 30, 2024. E1 also acknowledged the administration of Lisinopril to R2 was a medication error. When asked their policy on reporting medication errors, E1 reported their policy was to contact the medical practitioner. 6. The Compliance Officers, at the time of exit at 4:15PM, had not observed E1 or E2 take immediate action following the determination of a medication error.

Based on documentation review, observation and interview, the manager failed to ensure that the premises and equipment used at the facility were cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posted a risk to the physical health and safety of the residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Infection Control." The policy stated, "A manager will ensure that the premises ... are cleaned and disinfected ... to prevent minimize, and control illness or infection." 2. During an environmental tour of the facility, the Compliance Officers observed a glue-based fly trap hung, from a sprinkler head, above the kitchen counter used for food preparation. The trap held multiple flies and other insects caught in the sticky residue. 3. In an interview, E1 acknowledged the kitchen and food preparation areas were not cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection.

Based on observation and interview, the manager failed to ensure that garbage was stored in covered containers lined with plastic bags. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed uncovered garbage containers in the kitchen, located next to the food preparation areas. The Compliance Officers also observed uncovered, unlined garbage containers in a resident room. 2. In an interview, E1 acknowledged garbage was not stored in covered containers lined with plastic bags.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a water temperature of 125\'ba F a the shared bathroom for residents. 2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95\'ba F and 120\'ba F in areas used by residents.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the assisted living facility were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a bottle of Lysol Disinfectant Spray and DermaRite 3-N-1 Foaming Body Wash, Shampoo, & Peri-Cleanser stored by the facility in an unlocked cabinet above the toilet of a shared resident bathroom. 2. In an interview, E1 acknowledged the toxic materials store by the facility were not maintained in a locked area and inaccessible to residents.

Based on observation and interview, the manager failed to ensure that a resident bathroom contained paper towels in a dispenser or a mechanical air hand dryer for a bathroom that was used by more than one resident. The deficient practice posed a potential risk to infection control. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a shared resident bathroom with a paper towel dispenser that did not contain any paper towels. 2. In an interview, E1 reported they removed the paper towels due to resident behavior. E1 acknowledged the shared resident bathroom did not contain paper towels in a dispenser or a mechanical air hand dryer.

Based on record review and interview, the manager failed to ensure compliance with A.R.S. \'a7 36-411, which required owners to make documented, good faith efforts to verify the current status of a person's fingerprint clearance; for two of two personnel members sampled. The deficient practice posed a risk if E1 or E2 were a danger to vulnerable populations. Findings include: 1. A Review of of E1's and E2's personnel record did not reveal evidence of a fingerprint clearance card. 2. In an interview, E1 acknowledged E1's and E2's personnel record did not reveal evidence of a fingerprint clearance.

Based on observation, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrator and Assisted Living Facility Managers (NCIA Board) for one of one personnel members sampled. The deficient practice posed a risk if a caregiver was not qualified to provide the required services, and if the Department was provided false and misleading information related to a caregiver's certification and name. Findings include: 1. Upon arrival to the facility, the Compliance Officer observed E2 working at the facility with five residents present. 2. A review of E2's personnel record, revealed a different name on the file, compared to the name E2 provided the Compliance Officer, upon arrival. Further review of E2's personnel record, revealed a caregiver's certificate with a completion date of June 22, 2013. 3. A search of the caregiver certificate provided, revealed inaccurate start and completion dates of the training, and revealed a different instructor's name as compared to the name listed on the certificate. 4. In an interview, E2 reported to have completed E2's caregiver training in 2022. When asked about E2's real name, E2 stated E2 had given the Compliance Officer E2's nick name instead of E2's actual legal name. 5. In an interview, E1 acknowledged E2's caregiver's certificate was not valid, and instructed E2 to leave the facility.

Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, and according to policies and procedures for two of two personnel members sampled. The deficient practice, posed a risk to the health and safety of residents if a caregiver was unable to meet the needs of residents. Findings include: 1. A review of E1's personnel record (hired in July 2023), did not reveal evidence of skills and knowledge verification. 2. A review of E2's personnel record (hired in 2022), did not reveal evidence of skills and knowledge verification. 3. In an interview, E1 acknowledged E1's and E2's personnel record did not reveal evidence of skills and knowledge verification and confirmed E1 and E2 had provided services to residents since E1's and E2's date of hire.

Based on record review and interview, the manager failed to ensure a caregiver who was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two personnel members sampled. The deficient practice posed a health and safety risk to infection control if personnel were not free from TB. Findings include: 1. A review of E1's and E2's personnel records, revealed no evidence of E1's and E2's freedom from infectious TB. 2. In an interview, E1 acknowledged E1's and E2's personnel record did not reveal evidence of E1's and E2's freedom from TB.

Based on observation, record review, and interview, the manager failed to ensure, before providing assisted living services to a resident, a caregiver or an assistant caregiver received orientation specific to the duties to be performed by the caregiver or assistant caregiver, for two of two personnel members sampled. The deficient practice posed a risk to the health and safety of residents if personnel did not receive orientation as to the specific job duties. Findings include: 1. Upon arrival at the facility, the Compliance Officer observed E1 and E2 providing services to residents in the home. 2. A review of E1's and E2's personnel records, revealed no evidence of completed orientation. 3. In an interview, E1 acknowledged E1's and E2's personnel record did not contain documentation of completed orientation, and confirmed E1 and E2 had provided services to residents since E1's and E2's date of hire.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of one residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record, revealed a service plan for personal care services dated in August, 2023. However, the service plan did not include a description of R1's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. In an interview, E1 acknowledged R1's service plans did not include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments.

Based on resident record review and interview, the manager failed to ensure that a resident has a written service plan that includes the level of service the resident is expected to receive; for one of one residents sampled. Findings include: 1. A review of R1's medical record, revealed a current service plan dated in August, 2023. However, the plan did not include the level of service the resident was expected to receive. 2. In an interview, E1 acknowledged R1's service plan did not include the level of service the resident was expected to receive.

Based on record review, documentation review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of one residents sampled. The deficient practice posed a health and safety risk to the resident if a caregiver was unable to identify if a medication was administered. Findings include: 1. A review of R1's medical record, revealed medication orders for Humalog and Metformin, among other medications prescribed to R1. 2. A review of R1's medical record, revealed R1 was to receive medication administration. 3. The Compliance Officer made a request to review the medication administration record (MAR). However, the MAR was not available for review. 4. In an interview, E1 acknowledged the MAR for R1 was not available to review as a result of not being able to log onto the computer to access R1's MAR record.

Based on observation and interview, the manager failed to ensure a resident's sleeping area was not used as a passageway to another sleeping area. Findings include: 1. During the facility tour, the Compliance Officer observed a resident bedroom in the facility, where two residents resided. The Compliance Officer observed a walk-in closet which contained a bed in the bedroom's bathroom. 2. In an interview, E1 confirmed two of the facility's residents reside in the resident bedroom, and reported the closet served as a caregiver's resting area. 3. In an interview, E1 acknowledged the residents' sleeping area was being used as a passage way to another sleeping area.