St Therese Care Home 2, LLC

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. 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 the facility’s September 2025 personnel schedule revealed E1 and E2 worked every day. 2. A review of E1's personnel record revealed E1’s hire date of December 18, 2019. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. A review of E2's personnel record revealed E2’s hire date of December 18, 2019. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 4. A review of the facility’s policies and procedures revealed a policy addendum signed December 23, 2022, titled “Tuberculosis Infection Control.” The policy stated, “All employees need to undergo Annual Review on Knowledge and Practice Tuberculosis Prevention.” 5. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with the requirements A.R.S. § 36-411(A) and (C ). The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. According to A.R.S. § 36-411(C ) states “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. A review of E3’s personnel record revealed no documentation of the facility contacting previous employers. 3. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.

Based on observation, documentation review, record review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. Upon arrival at the facility, E2 and E3 were the only employees at the facility with two residents. 2. A review of the personnel schedule for July, August, and September 2025 revealed E3 was not documented on the schedule for September 19, 2025. 3. A review of E3’s personnel records revealed that E3 was hired on November 19, 2024. 4. During the inspection, the Compliance Officers observed E3 providing services to R1. 5. During an interview, E1 and E2 reported that E3 was considered a reliever on the schedule. E1 and E2 acknowledged that E3 was not listed on the schedule for September 19, 2025. 6. In an exit interview, the findings were reviewed with E1 and E2, 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. During the environmental tour, the Compliance Officers observed residents’ medical records sitting on a bookshelf in the office, which was on the right when you enter through the front door. 3. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two 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 a current written service plan dated August 10, 2025. This service plan indicated R2 received medication administration. 2. A review of R2's medical record revealed a signed medication order dated August 10, 2025. The medication order stated the following: “Midodirine HCL 5 mg 1 tab mouth TID hold SBP﹥130” 3. Review of R2's medical record revealed a September 2025 medication administration record (MAR). This MAR stated the following: “Midodrine HCL 5 mg 1 tab mouth TID hold SBP﹥130” administered from September 1, 2025, to September 18, 2025, at 7:00 am, 12:00 pm, and 7:00 pm. 4. Review of R2's medical record revealed a document titled "Resident Vital Signs" dated September 2025. This document revealed R2's vitals were only taken in the morning from September 1, 2025, to September 18, 2025. 5. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within calendar days after the resident's date of occupancy, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of R2's (admitted in 2023) medical record revealed evidence of freedom from infectious TB was not available for review. 2. In a joint interview, E1 and E2 acknowledged R2's evidence of freedom from infectious TB was not completed before or within calendar days after the resident's date of occupancy.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed documentation of R1's orientation to exits from the assisted living facility was not available for review. 2. A review of R2's medical record revealed documentation of R2's orientation to exits from the assisted living facility was not available for review. 3. In an interview, E2 reported R1 and R2 received orientation to exits from the facility. 4. In a joint interview, E1 and E2 acknowledged R1's and R2's medical records did not contain documentation of R1's and R2's orientation to exits from the facility.