Tangelo Grove Senior Care Home

Based on documentation review and interview, the assisted living home that contacted an emergency responder on behalf of a resident failed to provide to the emergency responder a written document that included all of the information required in A.R.S. § 36-420.04.A.1-9, for one of one applicable residents reviewed. 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 facility documentation revealed a binder titled "911 Binder - Tangelo Grove Emergency Binder." Within the binder was a dedicated section for R1, which contained a partially completed "Face Sheet," a copy of R1's September 2025 Medication Administration Record (MAR), and a DNR form. The information compiled for R1 did not contain all of the information required in A.R.S. § 36-420.04.A.1-9. 2. Further review revealed a blank "Assisted Living Resident Transfer Checklist" form in the back slot of the binder. The form had not been completed and provided to the emergency responder for R1 as required. 3. A review of the facility's policies and procedures revealed a policy titled "R9-10-809 - Transport and Transfer." The policy stated, "C. In an emergency transport, transfer situation, the facility will provide a copy of the resident's Emergency Medical Information Form, current medication list, and insurance cards." 4. In an interview, E2 acknowledged the assisted living home failed to provide the emergency responder with a written document that included the information required in A.R.S. § 36-420.04.A.1-9. E2 also acknowledged that the facility did not provide the emergency responder with details of the incident and what had happened that led to the call for emergency response.

Based on documentation review and interview, the assisted living home failed to complete and maintain a standardized form for each resident that included the required information prescribed in subsection A of A.R.S. § 36-420.04 (except for the information prescribed in subsection A.1), which shall be provided at the time the emergency responder is contacted, for ten of ten residents reviewed. 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 facility documentation revealed a binder titled "911 Binder - Tangelo Grove Emergency Binder." Within the binder were ten tabs, one for each of the current residents, except for R2 who did not have any information. Within each section were partially completed "Face Sheets," a copy of each residents September 2025 Medication Administration Record (MAR), and a DNR form, if applicable. The information compiled for each resident did not contain all of the information required in A.R.S. § 36-420.04. 2. Further review revealed blank "Assisted Living Resident Transfer Checklists" forms in the back slot of the binder. The blank forms had sections for all of the information required in A.R.S. § 36-420.04; however, they were not filled out. 3. In an interview, E2 acknowledged the assisted living home failed to complete and maintain a standardized form for each of the ten current residents that included the information required in A.R.S. § 36-420.04.

Based on record review, documentation review, and interview, the manager failed to ensure that an assisted living facility had a manager, caregivers, and assistant caregivers necessary to meet the needs of a resident and ensure the health and safety of a resident for one of three residents sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a service plan dated July 1, 2025. The service plan indicated R1 received directed care services; was non-ambulatory; required a "2 person" transfer and "Maximum" assistance; and was "unable to use [call bell], C/G does frequent [checks]." The service plan also indicated that R1 required maximum assistance with "emergency exiting, ambulation, transfers, toileting, bathing, skin care, dressing, comb hair, oral care, nail care...activities, exercise/ROM...[and] medications." 2. A review of the facility's work schedule revealed on August 3, 2025, for the "7am-7pm" shift, only one caregiver was documented as working with a facility census of 10 residents; on August 16, 2025, for the "7am-7pm" shift, only an assistant caregiver was documented as working, and for the "7pm-7am" shift, no employees were documented as working; and on September 16, 2025, there was no one documented as working for the "7pm-7am" shift. 3. A review of the facility's policies and procedures revealed a policy titled "R9-10-803.C.1.h," which was created "to ensure that the house has the appropriate staff available to care for the residents in case the caregiver assigned is not available to work." 4. In an interview, E2 was unable to say who worked on the aforementioned days in question. No further information was provided.

Based on documentation review and interview, the manager failed to ensure that documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings include: 1. A review of the facility's work schedule revealed a "Call out" on August 3, 2025, for the "7am-7pm" shift for one of two caregivers scheduled to work. No other employee was documented as covering the shift, leaving only one caregiver to attend to 10 residents from 7:00am to 7:00pm. Further review revealed a "Double call out" on August 16, 2025, for the only caregiver scheduled to work the "7am-7pm" and the only caregiver scheduled to work the "7pm-7am" shift. No other employees were documented as covering the shifts, leaving no one on the schedule for the 7:00pm to 7:00am shift, and only an assistant caregiver on the schedule for the 7:00am to 7:00pm shift. Further reviewed revealed on September 16, 2025, there was no one scheduled to work the "7pm-7am" shift. 2. A review of the facility's policies and procedures revealed a policy titled "R9-10-803.C.1.h," which was created "to ensure that the house has the appropriate staff available to care for the residents in case the caregiver assigned is not available to work." 3. In an interview, E2 was unable to say who worked on the aforementioned days in question and acknowledged the manager failed to document the days worked by the caregivers, including the hours worked by each, on August 3, 2025; August 16, 2025; and September 16, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure that at least the manager or a caregiver was present in an assisted living facility when residents were present. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of the facility's work schedule revealed on August 16, 2025, for the "7am-7pm" shift, only an assistant caregiver was documented as working, and for the "7pm-7am" shift, no employees were documented as working; and on September 16, 2025, there was no one documented as working for the "7pm-7am" shift. 2. A review of the facility's policies and procedures revealed a policy titled "R9-10-803.C.1.h," which was created "to ensure that the house has the appropriate staff available to care for the residents in case the caregiver assigned is not available to work." 3. In an interview, E2 was unable to say who worked on the aforementioned days in question. No further information was provided.

Based on documentation review, record review, and interview, the manager failed to maintain a personnel record for each employee as required by R9-10-806.C.1.a-c, for one of five employees sampled. The deficient practice posed a risk as required information could not be verified for an employee. Findings include: 1. A review of facility documentation revealed the employee schedule. E5 was regularly scheduled to work every Sunday from at least July 2025 to the present. 2. A review of personnel records revealed E5 did not have a personnel file available for review. 3. In an interview, E2 stated E5 had a personnel record at an another affiliated assisted living home and acknowledged E5 did not have a personnel record available for review at the current home at the time of the inspection.

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis 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 potential TB exposure risk to residents. Findings include: 1. A review of R3's medical record revealed a completed TB Screening and Risk Assessment; however, there was no documentation of evidence of freedom from infectious TB. Based on R3's date of admission, this documentation was required. 2. In an interview, E2 acknowledged there was no documentation of evidence of freedom from TB for R3 available for review at the time of the inspection.

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of Department documentation revealed this statute went into effect on October 1, 2021. 2. A review of E3's personnel record revealed E3 was hired in 2005. E3's personnel record contained a document titled "Fall Prevention and Fall Recovery Program." The document stated: "Tangelo Grove has developed and has administered a training program for all staff regarding fall prevention and fall recovery. Please see the attached information, training materials and documented training. Training will be ongoing throughout the calendar year." The first attached document, titled "Fall Prevention Initial Training," revealed E3 did not receive fall prevention and fall recovery training until January 20, 2023, more than one year after the statute went into effect. The second attached document, titled "Annual Fall Prevention Continued Competency Training," revealed the training was to be done annually. However, the review revealed no such annual training for E3 after January 20, 2023. 3. In an interview, E2 acknowledged E3 did not receive continued competency training annually after January 20, 2023. This is a repeat citation from the compliance inspection conducted on December 22, 2022.