Villa Tampico

Based on record review and interview, the manager failed to ensure compliance with A.R.S. § 36-411, for two of two sampled personnel. The deficient practice posed a risk if personnel were a danger to a vulnerable population. Findings include: 1. A review of E1's and E2's personnel records revealed documentation of verification each employee was not on the adult protective services registry. However, the documentation of verification was not dated. 2. A review of E2's personnel record revealed E2 was employed as a caregiver. E2's personnel record included a copy of a fingerprint clearance card with a marked expiration of November, 26, 2025. 3. Online verification of E2's fingerprint clearance card revealed the card was not valid. However, due to E2's date of hire being more than 20 working days prior to the date of the inspection, a valid fingerprint clearance card was required per A.R.S. § 36-411(A). 4. A review of E2's personnel record revealed a copy of a paper application for a fingerprint clearance card, dated November 6, 2025. 5. In an interview, E1 reported the facility had mailed the application for E2 to the Department of Public Safety (DPS) on November 6, 2025. 6. Online verification of E2's fingerprint clearance card application revealed no results. 7. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site complaint inspection conducted on May 16, 2025.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a kitchen cabinet located below the kitchen sink. The Compliance Officer observed the cabinet was equipped with magnetic locks. However, at the time of the inspection, the magnetic lock on the right hand cabinet door was locked in the open position and the Compliance Officer was able to open the cabinet without a magnet. Inside the cabinet, the Compliance Officer observed containers of Clorox bleach and Weiman stovetop cleaner. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411(A), for one of two personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. A.R.S. § 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work. Findings include: 1. A review of E3's personnel record revealed E3 had been hired as a caregiver in October of 2017 and had last worked as a caregiver at the facility on May 12, 2025. 2. A review of E3's personnel record revealed a fingerprint clearance card with a marked expiration date of March 26, 2025. 3. Online research at www.azdps.gov revealed E3's fingerprint clearance card was expired. 4. In an interview, E1 acknowledged E3 did not have a current fingerprint clearance card after March 26, 2025.

Based on documentation review and interview, the manager failed to ensure residents were treated with dignity, respect, and consideration. The deficient practice posed a potential resident rights violations if residents were subjected to ridicule, demeaning, or derogatory remarks. Findings include: A review of facility incident reports revealed an internal investigation report dated May 12, 2025. The incident report included witness statements from three residents alleging multiple incidents where residents had been intimidated, harassed, yelled at, ignored, roughly handled, and mocked by E3 and E4. In an interview with R1, R1 detailed multiple incidents when residents had been intimidated, harassed, yelled at, ignored, roughly handled, and mocked by E3 and E4. In an interview with R2, R2 detailed multiple incidents when residents had been intimidated, harassed, yelled at, ignored, roughly handled, and mocked by E3 and E4. In an interview with R3, R3 detailed multiple incidents when residents had been intimidated, harassed, yelled at, ignored, roughly handled, and mocked by E3 and E4. In an interview, E1 and E2 acknowledged E3 and E4 had not treated residents with dignity, respect, and consideration.

Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of two employees sampled. 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. R9-10-113.B.1.b states: For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: If the individual had a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, compliance with subsection (A)(2)(b)." 3. R9-10-113.A.2.b states: "If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201:. Referring the individual for assessment or treatment; and annually obtaining documentation of the individual ' s freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101." 4. A review of E5's personnel record revealed E5 had been hired as a caregiver in January of 2023. E5's personnel record included a positive Quantiferon-TB Gold Plus blood test, an X-ray and doctor's statement, dated October 2, 2023, stating E5 had, "no evidence of acute cardiopulmonary process, and a negative TB screening dated April 3, 2023. However, E5's personnel record did not include documentation of annual documentation of E5's freedom from symptoms of infectious tuberculosis, dated on or before October 2, 2024, per R9-10-113.A.2.b. 5. In an interview, E1 acknowledged the personnel file provided for E5 had not included documentation of evidence of freedom from infectious TB as required by R9-10-113.

Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of one residents sampled who was administered an opioid. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Opioid Prescribing, Ordering, Administration, Monitoring and Surveillance Quality Management Emergency Rule Effective 7/27/2017," which stated, "Before administering an opioid...the certified caregiver...will be responsible for the following:...Documenting on the respective Opioid Log Form for the following...The pain evaluation score assessed at time just prior to the initial dose of opioid medication...the paint evaluation score re-assessed two (2) hours after the initial dose of opioid medication." 2. A review of R2's medical record revealed a service plan, updated August 7, 2024, for directed care services including medication administration. The service plan indicated R2 received hospice services. 3. In an interview, E1 reported R2 had discharged from hospice on October 8, 2024 and the service plan had not yet been updated. 4. A review of R2's medical record revealed a list of medication orders, dated July 2, 2024, which included an order for, "Oxycodone HCL 5 MG tablet, take 1 tablet by mouth every morning for pain." 5. A review of R2's medical record revealed a Medication Administration Record (MAR) dated October 2024. The MAR indicated R2 had been administered Oxycodone on each day in October 2024. 6. A review of R2's medical record revealed documentation of R2's pain evaluation score prior to administration and R2's pain evaluation score two hours after administration, for October 9 through October 23, 2024, were not available for review. 7. In an interview, E1 acknowledged the medical record provided for R2 had not included documentation of an identification of R2's need for an opioid or documentation of the effect of the opioids administered to R2 in the manner required by the facility's policy.

Based on documentation review, observation, and interview, the manager failed to ensure a facility authorized to provide directed care services had a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area, which alerted employees of the egress of a resident from the facility. The deficient practice posed potential egress dangers to residents. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed the back door, leading to the secured backyard, did not sound to alert employees of the egress of a resident from the facility. 3. E3 turned the alert on and the Compliance Officer observed two residents with surprised looks on their face when it sounded, because the alert was loud. 4. In an interview E1 acknowledged the back door did not alert employees of the egress of a resident from the facility. E1 acknowledged the alert would be kept on and would explore options for a replacement. This is a repeat deficiency from the complaint and compliance inspection conducted on September 8, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure a facility authorized to provide directed care services had a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area, which alerted employees of the egress of a resident from the facility. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed when exiting from back door leading to the secured backyard, no alarm sounded to alert employees of the egress of a resident from the facility. 4. In an interview E1 acknowledged the back door did not alert employees of the egress of a resident from the facility due to the batteries being discharged.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. Findings include: 1. During the facility tour, the Compliance Officer observed an unlocked laundry room, accessible to residents. The Compliance officer observed the following toxic materials inside an unlocked cabinet in the laundry room: - a can of "furniture Polish"; - a bottle of "Weiman Disinfectant Stovetop cleaner"; - a can of "Comet"; - a bottle of "Snuggle" Fabric Refresher; and - a bottle of Shout Advanced Ultra Concentrated Gel". 3. In an interview, E1 acknowledged the toxic materials were stored in cabinets which were unlocked and accessible to residents.