Villas at Green Valley, Villa C

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the residents date of occupancy as specified in R9-10-113 for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. 1. A review of R1's medical record revealed no evidence of documentation of a negative TB skin test or blood test. 2. In an exit interview, the findings were reviewed with E1 and E2. E1 acknowledged that R1's medical record did not include evidence of freedom from infectious TB. E1 stated R1 did have a TB test and indicated they reached out to R1's POA to provide a copy, but were unable to retrieve it before the conclusion of the inspection.

Based on observation, documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of four personnel members sampled. Findings include: 1. A review of E5's personnel record revealed E5 was hired as an assistant caregiver on July 7, 2022. The record included an employee application which identified a single previous employer of E5 and indicated, "Dates worked from: Friday to Monday." Further review revealed an application for fingerprint clearance card dated October 18, 2022, over 90 days after E5's date of hire. E5's personnel record also included a valid fingerprint clearance card with an issue date of February 14, 2023. Evidence of a previously issued fingerprint clearance care was unavailable for review. 2. A review of staffing schedules from August 2022 revealed E5 worked the on the following shifts and dates: 9 A.M. through 7 P.M., August 1, 2, 3, 7, 8, 9, 10, 14, 15, 16, 17, 22, 23, 24, 29 and 30, 2023 7 A.M through 7 P.M., August 29 and 30, 2023 3. In an interview E1 reported E5 did not have a fingerprint clearance card on E5's date of hire. E1 acknowledged E5 worked as an assistant caregiver between E5's date of hire and October 18, 2022, without having applied for a fingerprint clearance card.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a current service plan indicating R1 required directed care and was to receive the following services: "Showering, Complete Assist, 2x per week;" and "Adaptive Devices/Prosthetics: Eyeglasses, Complete Assist." 2. A review of R1's medical record revealed a document titled, "Caregiver ADL Checklist," dated August 2023, used for documenting services provided and activities of daily living. The document indicated R1 was to receive a shower on Sunday's and Wednesdays, and included a section titled, "Bathing," to document the service. The document indicated R1 received a shower on Wednesday, August 2, and Wednesday, August 9, 2023, however the document indicated, "N/A" on Sunday August 6, and Sunday August 13, 2023. The record also contained a section to document the service, "Eyeglasses/ Hearing Aid," however the service was documented as "N/A" on August 1 through August 14, 2023. 3. In an interview, E1 acknowledged R1 was not being provided the services as described in R1's service plan.