Ageless Angels Assisted Living Home 1.

“Based on record review, documentation review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including 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 the facility’s documentation revealed no annual assessment of the facility's TB risk assessment.   2. In an interview, E4 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“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 two 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 that E1 had two negative skin tests dated outside the 12-month acceptance date from the hire date.  4. A review of E3’s personnel record revealed that E3 had two negative skin tests dated outside the 12-month acceptance date from the hire date.  5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on observation, record review, documentation review, and interview, the manager failed to ensure a personnel record was established and maintained for each employee as required for one of three personnel sampled. The deficient practice posed a risk as the required information could not be verified for E2.  Findings include: 1. A review of E2’s personnel record revealed the following:  No documentation of E2’s starting date of employment; No documentation of E2’s qualifications, including skills and knowledge; No documentation of E2’s completed orientation; No documentation of the two TB skin tests administered and read within 12 months of the hire date; No current CPR card;  No current first aid card;  No documentation of E2’s compliance with the requirements in A.R.S 36-411(A) and (C); and  No documentation of E2’s certification of completion according to R9-10-126. 2. A review of the facility’s February 2026 work schedule revealed E2 worked every Monday to Friday in the evening.  3. A review of the facility’s March 2026 work schedule revealed that E2 worked every Monday to Friday in the evening. 4. In an interview, E4 reported that E2 was hired for another assisted living facility. E4 reported that E2 works at both facilities. E4 acknowledged that a file for Ageless Angels was not created for E2. E4 reported photocopying the application and caregiver certification from the other assisted living home to keep at Ageless Angels. 5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“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 R1's medical record revealed documentation of TB signs and symptoms screening. However, there was no documentation of assessing risks of prior exposure to infectious TB. Based on R1's admission date, this documentation was required. 3. 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 two of two 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 January 1, 2026, which indicated that R1 received directed care services.  R1 required assistance with eating, oral care, nail care, hair care, dressing, bathing, toileting, and transferring.  2. A review of R1’s medical record revealed a March 2026 “Activities of Daily Living Chart.” However, no services were documented as completed from March 26, 2026, to March 30, 2026.  3. A review of R1’s medical record revealed an April 2026 “Activities of Daily Living Chart.” However, no services were documented as completed from April 1, 2026, to April 2, 2026.  4. A review of R2’s medical record revealed the following:  A current service plan dated March 1, 2026, which indicated that R2 received directed care services.  R2 required assistance with eating, oral care, nail care, hair care, dressing, bathing, toileting, and transferring.  5. A review of R2’s medical record revealed a March 2026 “Activities of Daily Living Chart.” However, no services were documented as completed from March 26, 2026, to March 30, 2026.  6. A review of R2’s medical record revealed an April 2026 “Activities of Daily Living Chart.” However, no services were documented as completed from April 1, 2026, to April 2, 2026. 7. In an interview, E3 reported that E2 called out and has not had an opportunity to document in the “Activities of Daily Living Chart.”  8. 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 a medication order from a medical practitioner for each medication that was administered to the resident, for one of two residents sampled. The deficient practice posed a risk as the medication administered could not be verified against a medication order. Findings Include: 1. A review of R1’s medical record revealed a current service plan dated January 1, 2026, which indicated that R1 received medication services.  2. A review of R1’s medication administration record (MAR) for March 2026 revealed that R1 was administered “Ondansetron 4mg” on March 2, 2026, and March 3, 2026.  3. A review of R1’s medical record revealed no signed medication order for “Ondansetron 4mg.” 4. In an interview, E3 reported that “Ondansetron 4mg” was administered without a signed medication order.  5. 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 medication administered to a resident 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 medication administration. Findings include:  1. A review of R1’s medical record revealed a signed medication order, dated March 9, 2026, at 3:07 pm, which indicated “Quetiapine 25 mg oral tablet 1 TAB by mouth at bedtime.”  2. A review of R1’s medication administration record (MAR) for March 2026 revealed that R1 was administered “Quetiapine 25 mg” one tablet twice a day from March 9, 2026, to March 22, 2026. However, the medication order indicated that R1 was to receive “Quetiapine 25 mg” at bedtime.  3. A review of R1’s medication administration record (MAR) for April 2026 revealed that R1 was administered “Quetiapine 25 mg” one tablet twice a day from April 1, 2026, to April 2, 2026.  4. In an interview, E3 acknowledged that R1 was administered “Quetiapine 25 mg” one tablet twice a day, even though the order changed to at bedtime.  5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was accurately documented in the resident's medical record for one of two residents reviewed. The deficient practice posed a health and safety risk to the resident if a caregiver did not know whether a medication was administered. Findings include: 1. A review of R2’s medical record revealed a current service plan dated March 1, 2026, which indicated that R2 received medication administration services.  2. A review of R2’s medication administration record (MAR) for April 2026 revealed that medication administration had not been documented as administered from April 1, 2026, to April 2, 2026.  3. In an interview, E3 acknowledged that the medication administration had not been documented as administered from April 1, 2026, to April 2, 2026. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”