Mingus Terrace Assisted Living Home.

“Based on documentation review, record review, and interview, the healthcare institution failed to implement tuberculosis (TB) infection control activities as specified in R9-10-113, for two of three personnel records reviewed. The deficient practice posed a risk as the caregivers received no organized instruction or information related to TB surveillance. 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: ...c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution." 2. A review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of December 22, 2024. Further review revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 3. A review of E3's personnel record revealed E3 worked as an assistant caregiver and had a hire date of February 5, 2025. Further review revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 4. In an interview, E1 reported there had been a lot of confusion regarding the TB rules. E1 acknowledged E2's and E3's personnel records did not contain documentation of training and education related to recognizing the signs and symptoms of TB. 5. This is a repeat deficiency from the compliance inspection conducted on January 25, 2024.”

“Based on record review, documentation review, and interview, the manager failed to ensure an employee had a valid fingerprint clearance card as required by A.R.S. § 36-411, for one of three employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A review of E2's personnel record revealed a hire date of December 22, 2024. 2. A review of facility documentation revealed a Mingus Terrace Work Schedule for April 2025. E2 had been scheduled to work 7 AM - 3 PM on April 1-4; 7-11; 14-18; 21-25; and 28-30, 2025. 3. Further review of E2's personnel record revealed documentation of a fingerprint clearance card (FPCC) that had expired June 6, 2023. There was a handwritten note on the copy of the card that said, "Exp - Resubmitted." There was no other documentation of an application for a new card or a copy of a new or current card. 4. Further review of E2's personnel record revealed a form regarding E2's hiring process titled "FOLLOW UP EMPLOYEE CHECKLIST." In the bottom section titled "Document to follow up on:," E1 had made note of E2's FPCC application needing follow up. 5. An on-line check of the State of Arizona Department of Public Safety (DPS) website revealed an "Invalid" status from a previous FPCC that was issued on June 6, 2017. It also revealed that E2 had submitted an application, which was received by DPS on January 31, 2025. The current status of that application stated, "Application Complete - Results mailed to applicant." No new or current FPCC had been issued. 6. In an interview, E1 reported E1 believed that E2 had submitted an application for a Good Cause Exception but that E2 had not provided E1 with a valid FPCC yet. E1 then asked E2 the status of the Good Cause Exception and E2 reported that E2 had not submitted it (or completed the process) yet. E1 acknowledged E2 did not have a valid FPCC and stated E2 would immediately be removed from the schedule until E2 obtained a valid card. 7. This is a repeat deficiency from the compliance inspection conducted on March 1, 2023.”

“Based on record review and interview, the manager failed to ensure that a personnel member who was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for two of three personnel reviewed. The deficient practice posed a potential TB infection risk to residents. Findings include: 1. A review of E2's personnel record revealed a hire date of December 22, 2024. Further review revealed one negative TB skin test dated August 31, 2020, and a second negative TB skin test dated December 26, 2024. 2. A review of E3's personnel record revealed a hire date of February 5, 2025. Further review revealed one negative TB skin test dated February 5, 2025; however, no documentation of a second TB skin test was available for review. 3. In an interview, E1 reported E2 and E3 would each get a second TB skin test completed immediately. E1 acknowledged E1 failed to implement TB infection control activities, including baseline screening for E2 and E3. 4. This is a repeat deficiency from the compliance inspection conducted on January 25, 2024.”

“Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. Findings include: 1. Review of the record for E1 (hired March 20, 2007), failed to reveal documentation of fall prevention and fall recovery training. 2. Review of the record for E2 (hired May 24, 2022), failed to reveal documentation of fall prevention and fall recovery training. 3. Review of the record for E4 (hired May 25, 2023), failed to reveal documentation of fall prevention and fall recovery training. 4. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been administered to all staff. This is a repeat deficiency from the compliance inspection conducted on March 1, 2023.”

“Based on record review and interview, the manager failed to ensure that for three of three sample resident records, a standardized emergency responder patient information form as described in subsection A. of this section, was completed and maintained for each resident. Findings include: 1. The record for R1 failed to contain the completed emergency responder patient information documentation. 2. The record for R2 failed to contain the completed emergency responder patient information documentation. 3. The record for R3 failed to contain the completed emergency responder patient information documentation. 4. During an interview, E1 acknowledged that the required documentation was not available for review.”

“Based on record review and interview, the manager failed to ensure that two of three sample personnel records, contained evidence of freedom from infectious tuberculosis (TB), on or before the date the individual began providing services to residents as specified in R9-10-113. Findings include: 1. The record for E3 (Caregiver, hired October 1, 2023) contained documentation indicating that only one TB test was administered. No other TB test documentation conducted within the past 12 months was found in the record. 2. The record for E4 (Caregiver, hired May 25, 2023) contained documentation indicating that only one TB test was administered. No other TB test documentation conducted within the past 12 months was found in the record. 3. During an interview, E1 acknowledged that the employees worked more than 8 hours per week and the documentation did not reflect that the employee records contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.”

“Based on interview and record review, the chief administrative officer failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. Review of the record for E1 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 2. Review of the record for E2 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 3. Review of the record for E3 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 4. Review of the record for E4 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 5. During an interview, E1 acknowledge that the required documentation was not available.”