H & a Family Care Home.

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for three of three personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population.   Findings Include:   1. A.R.S. § 36-411 states: C. Each residential care institution, nursing care institution, and home health agency shall make documented, good-faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A review of E1's personnel record (hired on April 25, 2016) did not include documentation of the verification that E1 was not on the adult protective services registry. 3. A review of E2's personnel record (hired on November 1, 2025) did not include documentation of the verification that E2 was not on the adult protective services registry. 4. A review of E3's personnel record (hired on January 1, 2026) did not include documentation of the verification that E3 was not on the adult protective services registry. 5. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for two of three personnel 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 E2's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E2 had signs or symptoms of TB. Based on E2's hire date, this documentation was required. 3. A review of E3's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E3 had signs or symptoms of TB. Based on E3's hire date, this documentation was required.   4. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two 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 no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required.   3. A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as the Department was provided false and misleading documentation as the facility pre-filled activities of daily living documentation.   Findings include:   1. A review of R2's medical record revealed a document titled "Activities of Daily Living," which documented the services that were provided to R2 in January 2026. Further review of the documentation revealed all services on January 30, 2026 (the day of the inspection) had been prefilled with initials to indicate all services had been provided for the day.   2. In an exit interview, the findings were reviewed with E1 and E4, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident’s weight or documentation from a medical practitioner indicating that weighing the resident was contraindicated, for one of two residents sampled.  Findings include: 1. A review of R1’s medical record revealed a service plan update dated January 15, 2026, and indicated R1 received directed care services. However, R1’s service plan did not include R1’s weight or documentation from R1’s medical practitioner stating that weighing R1 was contraindicated.  2. In an exit interview, the findings were reviewed with E1 and E4, and no additional information was provided. This is a repeat deficiency from the on-site inspection completed on October 5, 2023.”

“Based on documentation review, record review, and interview, the manager failed to ensure that when medication was stored by an assisted living facility, policies and procedures were implemented for discarding medication for one of two medical records reviewed, which posed a health and safety risk to a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Disposal of Medications." The policy stated "...All expired and discontinued medications...as follows: The medication will be offered to the resident's family first...In the event no one wants the medication it will be disposed of by the facility dissolving the medication in warm water, hydrogen peroxide or vinegar in a disposable container of zip lock bags, the dissolved medication will be poured to an old newspaper...then be placed in the trash receptable...All medication disposal will be documented on the Medication Disposal Form and signed and dated by the parties involved..." 2. A review of R1's medical record contained a document titled "Doctor's Orders" dated August 1, 2025, which included the following medication order: -Citalopram; 20 mg; by mouth..." 3. The Compliance Officer observed a Citalpram 20mg medication bottle in R1's medicine bin, which stated "Take 1 Tablet Once Daily." Further review of the medication label attached to the bottle revealed the medication had expired on August 15, 2025. 4. In an interview, E1 and E4 acknowledged the medication had expired. 5. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided. This is a repeat deficiency from the inspection conducted on October 5, 2023.”