Ashbrook Home Care LLC.

“Based on record review and interview, the manager failed to ensure that there was a document for Emergency responders that met the requirements for A.R.S. 36-420.04.A.1-9. Findings include: 1. A review of R1's medical records revealed a form used for Emergency responders, however, the form did not contain an area for the reason the emergency responder was notified, the name and address for the pharmacy, or the facility information. 2. In an interview, E2 acknowledged that the form used for Emergency responders did not have all the required information per A.R.S. 36-420.04.A.1-9.”

“Based on record review, document review, and interview, the manager failed to ensure that the health care institution provided training and education, annually, related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution and annually assessing the health care institution's risk for exposure to infectious tuberculosis. Findings include: 1. A review of E1's, E2's and E3's employee records revealed No documentation related to annual training for the signs and symptoms or tuberculosis, at the time of the inspection. 2. A review of facility documents revealed No documentation for the annual assessment of the facility's risk for exposure to infectious tuberculosis, at the time of the inspection. 3. In an interview E1 and E2 acknowledged that the manager failed to ensure there was training for signs and symptoms of tuberculosis for staff or volunteers and there was not an annual facility assessment to identify the facility's risk of exposure to infectious tuberculosis.”

“Based on record review and interview, the manager failed to ensure compliance with A.R.S. 36-411. Findings include: 1 . A review of E1's, E2's and E3's employee records revealed no APS check for E1, E2 or E3. 2 . In an interview, E2 acknowledged that the manager failed to ensure compliance with A.R.S. 36-411.”

“Based on record review and interview, the manager failed to ensure that medication administered to a resident was documented in the resident's medical record. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. The Compliance Officer arrived at the facility at 10:43 AM. 2 . A review of R1's medication administration record (MAR) revealed that the following medications were not signed off as administered for June 26, 2025, for the morning medications: Boost 1 1/2 carton Three times a day (TID) Acetaminophen 325 milligrams (mg) 2 tablets (tabs) TID Quetiapine 25 mg 1 tab Twice a Day (BID) Sertraline 50 mg 1 tab daily Duloxetine 30 mg 1 tab daily Senna 50 mg 1 tab BID 3 . In an interview, E2 acknowledged that E2 had not signed off the medications for June 26, 2025, however E2 reported that medications were passed.”

“Based on observation and interview, the manager failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months and had a tag attached to the fire extinguisher that specified the date of the last servicing and the identification of the person who serviced the fire extinguisher. Findings include: 1 . During the facility tour, the Compliance Officer observed a fire extinguisher, however the tag read August 2022/2023 as the last inspection date. 2 . In an interview, E2 acknowledged that the fire extinguisher had not been serviced in the last 12 months.”

“Based on observation and interview the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed a broken window in a resident room. 2. In an interview, E2 acknowledged that the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury.”

“Based on observation and interview the manager failed to ensure that oxygen container were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During a tour of the facility, the Compliance Officer observed two oxygen tanks, in a resident's room that were not secured in a upright position. 2. In an interview, E2 acknowledged that the manager failed to ensure that oxygen tanks were secured in an upright position. This is a repeat citation from the onsite compliance inspection conducted on July 27, 2023.”