Monte Manor Assisted Living.

“Based on record review, documentation review, and interview, the health care institution failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for two of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E1's personnel record revealed no documentation of initial competency training in fall prevention and fall recovery. Based on E1's date of hire, this documentation was required. 2. A review of E2's personnel record revealed fall prevention and fall recovery training dated April 2, 2024. However, current documentation of fall prevention and fall recovery training was not available. 3. A review of the facility's documentation revealed a policy titled, "Policy on ARS 36-420.01 Health Care Institutions; Fall Prevention and Fall Recovery Training Policy" with the following verbiage included, "POLICY: In compliance to Section 36-420.01, as one of the Health Care Institutions, we have included Fall Prevention and Fall Recovery Training for all staff prior to providing services to our residents. This will be included in their Orientation Training, completed upon date of hire. Fall Prevention and Fall Recovery Training will be part of the Ongoing Continued Education for all staff and required to be completed at least once every 12 months." 4. In an exit interview, the findings were reviewed with E1, no additional information was provided.”

“Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. § 36-420.04.A.1-9 for two out of two residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R1 and R2's medical records revealed there was no standardized form to be used if an emergency responder was contacted. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review, documentation review, and interview, the health care institution failed to ensure that the health care institution implemented tuberculosis (TB) infection control activities that included annually providing training and education related to recognizing the signs and symptoms of TB and annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of E1's personnel record revealed no documentation of training in recognizing the signs and symptoms of infectious TB.  2. A review of E2's personnel record revealed no documentation of training in recognizing the signs and symptoms of infectious TB. 3. A review of the facility's documentation revealed no documentation of assessing the health care institution's risk of exposure to infectious TB. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on documentation review, observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. A.R.S. § 36-401.A.49. "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 2. During an environmental inspection of the facility, the Compliance Officer (CO) observed E3 and E4 assisting R1, R4, and R6 with various care needs, including assistance with incontinence care. The CO observed no manager or caregiver supervision during these interactions. 3. In an interview, E1 reported E3 and E4 were assistant caregivers who lived at the facility. E1 also reported E1 and E2 were present in the facility to assist residents during nighttime hours when E1 was not present at the facility. 4. A review of E3's and E4's personnel records revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. Therefore, E3 and E4 were not qualified to be left alone with the residents based on the lack of caregiver training.   5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver who was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility for one of two 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, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E1's personnel record revealed a TB skin test dated less than 12 months from the date of hire showing evidence of freedom from infectious TB. However, there was no documentation of a second TB skin test available. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that before or at the time of an individual’s acceptance by an assisted living facility there was a documented residency agreement with the assisted living facility that included whether the manager or a caregiver is awake during nighttime hours, for two of two residents sampled. Findings include: 1. A review of R1 and R2's medical records revealed a residency agreement for both residents at the time of admission to the facility, however, there was no clear verbiage in the residency agreement that stated whether or not a caregiver was awake during nighttime hours. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a resident had a service plan that included the amount, type, and frequency of assisted living services and ancillary services that were provided to the resident. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1 and R2's medical records revealed a service plan for both that included the following services to be provided to both residents: dressing room maintenance laundry checking feet checking fluid intake checking pressure areas checking skin and applying lotion daily 2. These services stated in their service plan did not include the amount, type, and frequency of which the service should be provided to the residents. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that the caregiver or assistant caregiver documented the services provided in a resident’s medical record according to the resident’s service plan for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2’s medical record revealed a service plan dated June 10, 2025. This service plan stated: Nail care, check nails daily, trim as needed, and check every bath; Oral care, two times daily; Blood pressure checks three times a day starting November 21, 2025; and Check blood sugar daily, if blood sugar less than 70, give [R2] 4 oz of fruit juice or give 1 tablespoon of sugar in water and recheck every 15-20 mins. 2. A review of R2’s activities of daily living sheet for November 2025 revealed no documentation of the following: No documentation of nail care; Oral care documented as done once a day instead of twice; No documentation of blood pressure readings on November 21-30, 2025; and blood pressure only checked twice a day instead of three times on November 27-30, 2025; and No documentation of blood sugar checks. 3. In an interview, E1 reported they believed these services were provided. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident’s medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R2's medical record revealed R2 refused the flu vaccination in 2022.  However, current documentation was not available that showed the flu vaccination was received or refused. Additionally, documentation was not available that showed the pneumonia vaccination was received or refused.  Based on R2’s acceptance date, this documentation was required.   3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, record review, and interview, the manager failed to ensure that if pets or animals were allowed in the assisted living facility, pets or animals were licensed consistent with local ordinances; and for a dog or cat, vaccinated against rabies. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer (CO) observed a dog was present at the facility and greeted the CO at the door. 2. In an interview, E1 acknowledged the dog was currently living at the facility. 3. A review of the dog's medical record revealed there was no current license or current vaccination against rabies. The dog's latest license was obtained on September 4, 2020. The dog was last vaccinated against expired on January 13, 2025. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”