Catalina Springs Memory Care.

“Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities, including baseline screening, for two of five personnel members and four of five residents sampled. Findings include:   1. A review of E3's personnel record revealed evidence of documentation of baseline screening for TB; however, the form used for documenting the screening was not signed by an occupational health reviewer as required.     2. A review of E4’s personnel record revealed evidence of documentation of baseline screening for TB; however, the form used for documenting the screening did not include an assessment of E4’s risk of prior exposure to TB as required.   3. A review of R2’s, R3’s, R4’s, and R5’s medical records revealed evidence of documentation of baseline screening for TB; however, the form used for documenting the screening did not include an assessment of R2’s, R3’s, R4’s, and R5’s risk of prior exposure to TB as required.   4. In an interview, E1 acknowledged the form used for documenting the baseline screening of E3 was not signed by an occupational health reviewer. E1 also acknowledged the form used for documenting the baseline screening of E4, R2, R3, R4, and R5 did not include an assessment of each individual's risk of prior exposure to TB.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for five of six residents sampled.        Findings include:       1. A review of R4's medical record revealed a current service plan describing the services which would be provided by the facility staff.       2. A review of R4’s electronic medical record revealed documentation titled "Care Tracking Sheet," which listed the services provided to R4 and included boxes for caregivers to mark when services were provided. However, the Care Tracking Sheet contained multiple gaps indicating a caregiver had not accurately documented the services provided to each resident. In addition, the Care Tracking Sheet contained numerous points of documentation indicating various services were “Not Completed.”      3. A request was made for documentation describing why numerous services were not completed. However, such documentation was unavailable for review.       4. In an interview, E1 agreed the Care Tracking Sheets for R4 had not been completed on each shift documenting services provided per R4’s service plan.”

“Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, emergency or injury and needed medical services, as required per R9-10-818.D.2.       Findings include:       1. A review of facility incident reports from March 1, 2025, through March 19, 2025, revealed one incident report documenting accidents, emergencies, or injuries where medical services were needed. A review of the incident report dated March 5, 2025, revealed “paramedics” were called after R6 had fallen and was found “bleeding from [their] nose and [their] forehead.” The report outlined actions taken by the caregiver, including contacting R6's medical provider and emergency contact. However, the report did not indicate if first aid was provided.        2. In an interview, E1 advised the caregiver had administered first aid to R6, but failed to document appropriately. E1 agreed the incident report did not contain all documentation as required per R9-10-818.D.2.”

“Based on record review, documentation review, and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of four residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. A review of R2's medical record revealed a current written service plan for directed care services dated May 10, 2024. However, a service plan after August 10, 2024 was not available for review. 2. In an interview, E1, and E2 acknowledged R2 was receiving directed care services and the service plan was not updated at least once every three months.”

“Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for one of four directed care residents sampled. Findings include: 1. A review of R1's medical record revealed documentation of service plan dated May 10, 2024, indicating R1 was receiving directed care services. However, the service plans did not contain the following: - Offering sufficient fluids to maintain hydration, and - Encouragement to eat meals and snacks. 2. In an interview, E1 and E2 acknowledged the service plan for R1 did not contain all of the requirements for directed care residents.”

“Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for three of five employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. A.R.S. \'a7 36-411(C) states: C. Owners shall make documented, good faith efforts to: "1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. Findings include: 1. A review of E2's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E2's fitness to work in a residential care institution, nursing care institution or home health agency. No other documents were available for review during the survey. 2. A review of E3's personnel record revealed a valid fingerprint clearance card and an application listing four prior employers. However, the Compliance Officer observed on a document titled "References" there was only one professional/Employment reference was listed. On the document was "Telephone" circled and the initials of the business officer personal. There were no good faith efforts to contact previous employers for information or recommendations that may be relevant to E3's fitness to work in a residential care institution, nursing care institution or home health agency. No other documents were available for review during the survey. 3. A review of E5's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, the Compliance Officer observed on a document titled "References" there was only one professional/Employment reference was listed. On the document was "Telephone" circled and the initials of the business officer personal. There were no good faith efforts to contact previous employers for information or recommendations that may be relevant to E5's fitness to work in a residential care institution, nursing care institution or home health agency. No other documents were available for review during the survey. 4. In an interview, E1, acknowledged the personnel records provided for review had not included documentation of compliance with all subsections of A.R.S. \'a7 36-411.”

“Based on record review, documentation review, and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for five of five directed care residents sampled. Findings include: 1. A review of R1's medical record revealed documentation of a service plan dated October 3, 2023. The service plan indicated R1 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; and - Encouragement to eat meals and snacks. 2. A review of R2's medical record revealed documentation of a service plan dated October 18, 2023. The service plan indicated R2 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; and - Encouragement to eat meals and snacks. 3. A review of R3's medical record revealed documentation of a service plan dated November 8, 2023. The service plan indicated R3 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; and - Encouragement to eat meals and snacks. 4. A review of R4's medical record revealed documentation of a service plan dated October 27, 2023. The service plan indicated R4 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; and - Encouragement to eat meals and snacks. 5. A review of R5's medical record revealed documentation of a service plan dated November 15, 2023. The service plan indicated R5 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; and - Encouragement to eat meals and snacks. 3. In an interview, E1 reported being unaware the service plans did not contain all of the requirements for directed care residents and acknowledged the documents were missing these requirements.”