Brookdale Union Hills.

“Based on documentation review, observation, and interview, the governing authority failed to notify the Department immediately when there was a change in the manager. The deficient practice posed a risk as the Department was unaware as to whether the facility maintained a qualified manager. Findings include: 1. A review of Department documentation revealed a letter from E3 dated May 23, 2025, which indicated E3 was the manager effective immediately. The review revealed no other notification to the Department of a change in the manager thereafter. 2. The Compliance Officer did not observe E3's manager certificate posted in the facility. 3. In an interview, E2 reported the following: - E1 was the manager from February 13, 2023, through May 25, 2025; - E3 was not the manager effective May 23, 2025, and had not been the manager at this facility; - E4 was the manager from May 25, 2025, through August 2, 2025; - E1 was again the manager from August 3, 2025, through the present; and - E2 would be taking over as the manager once E2 passed the certification test and had E2’s manager’s certificate. 4. A secondary review of Department documentation confirmed the Department received no notification of the change in manager between E1 and E4 in May 2025 or between E4 and E1 in August 2025. Technical assistance was provided on this rule during the complaint inspections conducted on October 6, 2025, and June 19, 2025.”

“Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of five residents sampled receiving directed care services.   Findings include: 1. A review of R5's medical record revealed a written service plan for directed care services, dated September 3, 2024. However, required service plan updates, dated on or before December 31, 2024 and March 31, 2025 were not available for review. 2. In an interview, E1 and E2 acknowledged R5's current service plan had not been provided for review.”

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of five residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R5's medical record revealed a service plan for directed care services. The service plan reported the following: - "Catheter Care: empty drainage bag on each shift and as needed" 2. Review of R5's medical record revealed an ADL record for the month of April 2025 where catheter care was left blank on first shift (6:00 AM - 2:00 PM) on April 19th and April 26, 2025. 3. In an interview, E1 and E2 acknowledged the caregiver provided the service to R5 but did not document it. This is a repeat deficiency from the compliance inspection conducted on January 19, 2023.”

“Based on documentation review and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. Findings include: 1. A.R.S. \'a7 46-454(A) stated "...other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. A.R.S. \'a7 46-454(B) stated "If an individual prescribed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law..." 3. R9-10-101.110 stated "Immediate" means without delay. 4. E1 reported on July 19, 2024, R1's POA was in the facility on a visit. E1 reported being told by R1's POA "by the way, mention being raped and has skin issue with her leg". The progress notes dated July 19, 2024 revealed POA in the facility to visit R1. The progress notes stated R1 "became very agitated, yelling at them...waited to calm down...leakage on right lower leg. Nurse wrapped it...". E1 reported to have talked to R1 regarding what the POA just mentioned and R1 stated "I'm fine". E1 indicated APS and/or police were not notified. 5. In an interview, E2 reported not being aware of the aforementioned until returning from vacation. E2 reported upon return to the facility on August 1, 2024, R1 made same allegation and an internal investigation was conducted along with notification to APS and Police on August 1, 2024. E1 and E2 acknowledged documentation was not available that showed the incident on July 19, 2024 for R1 was reported immediately according to A.R.S. \'a7 46-454. This is an uncorrected deficiency from the complaint investigation conducted on May 8, 2024.”

“Based on documentation review, record review, and interview, a manager who had a reasonable basis to believe abuse, neglect, or exploitation occurred on the premises failed to immediately report the suspected abuse, neglect, or exploitation of the resident according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A.R.S. \'a7 46-454(A) states: "A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online." 2. Arizona Administrative Code (A.A.C.) R9-10-101(111) states "[i]mmediate" means "without delay." 3. In an interview, E2 reported E2 believed R1 was abused while on the premises. 4. A review of R1's medical record revealed a series of progress notes detailing the suspected abuse. The review revealed the suspected abuse first occurred on April 30, 2024. 5. In an interview, E2 confirmed the suspected abuse first occurred on April 30, 2024. However, E2 reported E2 did not report the suspected abuse until May 2, 2024.”

“Based on documentation review, record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility documentation revealed a document titled "Fall Management Policy" that stated "1. The Executive Director (ED) is responsible for verifying that associated have completed the Brookdale Foundations Falls Management training course during orientation and should review annually thereafter..." 2. Review of E5's personnel record revealed E5 worked as a caregiver and had a hire date of December 16, 2021. The personnel record revealed no documentation of completing fall prevention and fall recovery training. 3. Review of E6's personnel record revealed E6 worked as a caregiver and had a hire date of June 1, 2016. The personnel record revealed no documentation of completing fall prevention and fall recovery training. 4. In an interview, E1, E2, and E3 acknowledged documentation was not available that showed E5 and E6 completed training for fall prevention and fall recovery.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of five employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... 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..." 2. Review of E2's personnel record revealed E2 worked as a nurse and had a hire date of August 7, 2023. The personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution. 3. In an interview, E1, E2, and E3 acknowledged documentation was not available that showed E2's work references were obtained upon hire at the facility. 4. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.”

“Based on 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 five employees reviewed. 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. Review of E2's personnel record revealed no documentation of freedom from infectious TB. Based on E2's hire date, this documentation was required. 4. Review of E4's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E4's hire date, this documentation was required. 5. In an interview, E1, E2, and E3 acknowledged E2 and E4 did not provide documentation of freedom from infectious TB as specified in R9-10-113. 6. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for three of five caregivers reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "CPR and First Aid Training" that stated "1. Nurses, caregiver, managers or volunteers who provide direct care to residents will be required to complete CPR and first aid training as required by Arizona regulations...2. This training will be validated by a demonstration of the nurse's, caregiver's, manager's or volunteer's ability to perform CPR and first aid. 3. The CPR and first aid certificates will be renewed according to the approved trainer guidelines but no later that 2 years from the issued date of the certificates..." 2. Review of E2's personnel record revealed E2 worked as a nurse and had a hire date of August 7, 2023. The personnel record revealed no documentation of CPR training. 3. Review of E5's personnel record revealed a CPR and first aid card with an expiration date of September 1, 2023. There was no other documentation of CPR and first aid training in E5's record. 4. Review of E7's personnel record revealed E7 worked as a caregiver and had a hire date of July 6, 2023. The personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on April 13, 2022, and valid for two years. There was no other current documentation of CPR training available for review that documented E7 had attended an approved CPR training course that included a demonstration of the individual's ability to perform CPR. 5. In an email exchange, a representative from NationalCPRFoundation, stated "Our courses are online only." 6. In an interview, E1, E2, and E3 acknowledged E2 and E5 did not have current documentation of first aid and CPR training and E7 did not have current documentation of CPR training, that included a demonstration of the individual's ability to perform CPR. 7. This is a repeat deficiency from the compliance inspections conducted on January 27, 2022, and January 19, 2023.”

“Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of five residents reviewed. 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. Review of R8's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R8 had signs or symptoms of TB. Based on R8's acceptance date, this documentation was required. 3. In an interview, E1, E2, and E3 acknowledged R8 did not provide documentation of freedom from infectious TB as specified in R9-10-113. 4. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.”

“Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of eight residents reviewed. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed. Findings include: 1. Review of R2's medical record revealed a current written service plan dated August 3, 2023. This service plan stated "Skin is intact". 2. Review of R2's medical record revealed a document titled "Home Health/Hospice/Third Party Provider Collaboration Notes" dated October 2, 2023. This document stated "...1 open right heel blister..." 3. Review of R2's medical record revealed R2's service plan was not updated to show this skin issue. 4. In an interview, E2 and E3 acknowledged R2 had a wound to the right heel and E1, E2, and E3 acknowledged R2's service plan was not updated after this significant change of condition. 5. This is a repeat deficiency from the complaint investigation conducted June 13, 2023.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and if a review was required in subsection A(3)(d), the nurse or medical practitioner who reviewed the service plan, for two of eight residents reviewed. The deficient practice posed a health and safety risk if the required individual did not acknowledge the services that were to be provided. Findings include: 1. R9-10-808.A(3)(d) states "For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner." 2. Review of R5's medical record revealed a current written service plan dated August 17, 2023. This service plan indicated R5 received medication administration. However, the service plan did not include a signature and date by the resident or resident's representative, the manager, and the nurse or medical practitioner. 3. Review of R8's medical record revealed a current written service plan dated July 9, 2023. This service plan indicated R8 received medication administration. However, the service plan did not include a signature and date by the nurse or medical practitioner. 4. In an interview, E1, E2, and E3 acknowledged R5's and R8's service plans were not signed and dated by the required individuals.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to two of four residents reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 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. Review of R2's medical record revealed R2 received the flu vaccination September 28, 2022. However, current documentation was not available that showed the flu vaccination was offered or received. In addition, documentation was not available that showed the pneumonia vaccination was offered or received. Based on R2's acceptance date, this documentation was required. 3. Review of R3's medical record revealed R3 received the flu vaccination September 28, 2022. However, current documentation was not available that showed the flu vaccination was offered or received. In addition, documentation was not available that showed the pneumonia vaccination was offered or received. Based on R3's acceptance date, this documentation was required. 4. In an interview, E1, E2, and E3 acknowledged R2's and R3's medical records did not include current documentation that showed the flu and pneumonia vaccinations were offered or received.”

“Based on record review and interview, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R3's medical record revealed a current written service plan for directed care services dated September 14, 2023. This service plan stated "...requires 2 person and a hoyer for transfers". 2. Review of R3's medical record revealed a written determination from R3's medical practitioner signed and dated February 3, 2023. However, documentation was not available that stated R3's needs could be met by the facility and R3's needs were within the facility's scope of services, at least once every six months. 3. In an interview, E2 reported R3 was unable to ambulate even with assistance and E1, E2, and E3 acknowledged R3's medical practitioner did not provide a written determination at least once every six months. 4. This is a repeat deficiency from the compliance inspections conducted February 4, 2021, January 27, 2022, and January 19, 2023.”

“Based on record review and interview, the manager failed to ensure the facility did not retain a resident who had a stage 3 or stage 4 pressure sore, unless the facility obtained a written determination from a medical practitioner, upon the onset of the condition and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who had a stage 3 or stage 4 pressure sore. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R7's medical record revealed a document titled "Home Health/Hospice/Third Party Provider Collaboration Notes" dated August 1, 2023. This document was signed by a nurse and stated "Stage III coccyx". 2. Review of R7's medical record revealed no documentation indicating R7's medical practitioner examined R7 upon the onset of the condition and every six months thereafter, signed and dated a determination that stated R7's needs could be met by the facility, and reviewed the facility's scope of services. 3. In an interview, E1, E2, and E3 acknowledged R7's medical practitioner did not provide a written determination upon the onset of the condition and every six months thereafter.”

“Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for one of eight residents reviewed that received directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R1's medical record revealed a signed order dated October 4, 2023. This order stated "Decubitus/Pressure Ulcer/Inner Buttocks Coccyx..." 2. Review of R1's medical record revealed a current written service plan dated October 5, 2023. This service plan stated " ...(R1) has a wound on (R1's) back, left foot bottom..." This service plan revealed no documentation of skin maintenance to treat the skin issue on the inner buttocks coccyx. 3. In an interview, E1, E2, and E3 acknowledged R1's service plan did not include skin maintenance to treat the skin issue on the inner buttocks coccyx.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of five residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated October 5, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated August 27, 2023. This medication order stated "Dilitiazem Hydrochloride 60mg oral tablet; Take 1 tab(s) oral 3 times a day for hypertension; Hold for SBP (systolic blood pressure) less than 110 or HR (heart rate) less than 65". 3. Review of R1's medical record revealed an October 2023 medication administration record (MAR). This MAR stated "Dilitiazem HCL Tablet 60mg take 1 tablet by mouth three times a day for increased BP, Hold for SBP less than 110 or HR less than 65" and indicated the following: -R1's HR was less than 65 at 8am on October 16th, 22nd, 25th, 28th, and 30th, however, indicated one tab was administered. -R1's HR was less than 65 at 1pm on October 2nd, however, indicated one tab was administered. -R1's HR was less than 65 at 6pm on October 15th, however, indicated one tab was administered. 4. During an observation of R1's medications, Dilitiazem HCL 60mg was observed. 5. Review of R4's medical record revealed a current written service plan dated August 13, 2023. This service plan indicated R4 received medication administration. 6. Review of R4's medical record revealed a signed medication order dated October 18, 2023. This medication order stated "Midodrine HCL Oral Tablet 5mg Give 0.5 tablet by mouth three times a day for hypotension hold if SBP higher > 120". 7. Review of R4's medical record revealed an October 2023 MAR. This MAR stated "Midodrine HCL Oral Tablet 5mg Give 0.5 tablet by mouth three times a day for hypotension hold if SBP higher > 120" and indicated the following: -R4's SBP was higher than 120 at 8am on October 14th, 16th, 23rd, 25th-27th, and 30th, however, indicated 1/2 tab was administered. -R4's SBP was higher than 120 at 1pm on October 14th, 16th, 23rd, 25th-27th, and 30th, however, indicated 1/2 tab was administered. -R4's SBP was higher than 120 at 6pm on October 3rd, 7th, 9th-10th, 15th-16th, 22nd-24th, and 29th-30th, however, indicated 1/2 tab was administered. 8. During an observation of R4's medications, Midodrine HCL 5mg was observed. 9. In an interview, E1, E2, and E3 reported the medications were administered per the MAR and acknowledged R1's and R4's medications were not administered in compliance with the available medication order. 10. This is a repeat deficiency from the compliance inspection conducted January 27, 2022 and the complaint investigation conducted on January 19, 2023.”

“Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for one of four residents reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R7's medical record revealed a document from Banner Boswell Medical Center dated November 16, 2022. This document stated "Fracture of unspecific part of neck of right femur". In addition, R7's service plan dated May 25, 2023 stated "(R7) recently had a fall and broke (R7's) hip..." However, documentation was not available that showed R7's emergency contact and primary care provider were notified of this incident. 2. In an interview, E1 reported E1, E2, and E3 were not working at the facility when this incident occurred. E1, E2, and E3 acknowledged R7's medical record did not include documentation that showed a caregiver immediately notified the resident's emergency contact and primary care provider.”

“Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of four residents reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R7's medical record revealed a document from Banner Boswell Medical Center dated November 16, 2022. This document stated "Fracture of unspecific part of neck of right femur". In addition, R7's service plan dated May 25, 2023 stated "(R7) recently had a fall and broke (R7's) hip..." However, documentation was not available that showed the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future. 2. In an interview, E1 reported E1, E2, and E3 were not working at the facility when this incident occurred. E1, E2, and E3 acknowledged R7's medical record did not include documentation that showed the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future. 3. This is a repeat deficiency from the compliance inspection conducted January 19, 2023.”

“Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. Review of facility's documentation revealed a policy titled "Tuberculosis (TB) Associate Requirements by State - Reference" that stated "AZ...Annual Facility Risk assessment & TB education..." 2. Review of E2's personnel record revealed E2 worked as a nurse and had a hire date of August 7, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. Review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of July 6, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 4. Review of E6's personnel record revealed E6 worked as a caregiver and had a hire date of June 1, 2016. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 5. Review of E7's personnel record revealed E7 worked as a caregiver and had a hire date of July 6, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 6. In an interview, E1, E2, and E3 acknowledged E2's, E4's, E6's, and E7's personnel records did not include documentation of completing training and education related to recognizing the signs and symptoms of TB. 7. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.”

“Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included an annual assessment of the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility's documentation revealed a policy titled "Tuberculosis (TB) Associate Requirements by State - Reference" that stated "AZ...Annual Facility Risk assessment & TB education..." 2. Review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 3. In an interview, E1, E2, and E3 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 4. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.”