The Inn at Freedom Plaza.

“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 three 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 the facility's personnel schedule revealed E3 was expected to interact with residents more than eight hours per week. 4. A review of E3's personnel record revealed a hire date of October 4, 2023. Further review revealed a “TB Risk Assessment from a medical provider dated October 31, 2024, that stated, “Vaccinated outside the U.S.” Additionally, the record contained a letter, more than 12 months old, titled “Evaluation for TB Risk Assessment” from the same medical provider that stated, “CXR performed. No signs of active disease. Untreated Latent TB infection. Recommend annual screening.” Further review of E3’s medical record revealed no documentation of a positive TB skin test, indicating the use of a chest x-ray or annual screening documentation for 2025. Based on E3's date of hire, this documentation was required. 5. In an interview, E1 acknowledged E3 did not have a positive TB skin test in E3’s personnel record. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, record review, documentation review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the resident’s health and safety. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following medications stored in R1’s private bathroom: - One box Maximum Strength Sinus Relief Daytime/Nighttime caplets - One box Cooling Severe Daytime Cold & Flu Relief caplets The boxes appeared to be opened and appeared to have been used. 2. A review of R1's medical record revealed a current service plan dated January 23, 2026. The service plan indicated R1 received medication administration. 3. A review of the facility’s policies and procedures revealed a policy titled, “Medication & Treatment -Storage Policy” which stated, "1. Medications and treatments stored by the community are to be stored in designated locations that must be locked when not in use or when unattended.” 4. In an interview, E1 reported R1’s family member brought the medications into the facility for R1’s use, but E1 has advised the family member to stop bringing medications into the facility. 5. 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 manager failed to ensure a caregiver provided 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 (NCIA Board), for one of one individual sampled who was hired as a caregiver . The deficient practice posed a risk if E4 was not qualified to provide the required services. Findings include: 1. Review of E4's personnel record revealed E4 was hired as a caregiver and had a caregiver training certificate from Platinum Training Services ALTP #0152 dated April 21, 2013 . No other documentation of completing a caregiver training program approved by the Department or the NCIA Board was available. 2. Review of NCIA Board documentation revealed ALTP#0152 was a caregiver training program called Comprehensive Training Services, LLC. 3. Review of the https://azcg.tmutest.com/search website revealed no documentation of a caregiver training certificate for E4. 4. Review of facility documentation revealed a personnel schedule dated March 2024. The personnel schedule revealed E4 was scheduled to work from 6:00AM to 2:00PM on the following dates: -March 4-5, 2024; -March 7-12, 2024; -March 14-15, 2024; -March 18-19, 2024; -March 21-23, 2024; -March 26, 2024; and -March 28-30, 2024. 5. In an interview, E1 reported E4 worked as a caregiver and acknowledged the lack of consistency in E4's caregiver certificate. E1 acknowledged E4 did not have documentation of completing a caregiver training program approved by the Department or the NCIA Board.”