Mom and Dad Solutions Assisted Living LLC.

“Based on documentation review and interview, the manager failed to submit a documented report to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management". This policy stated "...1) An Assurance Checklist will be performed by the manager/caregiver/designee on a regular basis and at least once every 3 months..." 2. The Compliance Officer requested to review the facility's quality management reports submitted to the governing authority. However, the reporters were not provided for review. 3. In an interview, E1 and E2 acknowledged the quality assurance program had not been implemented.”

“Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation 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, as specified in R9-10-113, for one of three employees reviewed. 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. 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. A review of E3's personnel record revealed no evidence of freedom from infectious tuberculosis on or before the date of hire.   4. In an interview, E1 and E2 acknowledged E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113.”

“Based on documentation review, 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 three of three residents sampled. 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. A review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3. A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 4. A review of R3's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R3 had signs or symptoms of TB. Based on R3's date of acceptance, this documentation was required. 5. In an interview, E1 and E2 acknowledged R1, R2, and R3's medical records did not include documentation of a risk assessment of prior exposure to infectious TB or a determination if they had signs or symptoms of TB.”

“Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza( flu) and pneumonia according to A.R.S. § 36-406(1)(d), which required the facility to make the vaccinations available to the resident on site on a yearly basis; for one of two sampled residents' records that were reviewed who had resided at the assisted living facility for more than 12 months. 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 R1's medical record did not include documentation to indicate the vaccines were offered, given, or refused. Based on R1's acceptance date, this documentation was required. 3. During an interview, E1 and E2 acknowledged R1's medical record did not include documentation showing the flu and pneumonia vaccines were offered or received.”

“Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2)(b)(iii), for two of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.   Findings include:   1. R9-10-814(B)(2)(b)(iii) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R1's service plan (dated April 1, 2025) revealed R1 received directed care services, and was confined to a bed or chair.  3. A review of R1's medical record revealed documentation of the determination required dated March 1, 2024. However, additional documentation signed by R1's primary care provider was not available for review.   4. A review of R2's service plan revealed R2 received directed care services and was confined to a bed or chair. 5. A review of R2's medical record revealed documentation of the determination required dated April 4, 2024. However, additional documentation signed by R2's primary care provider was not available for review.   6. In an interview, E1 and E2 acknowledged the facility did not obtain a written determination from R1's and R2's medical practitioners every six months as required.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a bottle of "Fantastik Bleach", "Great Value Disinfectant Spray", and an open container of "Comet Cleansing Powder" in an unlocked cabinet under the kitchen sink. The Compliance Officer also observed a bottle of "Clorox Toilet Bowl Cleaner" and a can of "Scrubbing Bubbles Bathroom Grime Fighter" in an unlocked cabinet under the bathroom sink. 2. In an interview, E1 and E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents.”