North Scottsdale Assisted Living.

“Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for three of three personnel 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 "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. The Compliance Officer observed E3 working the day of the inspection.  4. A review of the facility’s October 2025 work schedule revealed the following:  E3 worked from October 1, 2025, to October 3, 2025; October 6, 2025, to October 10, 2025; October 13, 2025, to October 16, 2025; October 20, 2025, to October 23, 2025.  5. A review of E3’s personnel record revealed an approximate hire date of 2024. E3 had one TB skin test administered and read that was less than 12 months old. However, there was no second TB skin. 6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on observation, record review, documentation review, and interview, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as the required information could not be verified for E3.  Findings include: 1. Upon arrival, the Compliance Officers observed E3’s cooking and cleaning.  2. A review of E3’s personnel record revealed the following:  No documentation of E3’s name, date of birth, and contact telephone number No documentation of E3’s starting date  No documentation of E3’s qualifications  No documentation of E3’s education and experience  No documentation of E3’s completed orientation Documentation of the second TB skin test No documentation of E3’s compliance with the requirements in A.R.S 36-411(A) and ( C )  3. A review of the facility’s October 2025 work schedule revealed the following:  E3 worked from October 1, 2025, to October 3, 2025.  E3 worked from October 6, 2025, to October 10, 2025.  E3 worked from October 13, 2025, to October 16, 2025.  E3 worked from October 20, 2025, to October 23, 2025.  4. In an interview, E2 reported that E3 was an assisted caregiver.  5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of three residents reviewed. The deficient practice posed a health and safety risk to the resident if a caregiver did not know whether a medication was administered.  Findings include: 1. A review of R2's medical record revealed the following:  a current written service plan dated June 20, 2025. This service plan indicated R2 received medication administration.   Medication order dated July 29, 2025, for “Senna Lax 8.6 mg tablet 1-2 tablet by mouth.” 2. A review of R2's October 2025 Medical Administration Record (MAR) revealed “Senna Lax 8.6 mg tablet” was not listed.  3. The Compliance Officer observed R2’s medication organizer prefilled with “Senna Lax 8.6 mg tablet.” The Wednesday and Thursday morning slots were empty.  4. In an interview, E1 reported that R2 was administered “Senna Lax 8.6 mg” that morning. 5. A review of the facility’s policies and procedures revealed a policy titled “Medication Including Opioids, Narcotics and Schedule 2.” The policy stated, “The trained caregiver will initial in the MAR and include the date and time the medication was given to the Resident and the medications that were taken.” 6. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided. 7. This is a repeat deficiency from the inspection conducted on October 2, 2023.”

“Based on observation and interview, the manager failed to ensure that food requiring refrigeration was maintained at 41°F or below. The deficient practice posed a risk of potential foodborne illness.     Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed opened bottles of Hoisin Sauce, A.1. Original Sauce, Mama Sita’s Garlic Oyster Sauce, and Great Value Soy Sauce in a kitchen cabinet near the refrigerator. The labels on all bottles stated “Refrigerate after opening.” 2. In an interview, E1 reported that E1 did not realize the bottles needed to be refrigerated. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure that an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. A review of the facility's disaster drill documentation revealed documentation of a disaster drill conducted on April 8, 2025. However, documentation of additional drills was not available for review. 2.  In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement an evacuation. Findings include: 1. A review of the facility's evacuation drill documentation revealed documentation of a drill conducted on April 22, 2025. However, documentation of additional drills was not available for review. 2.  In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure that a smoke detector was installed in the laundry room and the smoke detectors were tested once a month. The deficient practice posed a health and safety risk to the residents.  Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed no smoke detector in the laundry room and no fire alarm system.  2. A review of the facility's documentation revealed a “Maintenance Log.” The “Maintenance Log” indicated that the smoke detectors were last tested in August of 2025.  3. In an interview, E2 acknowledged that the smoke detectors have not been tested since August 2025.  4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were free from conditions or situations that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to a resident.  Findings include:  1. During an environmental inspection of the facility with E1, the Compliance Officers observed three hospital tables and a Hoyer lift blocking the sliding glass door that led to the backyard.  2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”