Summerfield at Jentilly Assisted Living Home.

“Based on documentation review, record review, and interview, the health care institution’s chief administrative officer failed to implement tuberculosis (TB) infection control activities that included annually assessing the health care institution’s risk of exposure to infectious tuberculosis, and annual training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed. Findings include: 1. A review of the facility’s documentation revealed no completed documentation of a TB facility risk assessment. 2. A review of the facility's policies and procedures revealed a policy titled "Infection Control." This policy included tuberculosis requirements for employees, but no policy was available related to tuberculosis facility risk assessment. 3. A review of E2's personnel record revealed documentation of training and education related to recognizing the signs and symptoms of TB for 2024; however, there was no documentation for the years following. Based on E2's date of hire, this documentation was required.   4. A review of E3's personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. Based on E3's date of hire, this documentation was required.   5. In an interview, E1 reported that E1 was not sure if the facility completed a yearly TB risk assessment. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, observation, and interview, the governing authority did not ensure compliance with A.R.S. § 36-411 for two of two personnel sampled. The deficient practice posed a risk if E2 and E3 were a danger to a vulnerable population.  Findings include:  1. A.R.S. § 36-411(C)(1) states, "Each residential care institution, nursing care institution and home health agency 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…” 2. A review of E2's personnel record revealed no documentation of a professional reference verification document. Documentation of the facility's good-faith efforts to contact previous employers was not available. 3. A.R.S. § 36-411(C)(2) states, "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card." 4. A review of E3's personnel record revealed no documentation of a valid fingerprint clearance card. 5. During an environmental inspection of the facility, the Compliance Officer observed E3 assisting with care in a resident's room. 6. A review of E3's personnel record revealed no documentation of a valid fingerprint clearance card. 7. In an interview, E1 reported that E3 should have a valid fingerprint clearance card, but documentation of R3's FPCC was not available for review. 8. A.R.S. § 36-411(C)(3) states: "3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459 [and] 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.” 9. A review of E2’s personnel records revealed E2 was hired on August 8, 2024. E2’s personnel record revealed no documentation that E2 was not on the adult protective services registry pursuant to section 46-459. 10. A review of E3's personnel records revealed E3 was hired on December 12, 2025. E1’s personnel record revealed no documentation that E3 was not on the adult protective services registry pursuant to section 46-459. 11. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at the assisted living facility and as specified in R9-10-113, for one of two personnel sampled. The deficient practice posed a potential illness 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 facility’s policies and procedures revealed a policy titled "Infection Control." This policy stated," 1. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, and any individual 12 years of age or older residing in the facility, provides evidence of freedom from infectious tuberculosis as follows: a. on or before the date the individual begins providing services one of the following must show evidence of freedom from infectious tuberculosis: Documentation of a negative Mantoux skin test or other tuberculosis screening test recommended by the US Centers for Disease Control and Prevention CDC administered within 12 months before the date the individual begins providing services at or on behalf of the facility or is admitted to the facility that includes the date and the type of tuberculosis screening test." 3. A review of E2's personnel record revealed two two-step tuberculosis skin tests, one dated more than 12 months before E1's start date. Based on E2's date of hire, additional documentation was required. 4. In an interview, E1 reported that E2 was scheduled to interact with residents more than eight hours a week. 5. In an interview, E1 reported that E1 was unaware that E2's tuberculosis skin test was not in compliance with the facility policies and procedures, and with the requirements in R9-10-113. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) states: "A. 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…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 facility’s policies and procedures revealed a policy titled "TB Screening/Testing." This policy stated, "The manager will ensure that documentation is obtained indicating of freedom from infectious TB according to A.A.C. R9-10-113(b)(1) " 3. A review of R1's medical record revealed no documentation of R1's freedom from infectious tuberculosis. Based on R1's admission date, this documentation was needed. 4. In an exit interview, findings were reviewed with E1, and no additional information was provided.”

“Based on record review, documentation review, and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, 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. A review of R1’s medical record revealed no documentation that included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints before or at the time of admission, and the documentation was not signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. A review of R2’s medical record revealed no documentation that included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints before or at the time of admission, and the documentation was not signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. 3. In an interview, E1 reported that E1 was unaware that residents needed the aforementioned documentation. 4. In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on record review and interview, the manager accepted and retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2), for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include:  1. A review of R1's medical record revealed the a current written service plan dated December 11, 2025. The service plan indicated that R1 was unable to ambulate. 2. A review of R1's medical record revealed there was no documentation indicating R1's medical practitioner examined R1 upon acceptance and every six months thereafter, signed and dated a determination that stated R1's needs could be met by the facility, and reviewed that the facility's scope of services was available.   3. In an interview, E1 acknowledged that R1 was non-ambulatory and did not have the required documentation. E1 also reported being unaware that this documentation was needed for R1. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following: In an unlocked cabinet in the unlocked facility laundry room, three bottles of Clorox bleach, two bottles of Downey fabric softener, a bottle of Oxiclean laundry soap, two spray bottles of Lysol all-purpose cleaner, a bottle of pine sole, two cans of air freshener, a spray bottle of Shout power wash, a can of Barkeepers Friend powdered cleaner, and one can of W-D40 spray. 2. A review of the facility's policies and procedures revealed a policy titled, "Environmental and Physical Plant Standards." This policy stated," 15. Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dining areas, and medications and are inaccessible to residents." 3. In an exit interview, findings were reviewed with E1, and no additional information was provided.”