A R D C Scottsdale Home

Based on documentation review, observation, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. Review of the facility’s policies and procedures revealed a policy titled, “Fall Prevention and Fall Recovery" which stated, “This facility shall develop an initial training conduct and administer continued competency Training in Fall Prevention and fall recovery.” This policy does not define what continued competency is. 2. The Compliance Officer observed E2 and E3 working at the time of the inspection. 3. Review of E1’s personnel record revealed no documentation for fall prevention and fall recovery initial training and continued competency training. Based on E1’s hire date this documentation was required. 4. Review of E3’s personnel record revealed E3 was hired as a caregiver. The review revealed a “CERTIFICATE of COMPLETION” including “Fall Risk / Prevention and Recovery” from a third party company dated as issued on May 24, 2024, several months before E3 was hired at this facility as a caregiver. The review revealed no initial training upon hire or continued competency training thereafter. 5. In an exit interview, the findings were reviewed with E4 and no additional information was provided. This is a repeat citation from the inspection conducted on April 16, 2025, and an uncorrected deficiency from the inspection on October 20, 2025.

Based on record review and interview, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently, for one of five residents sampled. The deficient practice posed a risk to the resident's safety and wellbeing. Findings include: 1. Review of R5’s medical record revealed a document titled “Notes” which stated: September 15, 2025, “The caregiver informed this writer (E1) that the resident had bruising on the arm due to getting out of bed/ an unwitnessed fall.” September 22, 2025, “[R5] was combative, trying to punch and kick the staff when attempting to change his brief… In [R5’s family member’s] message, [R5’s family member] provided pictures of bruising to [R5], along [R5’s] arms and legs.” September 23, 2025, “This writer (E1) notified [R5’s family member] at 7:45 a.m. via text after receiving updates from the caregiver that the resident had an unwitnessed fall from the bed at 4 a.m. According to the caregiver’s report, there are no visible bruises at this time. [R5’s family member] replied at 8:25 a.m., stating that [R5’s family member] was at the home and had also been informed by ‘they’ of the fall. [R5’s] family members also inquired about incident reports in the event of injuries/ incidents. The writer asked who ‘they’ are, as the [R5’s family member] had mentioned ‘they let me know’. [R5’s family member] gave no further reply.” September 24, 2025, “ [R5’s family member] messaged this writer (E1) and informed me that [R5’s family member] was taking [R5] to the hospital via non-emergency as [R5’s] UTI symptoms were not being relieved, [R5] was very confused and complaining of pain… [R5’s family member] responded that [R5] had a broken hip, which is why [R5] was aggressive during brief changes.” 2. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individual was not qualified to provide the required services. Findings include: 1. The facility was licensed at the Directed Care Level. 2. A review of A.R.S. § 36-401.A.49. revealed "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 3. The Compliance Officer observed E2 and E3 working at the time of the inspection. 4. The Compliance Officer observed E2 putting on a glove and going into the common bathroom. Later E2 walked out with R4 and escorted R4 to R4’s room. E2 then helped R4 in R4’s room and left the door slightly ajar. E3 was talking to the visitors in another room. 5. Review of E2’s personnel record did not have the date of hire and role of the employee documented. A further review of E2’s personnel record revealed no 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. 6. Electronic review of https://azcg.tmutest.com/ revealed no results for a caregiver certificate for E2. 7. In an interview, E3 reported R4 had a colostomy bag and needed help with it. 8. In an interview, E4 reported E2 was in the process of getting a caregiver certificate. 9. In an interview, E3 and E4 reported that E2 was an assistant caregiver. In another interview, E3 and E4 acknowledged E2 could not be alone with the residents without direct supervision from a caregiver. 10. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation dated within 90 calendar days before acceptance and signed and dated by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of five residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R4's medical record revealed documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. However, this document was missing the date from the medical practitioner or a registered nurse. Based on R1’s acceptance date, this documentation was required. 2. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future. The deficient practice posed a potential risk of re-injury. Findings include: 1. Review of R5’s medical record revealed a document titled “Notes” which stated: September 15, 2025, “The caregiver informed this writer (E1) that the resident had bruising on the arm due to getting out of bed/ an unwitnessed fall.” September 24, 2025, “ [R5’s family member] messaged this writer (E1) and informed me that [R5’s family member] was taking [R5] to the hospital via non-emergency as [R5’s] UTI symptoms were not being relieved, [R5] was very confused and complaining of pain… [R5’s family member] responded that [R5] had a broken hip, which is why [R5] was aggressive during brief changes.” A further review of the document did not include any action taken to prevent the accident, emergency, or injury from occurring in the future. No other incident documentation was provided at the time of the inspection. 2. In an exit interview, the findings were reviewed with E4 and no additional information was provided. This is an uncorrected deficiency from the inspection conducted on October 20, 2025.

Based on documentation review, observation, interview, and record review, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) covering this rule. The P&P required initial training and continued competency training but did not include a timeframe for the continued competency training (e.g. every three months, every twelve months, etc.). 2. The Compliance Officer observed E1, E3, and E4 working at the facility. 3. In a series of interviews, E1 first reported the continued competency training was to be done every three months, then reported E1 was not sure how often the training needed to be conducted. E1 reported E1 was the governing authority and a caregiver; E2 was the manager; and E3, E4, and E5 were caregivers. E1 reported E5 no longer worked at the facility as of approximately one week before the date of the inspection. E3 confirmed E5 found a job at another facility. 4. A review of E1’s personnel record revealed no documentation demonstrating E1 received training regarding fall prevention and fall recovery, whether initial or continued. 5. A review of E2’s personnel record revealed E2 was hired as the manager. However, the review revealed no documentation demonstrating E2 received training regarding fall prevention and fall recovery, whether initial or continued. 6. A review of E3’s personnel record revealed E3 was hired as a caregiver. The review revealed a “CERTIFICATE of COMPLETION” including “Fall Risk / Prevention and Recovery” from a third party company dated as issued on May 24, 2024, several months before E3 was hired at this facility as a caregiver. The review revealed no initial training upon hire or continued competency training thereafter. 7. In an interview, when the Compliance Officer asked if E3 had received training regarding fall prevention and fall recovery from this facility this year, E3 stated, “No.” When the Compliance Officer asked if E3 had received such training from this facility since being hired at this facility, E3 stated, “No.” 8. A review of E4’s and E5’s personnel records revealed E4 and E5 were hired as caregivers. However, the review revealed no documentation demonstrating E4 and E5 received training regarding fall prevention and fall recovery, whether initial or continued. This is a repeat citation from the compliance inspection conducted on April 16, 2025.

Based on documentation review, observation. Interview, and record review, the chief administrative officer failed to establish and document tuberculosis (TB) infection control activities consistent with this rule and implement TB infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for five of seven sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include 1) TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement); 2) TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI); 3) no routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission; 4) encouragement of treatment for all health care personnel with untreated LTBI, unless treatment is contraindicated; 5) annual symptom screening for health care personnel with untreated LTBI; and 6) annual TB education of all health care personnel." 2. A review of facility documentation revealed a policy and procedure (P&P) titled "TUBERCULOSIS (“TB”) TESTING." However, the P&P was not in compliance with Arizona Administrative Code R9-10-113 and the recommendations in "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019." The P&P only required one TB test for personnel and did not cover assessing risks of prior exposure to infectious TB, determining if an individual had signs or symptoms of TB, annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by or providing volunteer services for the health care institution, and annually assessing the health care institution’s risk of exposure to infectious TB. 3. The Compliance Officer observed E1, E3, and E4 working at the facility. 4. In a series of interviews, E1 reported E1 was the governing authority and a caregiver; E2 was the manager; and E3, E4, and E5 were caregivers. E1 reported E5 no longer worked at the facility as of approximately one week before the date of the inspection. E3 confirmed E5 found a job at another facility. 5. A review of E1's personnel record revealed no documentation demonstrating E1 received initial training and education related to recognizing the signs and symptoms of TB. 6. A review of E2's personnel record revealed E2 was hired as the m

Based on documentation review, observation, interview, and record review, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for six of seven sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(1-4) states: "C. 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. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459…4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.” 2. A review of facility documentation revealed a policy and procedure (P&P) titled “FINGERPRINT.” The P&P stated: “Owner or Manager of this assisted living facility must…make efforts to verify with the Department of Public Safety (DPS) the status of prospective employee’s fingerprint clearance card: For new employees, the hiring person will check online, call, fax, e-mail request for verification to DPS office.” 3. The Compliance Officer observed E1, E3, and E4 working at the facility. 4. In a series of interviews, E1 reported E1 took over as the governing authority in January 2025. E1 reported E1 worked as a caregiver; E2 was the manager; E3, E4, and E5 were caregivers; and E6 was an assistant caregiver. E1 reported E5 no longer worked at the facility as of approximately one week before the date of the inspection. E3 confirmed E5 found a job at another facility. 5. A review of the Arizona Corporation Commission website revealed E1 took office as the Chief Executive Officer (Governing Authority) on December 31, 2024, before A.R.S. § 36-411(C)(3) applied. 6. A review of E1's personnel record revealed no documentation demonstrating facility personnel made documented, good faith efforts to verify E1 was not on the adult protective services (APS) registry. 7. A review of the APS registry website revealed E1 was not on the registry. 8. A review of E2’s personnel record revealed E2 was hired as the manager before January 1, 2025. The review revealed an “APPLICATION FOR EMPLOYMENT” which listed two of E2’s previous employers, the contact information for those employers, and the names and contact information for three of E2’s previous coworkers. The review revealed documentation demonstrating facility personnel contacted only one of E2’s previous employers and three of E2’s previous coworkers. The review further revealed no documentation demonstrating facility personnel made documented, good faith efforts to verify E2 was not on

Based on interview, documentation review, and record review, the governing authority failed to ensure a caregiver provided documentation of completion of 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 four caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings: 1. In an interview, E1 reported E5 had been a caregiver. E1 reported E5 no longer worked at the facility as of approximately one week before the date of the inspection. E3 confirmed E5 found a job at another facility. 2. A review of facility documentation revealed a policy and procedure (P&P) titled "APPLICANT AND EMPLOYEE REQUIREMENT.” The P&P stated: “Upon being hired by the facility the applicant must: Be certified in the level of care services the Assisted Living Facility is licensed to provide (Supervisory, Personal, Directed).” The review further revealed a personnel schedule which indicated E5 worked as a caregiver in October 2025. 3. A review of E5's personnel record revealed E5 was hired as a caregiver. The review revealed a photocopy of a caregiver certificate reportedly given by Comprehensive Training Services, LLC on August 31, 2010. However, E5's name was in a different font than the surrounding text and a faint, short vertical line preceded E5's name, as if E5’s name had been printed on another sheet of paper, cut out, attached to another individual’s certificate, and then the certificate was copied with the certificate now showing E5’s name. The review revealed an “Employment Application Form” which indicated E5 had worked at a hotel and casino from March of 2010 to 2014 or 2015 then at a food establishment from 2019 to 2025 before being hired at this facility. The application revealed no documentation demonstrating E5 had prior experience working as a caregiver. 4. In an interview, E1 acknowledged the inconsistencies in E5's certificate but offered no further comment.

Based on documentation review, observation, interview, and record review, the manager failed to ensure a caregiver’s or an assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, for five of six sampled applicable personnel members. The deficient practice posed a risk if a caregiver or an assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "STAFFING and RECORD KEEPING” which stated: “Each employee hired by this facility must have the following on Employee’s file: 5. Verification of skills and Knowledge.” The review further revealed a P&P titled “APPLICANT AND EMPLOYEE REQUIREMENT” which stated: “Upon being hired by the facility the applicant must: Verification of qualifications, knowledge, and skills to perform the duties of the job hired for.” 2. The Compliance Officer observed E1 and E4 working at the facility. 3. In a series of interviews, E1 reported E1 was the governing authority and a caregiver, E4 and E5 were caregivers; and E6 and E7 were assistant caregivers. E1 reported E5 no longer worked at the facility as of approximately one week before the date of the inspection. E3 confirmed E5 found a job at another facility. 4. A review of E1’s personnel record revealed no documentation demonstrating the manager verified and documented E1’s skills and knowledge. 5. A review of E4’s personnel record revealed E4 was hired as a caregiver. The review revealed “CAREGIVER SKILLS and KNOWLEDGE DOCUMENTATION” which included the skills and knowledge to be verified by the manager and a place for the manager to document whether E4 was competent in that skill or knowledge. However, other than E4’s name and signature, the form was left blank. The review further revealed a similar document titled “CAREGIVER SKILLS DOCUMENTATION.” However, this document was also left blank. The review further revealed no other documentation demonstrating the manager verified and documented E4’s skills and knowledge. 6. A review of E5’s personnel record revealed E5 was hired as a caregiver. The review revealed “CAREGIVER SKILLS and KNOWLEDGE DOCUMENTATION” which included the skills and knowledge to be verified by the manager and a place for the manager to document whether E5 was competent in that skill or knowledge. However, other than E5’s name and signature, the form was left blank. The review revealed no other documentation demonstrating the manager verified and documented E5’s skills and knowledge. 7. A review of E6’s and E7’s personnel records revealed E6 and E7 were hired as assistant caregivers. However, the review revealed no documentation demonstrating the manager verified and documented E6’s and E7’s skills and knowledge. 8. A review of facility documentation revealed a personnel schedule which indicated E6 and E7 worked in October

Based on documentation review, interview, observation, and record review, the manager failed to ensure a caregiver and an assistant caregiver 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 as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for four of seven sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) 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…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. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)." 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 4. A review of facility documentation revealed a policy and procedure titled “TUBERCULOSIS (“TB”) TESTING.” The P&P stated: “All employees and residents of this facility are required to provide one of the following [on] admission or starting date of employment and annually thereafter: 1. A report of a negative Mantoux Tuberculin (TB) skin test and blood tests are recommended within 12 months of the date of employment or residence in the facility or 2. A written and signed physician’s statement dated within 12 months of employment or residence in the facility indicating freedom from pulmonary tuberculosis, if the individual has a positive skin test for tuberculosis

Based on documentation review, interview, and record review, the manager failed to ensure the manager provided current documentation of first aid training certification specific to adults before providing assisted living services to a resident, for one of one manager. The deficient practice posed a risk if a manager was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “CPR AND FIRST AID.” The P&P stated: “ In order to keep First Aid and CPR training and skills up to date, it is required that each employee and volunteer to provide the following: 1. Documentation that verifies the employee or volunteer has received CPR and First Aid training…6. The time frame in retaining is determined by the training agency used or the expiration: date shown on the card.” The review revealed a P&P titled “APPLICANT AND EMPLOYEE REQUIREMENT.” The P&P stated: “After being hired by this facility the employee shall ensure: The employee shall ensure that all required TB, CPR, first aid, and fingerprint clearance documentation is kept current and not allowed to lapse.” 2. In an interview, E1 reported E2 was the manager and often worked shifts as a caregiver. 3. In a telephonic interview, E2 confirmed E2 worked shifts as a caregiver. 4. A review of E2’s personnel record revealed E2 was hired as the manager. The review revealed a printout of a first aid training certification dated as expired on October 31, 2024, as well as a picture of a first aid training certification dated as issued on November 20, 2024. However, the review revealed no first aid training certification between November 1, 2024, and November 19, 2024. 5. In an interview, the Compliance Officer asked if E2 had first aid training certification between November 1, 2024, and November 19, 2024. E1 reported E1 would have to contact E2 to find out. By the end of the inspection, E1 and E2 provided no further documentation in compliance with this rule.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “RESIDENT MEDICAL RECORDS INCLUDING ELECTRONIC RECORDS." The P&P stated, "A resident's medical record is protected from loss, damage, or unauthorized use." The review further revealed a P&P titled "RECORDS MANAGEMENT." The P&P stated: "1. All records, including legal documents, resident information, employee information, contracted services and financial information shall be maintained in locked cabinets and/or in a locked room in the Facility…4. Access to records shall be restricted to authorized personnel, including Owner, Manager and Caregiver[s] only." 2. The Compliance Officer observed a posting on a wall between the kitchen and the dining room titled "Shower Schedule." The Compliance Officer observed the posting included the names of the residents and the days of the week the residents received either a shower or a bed bath. 3. In an interview, E1 acknowledged the residents’ medical records were not protected from loss, damage, or unauthorized use. This is a repeat citation from the complaint and compliance inspections conducted on May 16, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual administering the medication, for eight of nine total residents. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “MEDICAL RECORD ENTRIES.” The P&P stated, “All entries must be dated, legible, and authenticated.” The P&P continued, “ALWAYS put the date, time and signature on each entry.” 2. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R7’s, R8’s, and R9’s medical records revealed medication administration records (MARs) dated October 2025. The MARs revealed an individual with initials “AS” administered medications to each of the eight residents. The MARs revealed “AS” administered medications on October 1-7, 10-13, and 17-20, 2025. However, the MARs further revealed “AS” to be the initials of “ARDC Scottsdale Home” and not of an individual person. 3. In a telephonic interview, when the Compliance Officer asked who “AS” or “ARDC Scottsdale Home” referred to, E2 stated, “That’s only me.” When the Compliance Officer repeated what E2 had said, E2 clarified, stating, “Myself or [E1].” E2 reported only E1 and E2 had access to the “ARDC Scottsdale Home” login and account. 4. A review of facility documentation revealed a personnel schedule dated October 2025. However, the schedule did not include E1 and E2. 5. In an interview, E1 reported the personnel schedule was not entirely accurate. E1 reported E1 would provide the Compliance Officer with an updated personnel schedule. 6. A review of facility documentation revealed the updated personnel schedule provided by E1. However, the schedule revealed the following: - No documentation of E1 working on October 1-7, 10-13, and 17, 2025; - E1 worked from 6:00 AM to 6:00 PM on October 18-19, 2025; and - No documentation of E2 working. 7. A comparison of R1’s, R2’s, R3’s, R4’s, R5’s, R7’s, R8’s, and R9’s MARs with the personnel schedule revealed no documentation of the name and signature of the individual administering or providing assistance in the self-administration of medication under the “ARDC Scottsdale Home” account on October 1-7, 10-13, and 17, 2025. The review further revealed no such documentation for the medications administered on October 18-19, 2025, at 8:00 PM. 8. In an interview, E1 acknowledged the aforementioned MARs did not contain documentation of the name and signature of the individual administering or providing assistance in the self-administration of medication under the “ARDC Scottsdale Home” account.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed a front door, a back sliding glass door leading from the dining room to the back yard, and a back door leading from the kitchen to the back yard. The Compliance Officer observed alerts installed on all three doors. However, upon opening the doors, the Compliance Officer heard no alert. The Compliance Officer further observed no monitoring system in place. 3. A review of facility documentation revealed no policy and procedure regarding monitoring resident egress. 4. In a series of interviews, E3 reported the alerts had been working the morning of the inspection. E1 reported the alerts were connected to the internet and the facility was having issues with internet connection. E1 reported E1 would try to fix the alerts. 5. The Compliance Officer observed E1 and E3 working on the alerts. Afterward, the Compliance Officer observed the alerts on the front door and back sliding glass door were sounding. However, the alert on the back kitchen door did not sound.

Based on interview and documentation review, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented the items required by this rule. The deficient practice posed a potential risk of re-injury. Findings include: 1. In an interview, E1 reported two residents were currently in the hospital. 2. A review of facility documentation revealed a series of “Quality Management Program Quarterly (or As Needed) Summary Report Form[s]” dated between January 2025 and September 2025. Each form included a section for “Incidents requiring the response of emergency services (fire department, paramedics, police, etc.).” The forms revealed seven incidents meeting this criteria. However, the review revealed no incident reports or other documentation in compliance with this rule for the seven incidents. 3. In an interview, after looking for the incident reports, E3 stated, “I can’t find any.”

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to residents with access to the poisonous or toxic materials. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "FACILITY GROUNDS SAFE AND FREE OF HAZARDS." The P&P stated: "The facility manager and/or that [sic] owner and staff will ensure that all poisonous or toxic materials (this is to include all cleaning supplies) will be stored and maintained in labeled containers in a locked area separate from food preparation and storage, dining areas and medications." 2. The Compliance Officer observed two cans of paint on the back patio next to the sliding glass door. The Compliance Officer observed a freestanding cabinet on the back patio next to a door leading from the kitchen area to the back yard. The Compliance Officer observed a lock sitting in the latch installed on the cabinet. However, the cabinet was unlocked. Inside the cabinet, the Compliance Officer observed a variety of poisonous or toxic materials, including air freshener, bathroom cleaner, bleach, grout cleaner, laundry detergent, multi-purpose cleaner, multi-surface cleaner, odor eliminator, and window cleaner. 3. In an interview regarding the unlocked cabinet, E1 stated, "I told [the caregivers] a couple of times they gotta lock it." 4. The Compliance Officer observed an unlocked shed in the back yard. Upon opening the shed, the Compliance Officer observed several cans of paint. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on May 16, 2023.

Based on the record review and interview, the manager failed to ensure that the healthcare institution administered a training program for all staff regarding fall prevention and fall recovery, which included both initial training and continued competency training for one of the three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E3's personnel records revealed no fall prevention and fall recovery training documentation was available for the Compliance Officer to review. 2. In an interview, E1 acknowledged that the facility failed to administer a training program for staff regarding fall prevention and fall recovery.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(A), for one of three sampled employees. The deficient practice posed a risk if the individual was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(A) states, "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of E3's personnel record revealed documentation of E3's fingerprint clearance card. 3. A review of the Arizona Department of Public Safety website revealed E3's fingerprint clearance card was invalid. 4. In an interview, E1 acknowledged E3's fingerprint clearance card was invalid, and there was no documentation to reflect E3 had a valid fingerprint clearance card at the time of the inspection.

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis as specified in R9-10-113, for one of three personnel sampled. The deficient practice posed a potential TB exposure risk to residents and the Department was provided false or misleading information. Findings include: 1. A documentation review revealed a policy and procedure titled "STAFFING and RECORD KEEPING" dated August 15, 2022. The policy and procedure stated: "Each employee hired by this facility must have the following on Employee's file . . . 2. Copy of current TB skin test that reads 'negative result' . . . f. This facility must review completed personnel records prior to start working." 2. In an interview, E4 reported E5 was just recently hired as a caregiver. R9-10-113(B)(1)(a)(i) states, in part: "A health care institution's chief administrative officer shall, for an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain . . . the following as evidence of freedom from infectious tuberculosis: Documentation of a negative Mantoux skin test or other tuberculosis screening test that is recommended by the U.S. Centers for Disease Control and Prevention (CDC). 3. A review of the CDC website revealed the following regarding "Baseline Testing: Two-Step Test[s]:" "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used. This is because some people with latent TB infection have a negative reaction when tested years after being infected. The first TST may stimulate or boost a reaction. Positive reactions to subsequent TSTs could be misinterpreted as a recent infection. "Step 1 Administer first TST following proper protocol Review result Positive - consider TB infected, no second TST needed; evaluate for TB disease.* Negative - a second TST is needed. Retest in 1 to 3 weeks after first TST result is read. Document result "Step 2 Administer second TST 1 to 3 weeks after first test Review results Positive - consider TB infected and evaluate for TB disease. Negative - consider person not infected. Document result" 4. At 10:36 AM, the Compliance Officer requested all personnel records. 5. A review of E5's personnel record (at approximately 1:15 PM) revealed E5 was hired as a caregiver. The review revealed a "Mantoux Tuberculin Skin Test Record Form" dated April 6, 2023, before E5 was hired. The document revealed the results were negative. However, the review revealed no second skin test as recommended by the CDC and as required by rule. 6. In an interview, when the Compliance Officer asked if E5 had received a second skin test, E4 stated, "Yeah, but we can't find the paper." At 4:30 PM, during the exit interview, E3 provided the Compliance Officer with a document for E5 as well as a ne

Based on record review and interview, the manager failed to ensure a resident had a written service plan that included the frequency of assisted living services being provided to the resident, for six of six residents sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. A review of R1's medical record revealed a service plan dated May 1, 2023. The service plan revealed R1 was "Dependent" in "Dressing" and required the "assistance of 1 or 2 [caregivers]" in "Transferring to Bed or Chair." However, the service plan did not include a frequency for these two services. 2. A review of R2's medical record revealed a service plan dated April 25, 2023. The service plan revealed R2 was "Dependent" in "Dressing," used a catheter, and required a "Hoyer Lift" for "Transferring to Bed or Chair." However, the service plan did not include a frequency for these three services. 3. A review of R3's medical record revealed a service plan dated April 3, 2023. The service plan revealed R3 was "Dependent" in "Dressing." However, the service plan did not include a frequency for this service. 4. A review of R5's medical record revealed a service plan dated May 1, 2023. The service plan revealed "Assistance [was] needed" for R6 for "Dressing." However, the service plan did not include a frequency for this service. 5. A review of R6's medical record revealed a service plan dated April 14, 2023. The service plan revealed R6 was "Dependent" in "Dressing." However, the service plan did not include a frequency for this service. 6. A review of R9's medical record revealed a service plan dated April 25, 2023. The service plan revealed R9 was "Dependent" in "Dressing" and would "[Transfer] to Bed or Chair . . .With assist of 2 caregivers." However, the service plan did not include a frequency for these two services. 7. In an interview, E3 and E4 acknowledged the aforementioned service plans did not include the frequency of assisted living services being provided to the aforementioned residents. Technical assistance was provided on this rule during the compliance inspection conducted on June 7, 2022.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for one of six residents sampled. The deficient practice posed a risk as a service stated in the resident's service plan was not provided. Findings include: 1. A review of R2's medical record revealed a service plan dated April 25, 2023. The service plan revealed R2 was to be "Turn[ed] every 2-3 hours in bed." The review further revealed a document titled "ACTIVITIES OF DAILY LIVING" dated May 2023. The document had a place to document "Turn[ing R2] in bed . . . every 2 hours." However, the spaces for each day next to the service were blank. 2. In an interview, E4 stated R2 was not being turned every two to three hours because "[R2] doesn't want it." Technical assistance was provided on this rule during the compliance inspection conducted on June 7, 2022.

Based on record review, interview, and documentation review, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record, for six of six residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated May 1, 2023. The service plan revealed R1 was to receive a variety of services, including showers three times a week, partial baths on days showers were not given, oral care two times a day, dressing, catheter care every four hours, and transfers, among others. The review further revealed a document titled "ACTIVITIES OF DAILY LIVING" dated May 2023. However, the document revealed the following: - No documentation of transfers; - No place to document transfers; and - No documentation of services provided on May 6-7, 2023. 2. A review of R2's medical record revealed a service plan dated April 25, 2023. The service plan revealed R2 was to receive a variety of services, including partial baths on days bed baths were not given, oral care twice a day, daily nail care, dressing, toileting, and transfers, among others. The review further revealed a document titled "ACTIVITIES OF DAILY LIVING" dated May 2023. However, the document revealed the following: - No documentation of transfers; - No place to document transfers; - No documentation of dressing on May 6, 2023; and - No documentation of services provided on May 7, 2023. 3. A review of R3's medical record revealed a service plan dated April 3, 2023. The service plan revealed R3 was to receive a variety of services, including partial baths on days showers were not given, daily oral care, daily nail care, dressing, and toileting, among others. The review further revealed a document titled "ACTIVITIES OF DAILY LIVING" dated May 2023. However, the document revealed no documentation of services provided on May 6-7, 2023. 4. A review of R5's medical record revealed a service plan dated May 1, 2023. The service plan revealed R5 was to receive a variety of services, including partial baths on days bed baths were not given, oral care two times a day, daily nail care, dressing, toileting, and incontinence checks, among others. The review further revealed a document titled "ACTIVITIES OF DAILY LIVING" dated May 2023. However, the document revealed no documentation of services provided on May 6-7, 2023. 5. A review of R6's medical record revealed a service plan dated April 14, 2023. The service plan revealed R6 was to receive a variety of services, including partial baths on days bed baths were not given, oral care two times a day, daily nail care, dressing, and toileting, among others. The review further revealed a document titled "ACTIVITIES OF DAILY LIVING" dated May 2023. However, the document revealed no documentation of services provided on May 7, 2023. 6. A review of R9's medical record revealed

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected sensitive resident health information from being disclosed without the resident's consent or knowledge. Findings include: 1. A documentation review revealed a policy and procedure titled "RECORDS MANAGEMENT" dated August 15, 2022. The policy and procedure stated: "All records, including legal documents, resident information, employee information, contracted services and financial information shall be maintained in locked cabinets and/or in a locked room in the Facility. . . . Access to records shall be restricted to authorized personnel, including Owner, Manager and Caregiver[s] only." 2. During a tour of the facility, the Compliance Officer observed a posting on a wall between the kitchen and the dinning room. The posting was titled "Shower Plan" and included the names of the residents and the days of the week the residents received either a shower, a bed bath, or had a visit from hospice. In the dining room, the Compliance Officer observed a medication administration record binder and a narcotics administration binder on the counter. Both binders contained resident information. On the refrigerator next to the counter, the Compliance Officer observed a magnet. On multiple occasions during the inspection, the Compliance Officer observed facility personnel and visiting health care personnel (not facility personnel) use the magnet to open a cabinet under the counter. The Compliance Officer observed the cabinet contained resident medical records. 3. In an interview, E3 and E4 acknowledged the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. Technical assistance was provided on this rule during the compliance inspection conducted on June 7, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis, for one of six residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A documentation review revealed a policy and procedure titled "MEDICAL RECORDS and ELECTRONIC MEDICAL RECORDS" dated August 15, 2022. The policy and procedure stated, "A manager shall ensure that a resident's medical records contains resident information that includes . . . [d]ocumentation of freedom from infectious tuberculosis." 2. A review of R2's medical record revealed documentation of R2's freedom from infectious tuberculosis, dated as read on June 24, 2022. 3. At 4:30 PM, during the exit interview and unsolicited by the Compliance Officer, E3 provided the Compliance Officer with a document for R2 as well as a nearly identical document for E5 (E5's document was requested). 4. A review of R2's medical record, provided by E3 during the exit interview, revealed a document titled "CONSENT FOR TB SKIN TEST" dated April 3, 2023. The two signatures of the registered nurse (O1), the circle around the placement location, the result, and the circle around the impression were identical to those same items on the requested document for E5. The "Name of Patient," date and time the skin test was placed, and the date and time the skin test was read was in a different handwriting than the two signatures of O1. 5. In an interview, the Compliance Officer asked E4 where E3 obtained the document. E4 reported not knowing. When E3 returned from another room, the Compliance Officer asked E3 where E3 obtained the document, to which E3 stated, "Where I found it." The Compliance Officer informed E3 and E4 the documents for R2 and E5 were nearly identical and the handwriting of the two sections on the documents did not match. The Compliance Officer informed E3 and E4 the Compliance Officer had worked with O1 (whose signature was on the documents) in the past during other inspections. The Compliance Officer requested E3 or E4 call O1 to verify the test. E3 and E4 did not call. When the Compliance Officer volunteered to call O1, E4 stated, "How about we not call?" 6. In a series of interviews (between several private meetings of E3 and E4 in multiple locations), E3 and E4 first reported the second skin test document was legitimate. Later, speaking to E3, E4 stated, "Just tell [the Compliance Officer]," and E3 stated, "I falsified the document." 7. In a text message, as done on other occasions, the Compliance Officer asked O1 if O1 placed and read R2's second skin test. O1 stated: "No! I didn't! That's fake! That's not valid." Referring to the dates and times the skin test was placed and read, O1 stated, "That's not my hand[writing]." Technical assistance was provided on this rule during the compliance inspection conducted on June 7, 2022