Adam's House

Based on documentation review and interview, the assisted living home/center failed to maintain a copy of the document provided to the emergency responder for a period of two years after the date of the emergency for one of two resident sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A review of R1's medical record revealed an incident report on August 01, 2025. This report stated, "While at dinner, [R1] was eating at the table and ate a piece of a sandwich and took a big bite and started to choke on it... Staff then called 911 and shortly after [R1] lost consciousness. Staff performed CPR until EMS arrived and took over. Following extensive efforts to revive [R1] for the better part of an hour, [R1] was transferred to YRMC East Campus for higher level of care." 2. A review of R1’s medical record revealed that a standardized form was used for R1 to be provided to emergency medical services during an emergency. However, the documentation that was given to the emergency responder on August 1, 2025, was not available for review. 3. In an interview, E1 reported that the facility provided the required documentation to the emergency responder; however, E1 acknowledged that the documentation provided was not maintained for a period of two years after the date of the emergency.

Based on documentation review, observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. § 36-425(I), when there was a change in the manager and identifying the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. A.R.S. § 36-425(I) states "A health care institution shall immediately notify the department in writing when there is a change of the chief administrative officer..." 2. A review of Department records revealed the Department was notified that E2 was no longer the manager as of May 27, 2025, at "AL4280H ADAM'S HOUSE." 3. The Compliance Officer arrived at the facility at 10:14 AM and observed E1's manager's certificate posted at the facility. 4. In an interview, E1 reported that E1 was the manager of "AL4280H ADAM'S HOUSE" as of May 30, 2025. E1 also reported that E2 provided a resignation letter on May 27, 2025, stating E2’s last day would be May 30, 2025. 5. A review of E1's personnel record revealed a date of hire of May 30, 2025. 6. A review of Department records revealed the facility did not notify the Department in writing when there was a change in the manager. 7. In an interview, E1 reported that E1 was the current manager and acknowledged that the Department was not notified in writing of the change in manager.

Based on documentation review, record review, and interview, the manager failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to assess potential dangers to other residents at the facility in a timely manner. Findings include: 1. ARS § 11-593.B. stated, "Reporting is required in the following circumstances: 1. Death when not under the current care of a health care provider as defined pursuant to section 36-301. 2. Death resulting from violence. 3. Unexpected or unexplained death. 4. Death of a person in a custodial agency as defined in section 13-4401. 5. Unexpected or unexplained death of an infant or child. 6. Death occurring in a suspicious, unusual or nonnatural manner, including death from an accident believed to be related to the deceased person's occupation or employment. 7. Death occurring as a result of anesthetic or surgical procedures. 8. Death suspected to be caused by a previously unreported or undiagnosed disease that constitutes a threat to public safety. 9. Death involving unidentifiable bodies." 2. A review of Department documentation revealed a self-report notifying on August 12, 2025, of the Department of R1’s death. 3. A review of R1's medical record revealed an incident report on August 01, 2025. This report stated, "While at dinner, [R1] was eating at the table and ate a piece of a sandwich and took a big bite and started to choke on it. Staff started to then hit the back of [R1] in order to dislodge the piece of lettuce that [R1] was still trying to swallow in [R1]’s mouth. Once it was out, staff started to do the Heimlich in order to get the remainder of the food but were unsuccessful. Staff then called 911 and shortly after [R1] lost consciousness. Staff performed CPR until EMS arrived and took over. Following extensive efforts to revive [R1] for the better part of an hour, [R1] was transferred to YRMC East Campus for higher level of care." 4. In an interview, E1 reported that shortly after emergency medical services (EMS) transported [R1], the facility received a call from the hospital stating that [R1] had died shortly after arrival, and E1 acknowledged the Department was not notified of a resident's death within one working day after the resident's death.

Based on documentation review, observation, and interviews, the manager failed to ensure there was 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, which provided access to a secured outside area that monitored or alerted employees of the resident’s egress from the facility. This deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1 . A review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed multiple ambulatory residents. 3. A review of the facility's policy and procedure revealed a policy titled "Safety of Wandering Residents." The policy stated "5. If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security. Alarms that are triggered will be investigated immediately by the caregiver on duty. " 4. During the environmental inspection with E1, the Compliance Officer observed a door leading to the secured backyard. The door contained part of a device that was intended to alert employees of a resident’s egress to the outside area; however, a component of the device was missing, which resulted in the device being nonfunctional. 5. In an interview, E1 reported that the missing part had fallen off at some point, and E1 acknowledged that the exit door to the secured outside area did not monitor or alert employees of a resident’s egress from the facility.

Based on record review and interview, the manager failed to ensure a resident's written service plan is signed and dated by the resident's representative. Findings include: 1. A review of R1's medical record revealed R1 received directed care services. 2 . A review of R1's medical record revealed service plans dated November 27, 2024 and February 25, 2025. However, the service plans were not signed by the resident's representative. 3 . In an interview, E1 acknowledged R1's service plan was not signed by the resident's representative.

Based on documentation review, observation, interview, and record review, the governing authority failed to designate, in writing, a manager with a certificate or temporary certificate. The deficient practice posed a risk as the assisted living facility did not have a manager for approximately one month. Findings include: 1. A review of Department documentation revealed an email from the governing authority dated April 17, 2023. The email stated: "We wanted to inform you that our manager [E4] quit on 4/16/23. We are currently in the process of hiring a new manager. If you have any questions please feel free to reach out." The review further revealed an email from E4 dated April 26, 2023. The email stated, "I just wanted to let you know that I [E4] am no longer managing Adam's House on 7697 E Nightingale Star [Lane] Prescott Valley AZ 86305." The review revealed no documentation regarding the identity of the current manager or whether the facility had a manager after E4. 2. During the environmental inspection of the facility, the Compliance Officer observed E1's certified assisted living facility manager certificate posted in the office area. 3. In an interview, E1 reported E1 was the manager. 4. In an telephonic interview, the governing authority reported E4 resigned in April, the facility then had no manager, E5 was going to take over as manager but did not work out, and E2 eventually took over in May. The governing authority acknowledged the facility did not have a manager for approximately one month. 5. A review of the personnel records of E1, E2, and E5 revealed the following: -E2 was the manager between May 15, 2023, and October 1, 2023; -E1 was the manager effective October 1, 2023; and -E5 was not a currently certified manager and could not have been the facility's manager. 6. A review of the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers website revealed the following: -E1's temporary manager's certificate was active effective September 26, 2023; -E1's manager's certificate was active effective October 13, 2023; -E2's manager's certificate was active effective January 10, 2022; and -E5's manager's certificate expired in 2019. 7. In an interview, E1 and E2 acknowledged the facility did not have a manager between April 16, 2023, when E4 resigned and May 15, 2023, when E2 took over.

Based on documentation review and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify whether qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a series of personnel schedules dated between November 1, 2022, and December 6, 2023. However, the review revealed no personnel schedule for December 2022. 2. In an interview, E2 reported not knowing where the schedule for December 2022 was. E2 reported E2 took over as manager in May 2023 and was not given all documentation dated prior to E2's appointment.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet the needs of a resident. Findings include: 1. A review of R2's medical record revealed a document titled "INITIAL PHYSICIAN RECOMMENDATION FORM" dated October 21, 2023. The form was signed and dated by a registered nurse practitioner and stated, "[R2] does not require or [is] expected to receive continuous medical services or continuous nursing services and does not require restraints, including the use of bedrails." However, the form was signed and dated after R2 was admitted to the facility. 2. In an interview, E1 and E2 reported E1 and E2 sent the form to the nurse practitioner the day before R2 was admitted to the facility. E1 reported the nurse practitioner did not sign the form on time and decided to sign the form at the facility in person instead. Technical assistance was provided on this rule during the complaint and compliance inspections conducted on September 7, 2022.

Based on 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 and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the open living room area was being used as an office. On a desk in this office area, the Compliance Officer observed a variety of binders containing medication administration records and documentation of assisted living services provided to residents. 2. In an interview, E1 and E2 acknowledged the documents were not protected from loss, damage, or unauthorized use. E1 and E2 reported the remainder of the residents' records were kept in a locked closet. Technical assistance was provided on this rule during the complaint and compliance inspections conducted on September 7, 2022.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R1's medical record revealed a current service plan indicating R1 received medication administration services. The review also revealed a medication order dated August 2, 2023 for "DIVALPROEX SODIUM 125 MG (milligrams) CAP ...Sprinkle 4 Caps in Food (not Drinks) Three Times Daily." The review further revealed a medication administration record (MAR) dated December 2023. The MAR revealed R1 did not receive R1's third daily dose of "Divalproex" on December 1-3, 2023. The MAR stated the medication was "Not given" because it was "Not on hand." However, the MAR revealed R1 received R1's first and second daily doses of "Divalproex" on December 1-3, 2023. 2. In an interview, E2 reported the pharmacy sent separate pharmacy-provided multi-dose packs for each administration time (8:00 AM, 12:00 PM, and 8:00 PM). E2 reported the personnel member on duty at 8:00 PM on December 1-3, 2023, did not administer the medication and did not take the same medication from R1's pharmacy-provided multi-dose packs meant for different administration times. E2 stated, "That is a medication mistake." E1 and E2 acknowledged R1 did not receive R1's "Divalproex" as ordered on December 1-3, 2023.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for two of three personnel members sampled and one of one applicable resident sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) 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)." 2. A review of the CDC 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 facility documentation revealed a series of personnel schedules. The schedules revealed E1 worked several shifts in July and August 2023 before August 22, 2023, and E3 worked several shifts in September and October 2023 before October 30, 2023. 4. A review of the personnel records of E1 and E3 revealed the following: -A negative TST for E1 dated as read on October 11, 2022, before E1 began providing services at or on behalf of the assisted living facility; -A negative TST for E1 dated as read on August 22, 2023, after E1 began providing services at or on behalf of the assisted living facility; -A negative TST for E3 dated as read on September 16, 2023, before E3 began providing services at or on behalf of the assisted living facility, but after E3 was hired; and -A negative TST for E3 dated as read on October 30, 2023, after E3 began providing services at or on behalf of the assisted living facility; 5. In an interview, E1 and E2 acknowledged E1's and E3's second TSTs were not read before E1 and E3 provided services. 6. A review of R2's medical record revealed documentation of R2's freedom from infectious TB according to subsection (B)(1). However, the review revealed no documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if R2 had signs or symptoms of TB. 7. In an interview, E1 and E2 reported not knowing this rule applied to all residents. Technical assistance was provided on this rule during the complaint and compliance inspections conducted on September 7, 2022.

Based on documentation review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of facility documentation revealed a document titled "ANNUAL FACILITY TUBERCULOSIS RISK ASSESSMENT FORM." However, the document was not filled out. The review revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB. 2. In an interview, E2 reported the facility had a form for the annual TB risk assessment, but the facility had not yet done the assessment. E2 reported not knowing it was past due. Technical assistance was provided on this rule during the complaint/compliance inspection conducted on September 7, 2022.