Agave Hills LLC

Based on record review, documentation review, and interview, the health care institution failed to ensure a training program for all staff regarding fall prevention and fall recovery, which included initial training, was implemented for two of three personnel sampled. Findings include: 1. A review of E3’s and E4’s personnel records revealed documentation indicating E1 and E4 had received initial training in fall prevention and fall recovery was unavailable for review. 2. A review of facility documentation revealed a fall prevention and fall recovery program, which included initial training and continued competency training in fall prevention and fall recovery to all employees of the facility. 3. In an interview, E2 acknowledged E3 and E4 had not completed initial fall prevention and fall recovery training as required, per A.R.S. § 36-420.01.

Based on observation, documentation review, and interview, the Governing Authority failed to designate, in writing, a manager compliant with R9-10-803.A.3.b. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. During a tour of the facility, the Compliance Officer observed a document titled “Governing Authority Manager Delegation,” which identified E3 as the facility’s manager, “Effective Date: 5-16-25.” 2. A review of Department documentation revealed O1 was identified as being the assisted living facility’s manager. 3. Online research conducted through the Arizona Nursing Care Institution Administrators and Assisted Living Facility Managers, https://aznciab.portalus.thentiacloud.net/webs/portal/register/#/, revealed documentation indicating O1’s manager’s license expired on March 24, 2025, and had not been renewed. 4. A review of E3’s personnel record revealed E3 was hired as a licensed manager on May 15, 2025. 5. A review of E2’s personnel record revealed documentation of a current, valid assisted living facility manager’s license. 6. Online research conducted through the Arizona Nursing Care Institution Administrators and Assisted Living Facility Managers, https://aznciab.portalus.thentiacloud.net/webs/portal/register/#/, revealed documentation confirming E2’s and E3’s managers’ licenses were current and valid. 7. In an interview, E2 advised both E1 and E2 were the governing authority of the facility. E2 indicated E2 had not been designated as the manager after O1’s manager’s license had expired. E2 reported E2 did not sign any documents as a licensed manager and did not display their manager’s license in the facility after learning O1’s manager's license had expired. E2 confirmed the facility did not designate in writing a manager from March 24, 2025, until May 16, 2026 8. In an interview, E1 acknowledged the governing authority did not designate a manager in writing between March 24, 2025, and May 16, 2025.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alert employees of the egress of a resident from the facility. The 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 the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During a tour of the facility, the Compliance Officer observed a door leading to the outside patio and backyard of the facility, which allowed residents to be at least thirty feet away from the facility. The door was equipped with a thumb-turn locking handle as well as a thumb-turn locking deadbolt. No other methods of monitoring, control or alert of egress associated with the door were observed. The locks were not engaged, and the Compliance Officer was able to open the door with little effort. 3. In an interview, E2 agreed there was a means of exiting the facility, which allowed residents to be at least 30 feet away from the facility, which did not control or alert employees of the egress of a resident.

Based on record review and interview, the manager failed to ensure a resident's written service plan when initially developed and when updated was signed and dated by the resident or resident's representative, for one of three sampled residents. Findings include: 1. A review of R4's medical record revealed a service plan dated April 9, 2024, for directed care services. The service plan was signed and dated by the nurse on April 9, 2024, and the manager on April 12, 2024, however, the service plan was not signed and dated by R4's representative until May 15, 2024, thirty-seven days after the service plan was initiated. 2. A review of documentation provided by E2 revealed an email dated May 16, 2024. The email was sent to R4's representative detailing some concerns. One of them was not signing the care plan. 3. A review of R4's medical record revealed another service plan dated December 19, 2023, for directed care services. The service plan was signed and dated by the nurse on December 19, 2023, and the manager on December 19, 2023, however, the service plan was not signed and dated by R4's representative until March 14, 2024, eighty-seven days after the service plan was initiated. 4. A review of documentation provided by E2 revealed a text message with R4's representative dated March 13, 2024, asking the representative to sign the resident's care plan. 5. In an interview, E1 and E2 acknowledged the service plan provided for R4 had not been signed and dated by R4's representative within fourteen days when the plans were updated.

Based on documentation review, record review, and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities as specified in R9-10-113. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff. 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... c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis..." 2. A review of facility documentation revealed no policy or program had been established, documented, and implemented on TB infection control program as specified in R9-10-113, or address an annual 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; or an annual assessment of the health care institution's risk of exposure to infectious TB. 3. A review of E1. E2 and E'3s personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 4. A review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 5. In an interview, E1, and E2 acknowledged the facility had not established, documented, and implemented a TB infection control program as specified in R9-10-113. 6. Technical assistance was provided during the compliance inspection conducted on June 22, 2023.

Based on interview and documentation review, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager complied with all the requirements in R9-10-803(J). The deficient practice posed a health and safety risk if there was no documentation to show the manager investigated the suspected abuse. Findings include: 1. A review of documentation provided to the Department revealed allegations of abuse had occurred on the facility premises. 2. In an interview on January 11, 2024, E2 revealed the Adult Protective Services had been to the facility to notify the manager of the accusation of abuse by E6 towards R1. At that time the manager had reasonable basis to believe abuse had occurred on the premises while a resident was receiving services from the assisted living facility by a caregiver. 3. The Compliance Officer asked E2 for the facility's investigation documentation on this allegation. E2 reported talking to E6 about the incident to get E6's statement. E2 reported after the interview with E6, E6's employment was terminated. However, E2 had never documented this investigation which is required under A.R.S. \'a7 46-454. 4. In an interview, E2 acknowledged investigating the incident, however, not documenting the investigation.

Based on record review, documentation review, observation, and interview the manager failed to ensure a resident is treated with dignity, respect, and consideration. The deficient practice posed a direct health and safety risk if R1 was subjected to abuse by E6. Findings include: 1. A review of R1's medical record revealed R1 had been living at the assisted living facility for more than a year, and R1 was receiving personal care services from the facility. 2. A review of documentation provided to the Department revealed allegations of abuse had occurred on the facility premises. 3. In an interview on January 11, 2024, E2 revealed the Adult Protective Services had been to the facility to notify the manager of the accusation of abuse by E6 towards R1. At that time the manager had reasonable basis to believe abuse had occurred on the premises while a resident was receiving services from the assisted living facility by a caregiver. 4. The Compliance Officer observed a video provided to the Department which revealed R1 sitting on the floor holding onto a walker. E6 was pulling up on R1's left arm only. The Compliance Officer observed the way E6 was pulling on R1's arm was making it difficult to pick R1 up off the floor and into the chair. E6 is yelling at R1 "get up off the floor you put yourself there", and "get your ass in the chair". In the video you can see R1 is in a weakened state and unable to assist getting up off the floor and into the chair without assistance. E6 allows R1 to slide down the chair and back onto the floor. E6 takes R1's walker out of R1's right hand pushing it out of R1's reach and swearing at R1. E6 continues to yell at R1 to "get in the chair" over and over. R1 says something to E6 but it is inaudible. R1 tries to reach for the walker with R1's right hand and E6 moves the walker away again. R1 then tries to reach for E6 and E6 yells "don't touch me". E6 tries again to put R1 in the chair by pulling on one arm and yelling "stand up and move your legs", the video ends after that. 5. In an interview, E2 acknowledged E6 was the caregiver in the video and that the resident was not treated with dignity, respect, and consideration.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of three caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3's personnel record revealed a National CPR Foundation CPR/Automated External Defibrillator (AED)/First Aid training certification. The course was taken on March 5, 2023. 2. An online search of the National CPR Foundation revealed this is an online CPR course and did not include a hands-on demonstration class taught by an instructor. 3. A review of staff schedules revealed E3 was scheduled to work the 7:00 am to 7:00 pm shift on the following days: June 3, 5, 8, 10, 12, 15, 17, 19, and 22, 2023. 4. A review of policy's and procedures manual with a last reviewed date of January 27, 2023, revealed a document titled "Upon Employment" .... 5) Employees must maintain current CPR and First Aid certification that must be obtained within 30 days of expirations. a) CPR training must meet either American Heart Association, American Red Cross or National Safety Council and include hands-on demonstration and be taught by an instructor who's been certified by previously mentioned organizations". 5. In an interview, E1, and E2 reported being unaware E3's CPR certification was an online course, and acknowledged the facility's policies and procedures indicated online CPR course needed to be previously hands-on demonstration and be taught by an instructor from either American Heart Association, American Red Cross or National Safety Council.

Based on record review and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C), for one of three personnel sampled. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(C) states, "C. Owners 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." 2. A review of E3's personnel record revealed a document titled "Employment Application". This application had a section titled "Employment Record" however the section titled "Date Verified/Intial's" it was blank. The document had no reference verification for E3. No other evidence of documentation with contact to E3's previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution. 3. In an interview, E1 acknowledged the E3's personnel record was missing documentation of contact to previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution.