Arden Villa LLC

Based on observation, record review, documentation review, and interview, the governing authority failed to notify the Department immediately when there was a change in the manager. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E2's manager's certificate posted in the facility. 2. A review of the facility personnel record revealed no personnel record for E2. 3. A review of a review of Department documentation revealed that no notification was provided to the Department of a manager change. 4. In an interview, E1 reported E2 took over as the manager in September 2024. E1 reported E2 notified the Department when E2 took over. When the Compliance Officer informed E1 the Department had received no such notification, E1 reported E1 would have to check in with E2 regarding the notification.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for two of three employees reviewed. The deficient practice posed a safety risk to residents. Findings include: 1. ARS § 36-411(C)(3-4) states: "C. Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to: [...] (3) Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency may not hire the potential employee. (4) On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency shall take action to terminate the employment of that employee." 2. A review of E3's and E4's personnel records revealed no documentation of good faith efforts to verify that each employee was not on the adult protective services registry pursuant to section 46-459. 3. In an interview, E1 acknowledged that good-faith efforts to verify that each employee was not on the adult protective services registry were not conducted.

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 if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. A request for documentation of the caregivers and assistant caregivers working each day, including the hours worked by each revealed the facility had no documentation of the caregivers and assistant caregivers working each day, including the hours worked by each for May, August, and September of 2025. 2. In an interview, E1 acknowledged that the facility had no documentation of the caregivers and assistant caregivers working each day, including the hours worked by each for May, August, and September of 2025.

Based on observation, record review, and interview, the manager failed to ensure a caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of two caregivers. The deficient practice posed a risk if the employees were unable to meet residents' needs. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E4 working at the facility and providing assisted living services to residents. 2. A review of E4’s personnel record revealed that E4 did not receive orientation. 3. In an interview, E1 acknowledged E4 did not receive orientation.  4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure a personnel record was established and maintained for each employee as required, for two of two employees sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. The Compliance Officer arrived at the facility around 9:00 am. Upon arrival, the Compliance Officer observed E3 providing services to residents. 2. A review of facility personnel records revealed a personnel record for E3; however, the record only contained a fingerprint clearance card, cardiopulmonary resuscitation / first aid card, caregiver training program certificate, and an application. No other documentation was available for review. 3. A request for E2’s personnel revealed no personnel record for E2 was available for review. 4. In an interview, E1 acknowledged that no personnel record for E2 was available for review at the time of inspection. E1 also acknowledged that E3’s personnel record was an incomplete record.

Based on record review and interview, the manager failed to ensure that 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 an assisted living facility, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse. Findings include: 1. A review of R1’s medical record revealed R1's had no pre-admission determination, which included whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner. The pre-admission determination needed to be completed within 90 days before R1 was admitted to the facility 2. In an interview, E1 acknowledged R1 had no pre-admission determination documentation, which included whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner.

Based on observation, documentation, and interview, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a health and safety risk to the resident. Findings include: 1. R9-10-101.201 defines "Restraint" as any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. 2. During an environmental inspection of the facility, the Compliance Officer observed R1 sleeping and lying in bed with a pillow tucked under R1’s right backside. In front of R1's bed, there was a wheelchair and a table pushed next to the bed. 3. A review of R1's medical record revealed a service plan for directed care services dated June 2025. 4. In an interview, E3 reported the reason the wheelchair and a table were pushed next to the bed was to keep R1 from falling out of bed. 5. In an interview, the findings were reviewed with E1 and E3, and no additional information was provided.

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 as 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. During the environmental inspection of the facility with E3, the Compliance Officer observed that the front door of the facility's alert was not working. Also, the backyard sliding door, which exits to the back patio, had no monitors or alerts to alert employees of the egress of a resident from the facility. 3. In an interview, E1 acknowledged that the front door alert was not working, and the backyard sliding door had no monitors or alerts to alert employees of the egress of a resident from the facility.

Based on documentation review, observation, and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. During the environmental inspection of the facility with E3, the Compliance Officer observed that a medication cabinet in the kitchen area, which contained medication for four residents at the facility, was unlocked. 2. During the environmental inspection of the facility with E3, the Compliance Officer observed that a garage refrigerator, which contained medication for four residents at the facility, was unlocked. 3. In an interview, E1 acknowledged that the medication for four residents of the home, which was stored in the medication cabinet in the kitchen area and in the garage refrigerator, was unlocked and accessible to residents at the time of inspection.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed no documentation of disaster drills being conducted at least once every three months and documented within the last 12 months. 2. In an interview, E2 acknowledged no documentation of disaster drills being conducted at least once every three months and documented within the last 12 months was available for review at the time of inspection.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted once every six months and documented. The deficient practice posed a risk if employees were unable to evacuate the residents in an emergency. Findings include: 1. A review of facility documentation revealed no documentation of an evacuation drill being conducted once every six months and documented. 2. In an interview, E1 acknowledged that no documentation of an evacuation drill being conducted once every six months and documented was available for review at the time of inspection.