Arizona Pioneers' Home

Based on documentation review and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to health and safety. Findings include: 1. A review of facility documentation revealed an incident report detailing R2 eloping from the facility on October 01, 2025. The report stated: “[R2] verbalizing to 'go downtown' stair tower south alarm sounding soon after staff heard resident verbalizing intent, immediate inspection and response to alarm, noted that key pad at basement stair tower level lit and alarming, outside perimeter search initiated.” However, R2 was able to make their way out of the facility and leave the property of the facility before being found at a downtown shop. 2. A review of facility documentation revealed a policy titled “Wander Management Systems.” The policy stated “10. If the alarm of the wandering management system is activated, staff should respond immediately and investigate the cause of the alarm until the cause is determined.” 3. A review of R2’s medical record revealed R2 was receiving direct care services and a wandering risk. 4. During the environmental inspection of the facility, the Compliance Officers observed three levels of stairways, and residents on all floors have access to all three stairways. The Compliance Officers observed several residents of the facility from different levels accessing the stairways. The doors of the stairways did not have alerts or monitoring. The facility only used a wander bracelet for the resident to alert if the resident had left the level they were on. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure policies and procedures were documented to protect the health and safety of a resident that covered methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. Findings include: 1. A review of Department documentation revealed the facility is licensed for direct care. 2. During the environmental inspection of the facility, the Compliance Officers observed ambulatory residents on all three levels of the facility. 3. A review of the facility policy and procedure revealed a policy titled “Wander Management Systems.” The policy stated “10. If the alarm of the wandering management system is activated, staff should respond immediately and investigate the cause of the alarm until the cause is determined.” However, the policy did not cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. 4. A review of facility documentation revealed an incident report detailing R2 eloping from the facility on October 01, 2025. The report stated: “[R2] verbalizing to 'go downtown' stair tower south alarm sounding soon after staff heard resident verbalizing intent, immediate inspection and response to alarm, noted that key pad at basement stair tower level lit and alarming, outside perimeter search initiated.” However, R2 was able to make their way out of the facility from the second level and get to the first level and leave the property of the facility before being found at a downtown shop. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan for one resident sampled, who required behavioral care, was reviewed by a medical practitioner or behavioral health professional. The deficient practice posed a health and safety risk if the facility was unable to meet the needs of the resident. Findings include: 1. A review of R7's medical records revealed a document titled "Request for Continued Residency Form," which reported R7 received behavioral care services, and the primary care physician reviewed the community's scope of services and determined that the individual's needs can be met at the facility. 2. A review of R7's medical record revealed a service plan for personal care services dated July 2025. A review of R7's medical record revealed documentation of a diagnosis of "Anxiety/Depression, Bipolar Disorder, Depression, Major Depressive Disorder, History of OCD, REM Sleep Behavior Disorder, Somnolence". In addition, the medical record revealed R7 received administration of psychotropic medications. However, the service plan did not include a review by a medical practitioner or behavioral health professional. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.