Desert Palm at the Park

Based on documentation review, record 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 incomplete documentation identifying the staff 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 December 29, 2025, and the date of the inspection. The schedules indicated the following: - E3 did not work on January 1-4, 11, 18, and 25, 2026, or on February 1 and 8, 2026; 2026; - E4 did not work on January 3, 10, 17, 24, and 31, 2026, or February 7, 2026; - E5 did not work on January 5-11, 17-18, and 25, 2026, or February 1, 2026; - E6 did not work on January 1, 8, 12, 24, and 31, 2026; - E7 did not work on January 6, 13, 23, and 25, 2026; - E8 did not work on January 4-5, 15, 19-20, 22, and 26-27, 2026, or February 1-3, 2026; and - E9 did not work on January 2, 7, 9, 14, 16, 21-24, and 28-31, 2026, or February 4-11, 2026. 2. A review of R1’s, R2’s, R3’s, and R4’s medical records revealed documentation of assisted living services (ADLs) provided to the four residents, dated January 2026 and February 2026. However, the review revealed inconsistencies between the ADLs and the personnel schedules. These inconsistencies include, but are not limited to, the following: - E5 provided services on January 5, 11, and 17-18, 2026, and February 1, 2026, in contradiction with the personnel schedules; - E6 provided services on January 1, 8, and 31, 2026, in contradiction with the personnel schedules; - E7 provided services on January 6, 13, and 25, 2026, in contradiction with the personnel schedules; and - E8 provided services on January 26-27, 2026, and February 2-3, 2026, in contradiction with the personnel schedules. 3. In a telephonic interview, E2 reported the ADLs were correct, and facility personnel likely did not update the schedule to reflect necessary changes. 4. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 20, 2025, and a repeat citation from the complaint inspection conducted on October 28, 2024, and the complaint and compliance inspection conducted on April 13, 2023.

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established and documented that included the amount, type, and frequency of assisted living services being provided to the resident, for one of four sampled residents. The deficient practice posed a risk as a service plan guides a resident’s care. Findings include: 1. A review of R4's medical record revealed a service plan dated January 2, 2026. The service plan indicated R4 required assistance with transferring and received medication administration. However, the service plan did not include the frequency of transferring or medication administration. The service plan further revealed R4 required assistance combing R4’s hair daily. The review further revealed documentation of assisted living services (ADLs) provided to R4 dated January 2026 and February 2026. The ADLs revealed documentation demonstrating R4 received assistance transferring at least two times per day in January 2026, zero times per day in February 2026, and R4 did not receive assistance combing R4’s hair. 2. In an interview, R4 confirmed facility personnel transferred R4 out of R4’s wheelchair and into bed and vice versa. When the Compliance Officers asked if facility personnel combed R4’s hair, R4 stated, “No.” 3. In a separate interview, when the Compliance Officers asked if facility personnel transferred R4, E3 stated, “Yes.” E3 reported facility personnel transferred R4 six to eight times a day on average. 4. In a telephonic interview, when the Compliance Officer asked if R4’s service plan included the frequency of transferring, E2 stated, “No.” When the Compliance Officers asked if facility personnel combed R4’s hair, E2 stated, “No.” 5. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. Technical assistance was provided on this rule during the complaint inspection conducted on November 20, 2025.

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 four sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. A review of R4's medical record revealed a service plan dated January 2, 2026. The service plan indicated R4 required assistance combing R4’s hair daily. The review further revealed documentation of assisted living services (ADLs) provided to R4 dated January 2026 and February 2026. The ADLs revealed documentation demonstrating R4 did not receive assistance combing R4’s hair. 2. In an interview, when the Compliance Officers asked if facility personnel combed R4’s hair, R4 stated, “No.” 3. In a telephonic interview, when the Compliance Officers asked if facility personnel combed R4’s hair, E2 stated, “No.” 4. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. Technical assistance was provided on this rule during the complaint inspection conducted on November 20, 2025.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of four sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R4's medical record revealed a service plan dated January 2, 2026. The service plan indicated R4 required assistance transferring. The review further revealed documentation of assisted living services (ADLs) provided to R4 dated February 2026. However, the ADLs revealed no documentation demonstrating R4 received assistance transferring. 2. In an interview, R4 confirmed facility personnel transferred R4 out of R4’s wheelchair and into bed and vice versa. 3. In a separate interview, when the Compliance Officers asked if facility personnel transferred R4, E3 stated, “Yes.” E3 reported facility personnel transferred R4 six to eight times a day on average. 4. In a telephonic interview, when the Compliance Officer informed E3 that the ADLs did not include documentation of transferring in February 2026, E2 stated, “I don’t know how we missed that.” 5. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 20, 2025, and a repeat citation from the complaint and compliance inspections conducted on February 27, 2024, and April 13, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of a medication administered to a resident that included the name and signature of the individual administering the medication, for four of four residents reviewed. The deficient practice posed a health and safety risk to residents if the facility did not properly document medication administration for a resident. Findings include: 1. A review of facility documentation revealed a series of personnel schedules dated between December 29, 2025, and the date of the inspection. The schedules indicated the following: - E3 did not work at 12:00 AM on January 1, 2026, through February 11, 2026; - E3 did not work at 8:00 PM on January 19-31, 2026, and February 2-7, 9-11, 2026; - E3 did not work on January 1-4, 11, 18, and 25, 2026, or on February 1 and 8, 2026; - E4 did not work at 12:00 AM on January 1-15 and 17-31, 2026, and February 1-11, 2026; - E4 did not work at 8:00 PM on January 14, 19-23, and 25-30, 2026, and February 1-6, and 8-11, 2026; and - E4 did not work on January 3, 10, 17, 24, and 31, 2026, or February 7, 2026. 2. A review of R1’s, R2’s, R3’s, and R4’s medical records revealed medication administration records (MARs) dated January 2026 and February 2026. However, the review revealed inconsistencies between the MARs and the personnel schedules. These inconsistencies include, but are not limited to, the following: - E3 administered medication at 12:00 AM on January 5-10, 12-17, 19-24, and 26-31, 2026; and February 2-11, 2026, even though E3 did not work at that time on those dates; - E3 administered medication at 8:00 PM on January 19-24, and 26-31, 2026, and February 2-7, 9-11, 2026, even though E3 did not work at that time on those dates; - E4 administered medication at 12:00 AM on January 4, 11, and 25, 2026, and February 1, 2026, even though E4 did not work at that time on those dates; and - E4 administered medication at 8:00 PM on January 25, 2026, and February 1, 8, and 10, 2026, even though E4 did not work at that time on those dates. 3. In an interview, when the Compliance Officers asked if E3 worked the night shift (7:00 PM to 7:00 AM), E3 reported E3 never worked the night shift. E3 reported E3 did not stay past 7:00 PM. E3 reported E3 often pre-fills the residents’ medication cups and documents the administration on the MARs so the caregiver on the night shift can more easily administer the medications. E3 confirmed E3 did not administer medications as aforementioned. When the Compliance Officers asked if E4 worked the night shift in February 2026, E3 reported E4 did not. 4. In a telephonic interview, E2 reported E7 worked the night shift, administered medications at night, and should have been the one documenting on the MARs instead of E3 and E4. 5. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment.

Based on record review, observation, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. A review of R1’s, R3’s, and R4’s medical records revealed service plans that indicated R1, R3, and R4 were at the personal level of care and received personal care services. R1’s and R4’s service plans stated, “Call Bell: Yes” and “Call bell within reach.” 2. The Compliance Officers observed 21 segregated, single-point entry, condominium-style units, each containing between one and three individual bedrooms able to be occupied by one to two residents each. The Compliance Officers entered each of the 21 units and observed no working call buttons, intercoms, or other mechanical means to alert employees to a resident’s needs or emergencies in any of the bedrooms or units, including those of R1, R3, and R4. 3. At 9:04 AM, 9:34 AM, 10:01 AM, 10:33 AM, and 11:09 AM, the Compliance Officers pressed a call button in units 2, 5, 8, 12, and 19 respectively. However, the Compliance Officers observed no personnel come to the units to answer the calls. 4. In a series of interviews, when the Compliance Officers asked if R1’s call button worked, R1 stated, “No.” When the Compliance Officers asked if R4 had a bell, intercom, or other mechanical means to alert employees to R4’s needs or emergencies available in R4’s bedroom, R4 stated, “No.” When the Compliance Officers asked how R4 would get help from facility personnel if R4 needed it, R4 reported R4 would have to call on R4’s phone. When the Compliance Officers asked how R5 would call caregivers for assistance, R5 stated, “I go to the medical office.” When the Compliance Officers asked if R6 had a call button or another way to alert employees to R6’s needs, R6 stated, “No” and “Even if we have it there’s not enough people.” R8 stated R8’s call button “doesn’t work. When the Compliance Officers asked how R9 would call caregivers for assistance, R9 stated, “You don’t.” When the Compliance Officers asked how R10 would call caregivers for assistance, R10 stated, “Get up and go.” Referring to the call button in R11’s bedroom, R11 stated, “That doesn't work.” When the Compliance Officers asked if R12’s call button worked, R12 stated, “I don’t know.” R13 reported R13’s call button did not work. R14 and R15 reported not knowing whether R14’s and R15’s call buttons worked. When the Compliance Officers asked if R18 had a call button or another way to alert employees to R18’s needs, R18 stated, “No” 5. In a telephonic interview, E2 reported the call buttons in the facility did not work, and personal call pendants would not work due to the size and construction of the facility. E2 reported the facility wa

Based on interview, record review, observation, and documentation review, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. In a telephonic interview, E2 reported R2, R16, and R17 were the only residents at the directed level of care. 2. A review of R2’s medical record revealed a service plan that indicated R2 was at the directed level of care and received directed care services. 3. The Compliance Officers observed 21 segregated, single-point entry, condominium-style units, each containing between one and three individual bedrooms able to be occupied by one to two residents each. The Compliance Officers entered each of the 21 units and observed no working call buttons, intercoms, or other mechanical means to alert employees to a resident’s needs or emergencies in any of the bedrooms or units, including those of R2, R16, and R17. 4. The Compliance Officers observed a bell in R2’s bedroom. However, the Compliance Officers observed the bell was hanging from the wall out of reach behind a dresser. At 10:01 AM, the Compliance Officers pressed a call button in R17’s unit. However, the Compliance Officers observed no personnel come to the unit to answer the call. 5. In an interview, when the Compliance Officers asked a resident in R2’s unit if that unit had working call buttons, the resident stated, “No” 6. In a telephonic interview, E2 reported the call buttons in the facility did not work, and personal call pendants would not work due to the size and construction of the facility. E2 reported the facility was in the process of installing hotline phones in some of the bedrooms. 7. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 20, 2025, and a repeat citation from the complaint inspection conducted on July 10, 2025.

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 Officers observed 21 separate condominium-style units (numbered 1-12, 14-21, and A-4), each containing between one and three individual bedrooms able to be occupied by one to two residents each. The Compliance Officers observed each unit had one door leading from an indoor common area to the secured outdoor courtyard, which allowed residents to be at least 30 feet away from the facility. The Compliance Officers observed the following: - The door for unit 3 had an alert installed and set to the “Off” position; - The door for unit 5 did not have an alert installed; - The door for unit 9 had an improperly installed alert; and - The doors for units 12, 15, 17, and 20 had alerts installed and set to the “Chime” position. However, upon opening each of the seven aforementioned doors, the Compliance Officers heard no alerts. The Compliance Officers further observed no monitoring system in place. 3. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 20, 2025, and a repeat citation from the complaint inspections conducted on July 10, 2025; July 8, 2025; and May 14, 2024, and the complaint and compliance inspection conducted on February 27, 2024.

Based on documentation review, interview, and observation, the manager failed to ensure a designated caregiver was available in each building and each segregated area at all times. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. In an interview, E4 reported three caregivers were working during the inspection. 3. A review of facility documentation revealed a personnel schedule dated February 9-15, 2026. The schedule revealed four personnel members were scheduled to work between 7:00 AM and 7:00 PM on the date of the inspection, with one other personnel member and an administrator being available on call. 4. The Compliance Officers observed 21 segregated, single-point entry, condominium-style units, each containing between one and three individual bedrooms able to be occupied by one to two residents each. The Compliance Officers entered each of the 21 units and observed residents in 20 of the 21 units. However, other than in the medication room in unit 14, the Compliance Officers observed no caregivers in any of the units while the Compliance Officers were in the units. 5. In a series of interviews, R7 reported there was no caregiver in R7’s unit while the Compliance Officers were in the unit. When the Compliance Officers asked if R6 and R7 had call buttons or another way to alert employees to R6’s and R7’s needs, R6 stated, “No” and “Even if we have it there’s not enough people.” 6. In a telephonic interview, E2 acknowledged the facility did not have a designated caregiver in each segregated unit at all times. E2 reported such staffing was unrealistic 7. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 20, 2025.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of four sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a current service plan that indicated R1 received medication administration. The review revealed a series of medication administration records (MARs) dated January 2026 and February 2026. The MARs indicated facility personnel administered medications to R1 up to three times a day on January 1, 2026, through February 11, 2026. However, the review revealed no signed medication orders for any of the medications. 2. A review of R4’s medical record revealed a current service plan that indicated R4 received medication administration. The review revealed a medication order for “baclofen 20 mg tablet Take 1 tablet(s) 3 times a day by oral route for 30 days” dated January 9, 2026. The review further revealed a series of MARs dated January 2026 and February 2026. The MARs revealed facility personnel administered R1’s baclofen on January 10-22, 2026, for a total of approximately 13 days instead of the 30 days as ordered. The MARs further revealed facility personnel administered other medications to R1, including aripiprazole 10 mg, baclofen 20 mg four times a day, losartan potassium 25 mg, pregabalin 100 mg, tamsulosin 0.4 mg, trazodone 150 mg, and venlafaxine 75 mg. However, the review revealed no signed medication orders for these six medications, and no discontinue order for R1’s “baclofen 20 mg tablet Take 1 tablet(s) 3 times a day by oral route for 30 days.” 3. In a telephonic interview, E2 reported the facility had medication orders for the aforementioned medications. However, facility personnel did not provide such medication orders to the Compliance Officers. 4. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 20, 2025, and a repeat citation from the complaint inspections conducted on July 15, 2024, and November 2, 2023.

Based on observation, documentation review, 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. The Compliance Officers observed a mini fridge in the living room of unit 19. Sitting on the mini fridge, the Compliance Officers observed a round brown tablet with “W2” imprinted on it. 2. A review of drugs.com revealed the tablet as senna 8.6 mg. 3. In an interview, E3 reported the tablet should not have been on the mini fridge. 4. The Compliance Officers observed a dresser in R5’s bedroom. On top of the dresser, the Compliance Officers observed the following: - One red capsule, - One white capsule; - One round white tablet, - One oblong white tablet, - One oblong white tablet with “511” imprinted on it, - One oblong white tablet with “APO” imprinted on it, and - Four oblong white tablets with “114” on one side and “H” with a bar dividing the tablets in half on the other side imprinted on them. 5. A review of drugs.com revealed the oblong white tablet with “511” imprinted on it was divalproex sodium 125 mg, and the four oblong white tablets with “114” and “H” imprinted on them were methocarbamol 500 mg. 6. In an interview, R5 reported facility personnel gave R5 and medications and R5 had forgotten to take them. 7. In an interview, E3 reported R5 received medication administration. 8. In a telephonic interview, E2 reported medication should be locked up and never just left in a resident’s room. 9. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 20, 2025, and a repeat citation from the complaint inspections conducted on July 10, 2025, and October 28, 2024.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection. Findings include: 1. The Compliance Officer observed garbage stored in uncovered garbage containers in units 4, 9, 14, 17, 18. The Compliance Officers observed an overturned garbage container with garbage on the floor next to it in the bathroom of unit A-4. The Compliance Officers further observed garbage in an uncovered container in the common area between units 2 and 3. 2. In a telephonic interview, E2 reported many of the garbage cans at the facility did not have lids. E2 reported the facility was in the process of obtaining new trash cans with lids. 3. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 20, 2025.

Based on observation and interview, the manager failed to ensure oxygen containers were secured. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. The Compliance Officers observed an unsecured-but-upright oxygen container in unit 19. 2. In an interview, E3 acknowledged the oxygen container was not secured. 3. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. Technical assistance was provided on this rule during the complaint inspection conducted on November 20, 2025.

Based on 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 the physical health and safety of residents. Findings include: 1. The Compliance Officers observed a housekeeping cart in the living room of unit 2. On top of the cart, the Compliance Officers observed air freshener, “Comet” cleaner, disinfectant spray, and glass cleaner, along with several unlabeled bottles containing unidentified liquids. The Compliance Officers observed the housekeeping cart was unattended while the housekeeper was in another room. 2. The Compliance Officers observed an unattended maintenance cart next to a storage shed between units 4 and 5, accessible from the common area. On the cart, the Compliance Officers observed a bottle of “Concrete Bonding Adhesive” and a tube of “Dap All Purpose Acrylic Latex Caulk Plus Silicone.” 3. In an interview, when the Compliance Officers asked if the facility had a locked place to store poisonous or toxic materials. E3 stated, “Yes.” 4. The Compliance Officers observed a door in unit 14 with a sign that read “STAFF ONLY.” However, the Compliance Officers observed that the door was not locked. Upon opening the door, the Compliance Officers observed a container of disinfectant wipes on a shelf and an unlocked closet containing 13 spray cans of air freshener. 5. In an interview, E3 reported that the poisonous or toxic materials on the housekeeping cart, maintenance cart, and in the break room should have been supervised or maintained in locked areas inaccessible to residents. 6. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 20, 2025.

Based on documentation review, 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. A review of Department documentation revealed A.R.S. § 36-420.01(A) went into effect on October 1, 2021. 2. A review of facility documentation revealed a policy and procedure (P&P) titled “FALL MITIGATION.” The P&P stated: “The facility will conduct an in-service training for trained caregivers. The training will take place upon hire and will be repeated annually thereafter.” 3. A review of E5’s personnel record revealed E5 was hired as a caregiver after this statue went into effect. The review revealed E5 received training regarding fall prevention and fall recovery upon hire, on January 19, 2024, then again more than one year later on January 21, 2025. 4. In a telephonic interview, E2 confirmed training regarding fall prevention and fall recovery was to be conducted annually. When the Compliance Officer informed E2 that E5’s training regarding fall prevention and fall recovery was not completed annually, E2 stated, “Okay.” 5. A review of E6’s personnel record revealed E6 was hired as a caregiver after this statue went into effect. However, the review revealed no documentation demonstrating E6 received training regarding fall prevention and fall recovery upon hire. 6. In a telephonic interview, E2 reported E6 received the training at another location where E6 worked and not at this facility. 7. A review of E8’s personnel record revealed E8 was hired as an assistant caregiver after this statue went into effect. However, the review revealed no documentation demonstrating E8 received training regarding fall prevention and fall recovery upon hire. 8. In a telephonic interview, when the Compliance Officer informed E2 that E8 did not have training regarding fall prevention and fall recovery, E2 stated, “Okay.” 9. In an interview, when the Compliance Officer asked if the facility had any more documentation in the personnel records to provide, E3 stated, “No. It’s all there.” This is an uncorrected citation from the complaint inspection conducted on October 28, 2024; and a repeat citation from the complaint inspection conducted on and May 14, 2024; the complaint and compliance inspection conducted on February 27, 2024; and the complaint inspection conducted on January 20, 2023.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for five of five 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…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The webpage stated: "The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting." 1. A review of E1’s personnel record revealed E1 was hired as the manager more than one year before the date of the inspection. However, the review revealed no documentation of training and education related to recognizing the signs and symptoms of TB upon hire or annually thereafter. 2. A review of E5’s and E7’s personnel records revealed E5 and E7 were hired as caregivers more than one year before the date of the inspection. However, the review revealed no documentation of training and education related to recognizing the signs and symptoms of TB upon hire or annually thereafter. 3. A review of E6’s personnel record revealed E6 was hired as a caregiver less than one year before the date of the inspection. However, the review revealed no documentation of training and education related to recognizing the signs and symptoms of TB upon hire. 4. A review of E8’s personnel record revealed E8 was hired as an assistant caregiver less than one year before the date of the inspection. However, the review revealed no documentation of training and education related to recognizing the signs and symptoms of TB upon hire. 5. In a telephonic interview, when the Compliance Officer informed E2 that E1, E5, E6, E7, and E8 were missing the training, E2 stated, “Okay.” 6. In an interview, when the Compliance Officer asked if the facility had any more documentation in the personnel records to provide, E3 stated, “No. It’s all there.”

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) and (C), for two of five sampled personnel members. The deficient practice posed a risk if the employees were 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work." 2. A.R.S. § 36-411(C)(1) and (2) 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. A review of facility documentation revealed a policy and procedure (P&P) titled "FINGERPRINTING." The P&P stated: “The manager shall ensure as a condition of continued licensure of a residential care institution and as a condition of employment in a residential care institution, personnel and owner of residential care or contracted persons who provide direct care and who have not been subject to the fingerprinting requirements of a health professional's regulatory board shall have valid fingerprint clearance card or apply for a fingerprint clearance card…Procedure: Verify the current status of a person's fingerprint clearance card.” 4. A review of E1's personnel record revealed E1 was hired as the manager. The review revealed a fingerprint clearance card (FCC) dated as expired on September 13, 2025, and an application for another FCC dated September 22, 2025, after the previous card had already expired. The review revealed an “APPLICATION FOR EMPLOYMENT” which indicated E1 had previous employment. However, the review reve

Based on documentation review, observation, and interview, the manager failed to ensure a list of resident rights was conspicuously posted. The deficient practice posed a risk if residents were not properly informed of their rights. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(54)(a-b) states: "'Conspicuously posted' means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. The Compliance Officers observed a document titled "RESIDENT'S RIGHTS" posted on the back wall of a small office area near where the public entered the premises of the health care institution. However, the Compliance Officers observed the small office area was not accessible to residents. The Compliance Officers did not observe the rights posted in any other area of the facility. 3. In an interview, E3 and E4 acknowledged the small office area was not accessible to residents. Technical assistance was provided on this rule during the complaint inspection conducted on July 10, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver’s and assistant caregiver's skills and knowledge were verified and documented before the individual provided physical health services, for two of five sampled 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 series of personnel schedules which indicated E6 worked several shifts before September 17, 2025, and E8 worked on a regular basis between July 2025 and November 2025. 2. A review of E6's personnel record revealed E6 was hired as a caregiver. The review revealed an unnamed supervisor verified E6’s skills and knowledge on September 17, 2025. 3. A review of E8's personnel record revealed E8 was hired as an assistant caregiver. However, the review revealed no documentation demonstrating the manager verified E8’s skills and knowledge. 4. In a telephonic interview, when the Compliance Officer informed E2 that E6’s and E8’s skills and knowledge were not verified before E6 and E8 began providing services at the facility, E2 stated, “Okay.” 5. In an interview, when the Compliance Officer asked if the facility had any more documentation in the personnel records to provide, E3 stated, “No. It’s all there.”

Based on record review, interview, and documentation review, 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 incomplete documentation identifying the staff present each day to ensure the health and safety of residents and the Department was provided false or misleading information. Findings include: 1. A review of R1’s, R2’s, R3’s, R4’s, and R5’s medical records revealed documentation of assisted living services (ADLs) provided to R1, R2, R3, R4, and R5 and medication administration records (MARs). The ADLs and MARs revealed the following: - E5 provided assisted living services on September 27, 2025; - E7 provided assisted living services on September 18, 2025; - E9 provided assisted living services on September 8, 2025, and administered medication on October 13, 2025; and - E10 provided assisted living services on July 14, 2025. 2. In an interview, E3 reported facility personnel updated the personnel schedules daily as needed and added the final schedules to the schedule binder at the end of the week. E3 confirmed the schedules in the schedule binder were correct. 3. A review of facility documentation revealed a schedule binder which included a series of personnel schedules dated between November 2024 and November 2025. The schedules revealed the following: - E5 did not work on September 27, 2025; - E7 did not work on September 18, 2025; - E9 did not work on September 8, 2025, and October 13, 2025; - E9 did not work on October 13, 2025; and - E10 did not work on July 14, 2025. The schedule for April 7-13, 2025, revealed E7 worked from 2:00 PM to 6:00 AM on April 9, 2025, and E9 worked from 6:00 AM to 9:00 PM on April 9, 2025. However, below the main schedule portion, the document stated “April 9th: [E7] left home sick, [E9] to cover rest of shift.” However, the schedule did not indicate the time E7 left or the time(s) E9 covered for E7. The schedules did not include accurate documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. 4. In an interview, E3 reported E7 left the facility between 4:00 PM and 5:00 PM on April 9, 2025. E3 acknowledged the personnel schedules were not accurate. This is an uncorrected citation from the complaint inspection conducted on October 28, 2024, and a repeat citation from the complaint and compliance inspection conducted on April 13, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a manager, 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 five of five 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 “INFECTION CONTROL.” The P&P stated: “All personnel…of this facility are required to provide one of the following on acceptance and annually thereafter. Evidence of freedom from infectious tuberculosis.” 5. A review of E1's personnel record revealed E1 was hired as the manager. However, the review revealed no documentation assessing risks of prior exposure to infectious TB and determining if E1 had signs or symptoms of TB. 6. In a telephonic interview, when the Compliance Officer informed E2 that E1 was missing the assessment and screening, E2 stated, “Okay.” 7. A review of E5’s personnel r

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver received orientation specific to the duties to be performed by the assistant caregiver before providing assisted living services to a resident, for one of one sampled assistant caregiver. The deficient practice posed a risk if an assistant caregiver was unable to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “ORIENTATION AND TRAINING.” The P&P stated: “Personnel will be provided with orientation and training specific to their duties to cover the needs of the residents, promote their health and well being, safety and topics relevant to facility operations. The ORIENTATION AND TRAINING FORM will be used and kept in the individual’s personnel file.” The review further revealed a series of personnel schedules which indicated E8 worked on a regular basis between July 2025 and November 2025. 2. A review of E8's personnel record revealed E8 was hired as an assistant caregiver. However, the review revealed no documentation of E8’s orientation. 3. In a telephonic interview, when the Compliance Officer informed E2 that E8 did not have orientation, E2 stated, “Okay.” 4. In an interview, when the Compliance Officer asked if the facility had any more documentation in the personnel records to provide, E3 stated, “No. It’s all there.” This is a repeat citation from the complaint and compliance inspection conducted on February 27, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of three sampled caregivers. The deficient practice posed a risk if a caregiver 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 “CARDIOLULMONARY RESUSCITATION AND FIRST AID TRAINING.” The P&P stated: “No caregiver will be able to provide services to a resident with an expired or invalid CPR documentation” The review further revealed a series of personnel schedules which indicated E5 worked on July 1-2, 2025. 2. A review of E5’s personnel record revealed E5 was hired as a caregiver. The review revealed documentation of first aid and CPR certification dated as expired at the end of June 2025 as well as current documentation of first aid and CPR certification dated as issued on July 3, 2025. However, the review revealed E5 did not have current first aid and CPR certification for two days. 3. In a telephonic interview, when the Compliance Officer informed E2 that E5 worked for two days with expired first aid and CPR certification, E2 stated, “Okay.” 4. In an interview, when the Compliance Officer asked if the facility had any more documentation in the personnel records to provide, E3 stated, “No. It’s all there.” This is an uncorrected citation from the complaint inspection conducted on July 10, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included the individual’s starting date of employment, for one of five employees sampled. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “PERSONNEL RECORDS.” The P&P stated: “A personnel record for each individual includes: The starting date of service.” 2. A review of E8’s personnel record revealed E8 was hired as an assistant caregiver. However, the review revealed no documentation of E8’s starting date of employment. 3. In an interview, when the Compliance Officer asked if the facility had any more documentation in the personnel records to provide, E3 stated, “No. It’s all there.” This is a repeat citation from the complaint and compliance inspection conducted on April 13, 2023.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record for four of five sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan and the Department was provided false or misleading information. 1. A review of R1's medical record revealed a service plan for personal care dated as completed on January 9, 2025, and updated on July 9, 2025, and October 30, 2025. The service plan stated the following services were to be provided: - "Elimination: Incontinent – Both, Uses disposable undergarment – change every two hours/PRN, Peri care PRN;” - “Bathing: Shower - Hospice CNA, Complete bath 2X week/PRN, + 1 Staff 1x1 week.” The updated service plan stated “10-30-2025: Continue previous care plan. Resident discharged from hospice care;” - “Goals to be Met: Maintain skin integrity…, apply lotion and creams to maintain skin integrity, CG assist prevention of bruise injuries, pressure sores, and infections;” and - “Strategies to Maintain Personal Safety: Caregiver to do frequent checks on patient.” The review further revealed documentation of assisted living services (ADLs) provided to R1 dated October 2025 and November 2025. The ADLs revealed no documentation demonstrating R1 received incontinence care and frequent checks between October 1, 2025, and the date of the inspection. 2. A review of R3's medical record revealed a service plan for personal care dated as completed on January 30, 2025, and updated on May 19, 2025, and July 28, 2025. The service plan stated R3 was to receive assistance with “Mobility: Wheelchair, Transfer assistance: 1x assist to W/C or power chair.” The review further revealed ADLs dated September 2025 through November 2025. The ADLs revealed no documentation demonstrating R3 received assistance with mobility between October 1, 2025, and the date of the inspection. However, the ADLs did indicate R3 received “Shaving,” “Moisturiz[ing],” and “Nail Care” on September 1-30, 2025, and November 1-20, 2025. 3. In a telephonic interview, E2 reported caregivers did not assist R3 with shaving, moisturizing, and nail care daily as documented on the ADLs. 4. A review of R4's medical record revealed a service plan for personal care dated October 8, 2025. The service plan stated the following services were needed: - “Bathing: Shower - Complete Bath 2X week/PRN; Wash Hair, With Shower, Peri Care – Daily & PRN;” and -“Goals to be Met: Maintain skin integrity [and] Apply lotions and creams to maintain skin integrity…CG Assist with prevention of bruises, injuries, infections, pressure sores, and infections.” The review further revealed ADLs dated October 2025. The ADLs revealed no documentation demonstrating R4 received assistance with bathing and skin care on October 1-31, 2025. 5. A review of R5's medical record revealed a service plan for personal care date

Based on interview and observation, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as residents believed they were not treated with dignity, respect, and consideration. Findings include: 1. In a series of interviews, R3 reported believing an employee took R3’s shoes and the filters for R3’s nebulizer, stating, “Stuff comes up missing.” R5 shared complaints about employees taking R5’s bandaids and vitamins, stating, “I have no rights.” R6 reported the call button in R6’s bedroom did not work and R6 was often unable to get a hold of a caregiver. R6 reported R6 did not get help due to the call button not working. When the Compliance Officer asked what R7 would do if R7 required assistance from a caregiver, R7 stated, “I don’t know.” R8 reported the facility seemed run down. R8 stated R8 frequently had to hold up R8’s hands during lunch “like we’re children.” R9 shared a complaint about the low temperature inside, stating, “We need heat.” R9 reported R9 had complained to facility personnel twice over the last week. 2. One of the Compliance Officers observed R6’s call button. The Compliance Officer pressed the call button and waited for a caregiver to come to the room. However, no caregiver came. The Compliance Officers observed R8’s unit did not appear to be in good shape. The Compliance Officers observed dents, scraped off paint, and black marks on the walls in R8’s unit. The Compliance Officers observed several portions of the walls and doors in R8’s unit were covered by painted and unpainted, unfinished Oriented Strand Board (OSB). The Compliance Officers further observed the temperature in R9’s unit measured as low as 64° F in some areas. 3. In a telephonic interview, E2 reported R3’s and R5’s complaints were unfounded. E2 reported the call buttons did not work. This is an uncorrected citation from the complaint inspections conducted on July 10, 2025, and July 15, 2024.

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 “MEDICAL RECORD MAINTENANCE." The P&P stated, "A manager shall ensure that a resident's medical record is protected from loss, damage or unauthorized use." 2. The Compliance Officers observed a posting on a wall in the common area of unit 14. The Compliance Officer observed the posting included the first and last names of 13 residents along with the residents’ unit number and/or allergies. 3. In the exit interview, the Compliance Officer reviewed the findings and E2 and E3, and E2 and E3 offered no comment. Technical assistance was provided on this rule during the complaint inspection conducted on July 10, 2025.

Based on record review, interview, and observation, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. A review of R1’s, R2’s, R3’s, R4,’s and R5’s medical records revealed the five residents were at the personal level of care and received personal care services. Each of the five service plans stated, “Call Bell: Yes” and “Call bell within reach.” 2. In a series of interviews, R6 reported the call button in R6’s bedroom did not work and R6 was often unable to get a hold of a caregiver. R6 reported R6 did not get help due to the call buttons not working. When the Compliance Officer asked what R7 would do if R7 required assistance from a caregiver, R7 stated, “I don’t know.” R11 reported R11’s call button did not work either, stating, “It doesn’t work.” 3. The Compliance Officers observed no working call buttons, intercoms, or other mechanical means to alert employees to a resident’s needs or emergencies in any of the bedrooms or units, including in those of R1, R2, R3, R4, and R5. 4. In a telephonic interview, when the Compliance Officers asked if any of the rooms had working call systems, E2 stated, “No.” When the Compliance Officers asked if any of the residents had call pendants, E2 stated, “No.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on February 27, 2024, and this is a repeat citation from the complaint inspections conducted on January 20, 2023.

Based on documentation review, interview, and observation, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. A review of Department documentation revealed R10 received directed care services. 2. In a telephonic interview, E2 reported R10 was at the directed level of care and received directed care services. 3. The Compliance Officers observed no working call button, intercom, or other means to alert employees to R10’s needs or emergencies in R10’s bedroom or in R10’s unit. 4. In a telephonic interview, when the Compliance Officers asked if any of the rooms had working call systems, E2 stated, “No.” When the Compliance Officers asked if any of the residents had call pendants, E2 stated, “No.” This is an uncorrected citation from the complaint inspection conducted on July 10, 2025.

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 Officers observed 21 separate condominium-style units (numbered 1-12, 14-21, and A-4), each containing between one and three individual bedrooms able to be occupied by one to two residents each. The Compliance Officers observed each unit had one door leading from an indoor common area to the secured outdoor courtyard which allowed residents to be at least 30 feet away from the facility. The Compliance Officers observed the following: - The door for unit 5 did not have an alert installed; - The doors for units 3, 12, and A-4 had alerts installed and set to the “Off” position; - The doors for units 6, 9, 15-17, and 20 had alerts installed and set to the “Chime” position; - The door for units 11 and 19 did not have alerts properly installed (i.e. the magnet portions of the alerts were several inches below the alerts and were not within range); and - The doors for units 10 and 21 had alerts installed and set to an unknown position. However, upon opening each of the 14 aforementioned doors, the Compliance Officers heard no alerts. The Compliance Officers further observed no monitoring system in place. 3. In a telephonic interview, E2 stated, “We’re not using the door alarms anymore for our egress.” This is an uncorrected citation from the complaint inspection conducted on July 10, 2025, and a repeat citation from the complaint inspections conducted on July 8, 2025, and May 14, 2024, and the complaint and compliance inspection conducted on February 27, 2024.

Based on documentation review, observation and interview, the manager failed to ensure a designated caregiver was available in each building and each segregated area at all times. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of facility documentation revealed a personnel schedule dated November 2025. The schedule revealed no more than four personnel members were scheduled to work at any given time on the date of the inspection, with one other personnel member and an administrator being available on call. 3. The Compliance Officers observed 21 segregated, single-point entry, condominium-style units, each containing between one and three individual bedrooms able to be occupied by one to two residents each. The Compliance Officers entered each of the 21 units and observed residents in each unit. However, other than in the medication room in unit 14, the Compliance Officers observed no caregivers in any units while the Compliance Officers were in the units. 4. In a series of interviews, R6 reported R6 was often unable to get a hold of a caregiver. When the Compliance Officer asked what R7 would do if R7 required assistance from a caregiver, R7 stated, “I don’t know.” 4. In an interview, E3 acknowledged there was not a designated caregiver available in each of the segregated units at all times. 5. In a telephonic interview, E2 reported the facility did not have enough caregivers to have a caregiver in each segregated unit at all times. Technical assistance was provided on this rule during a provider phone call on November 18, 2025.

Based on documentation review, interview, and observation, the manager failed to ensure heating and cooling systems not controlled by a resident maintained the assisted living facility at a temperature between 70° F and 84° F at all times. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “ENVIRONMENTAL.” The P&P stated, “Heating and cooling systems maintain the facility at a temperature between 70F and 84 F at all times, unless individually controlled by a resident.” 2. In an interview, R9 reported R9’s unit was too cold, stating, “We need heat.” R9 reported R9 had complained to facility personnel twice over the last week. 3. The Compliance Officers observed the temperature in R9’s unit measured as low as 64° F in some areas. 4. In an interview, an unnamed employee reported the control unit to the heater was not within R9’s unit. 5. In a telephonic interview regarding the temperature in R9’s unit, E2 stated, “Residents don’t control it at all.” This is an uncorrected citation from the complaint inspection conducted on July 15, 2024.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for three of five sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a current service plan which indicated R1 received medication administration. The review revealed a medication administration record (MAR) dated November 2025 which indicated R1 received carbamazepine, donepezil, and olanzapine on November 7-11, 2025. However, the review revealed no signed medication orders for the three medications. 2. A review of R3's medical record revealed a current service plan which indicated R3 received medication administration. The review revealed MARs dated October 2025 and November 2025 which indicated R3 received cephalexin, Systane eye drops, and tolterodine. However, the review revealed no signed medication orders for the three medications. 3. A review of R5's medical record revealed a current service plan which indicated R5 received medication administration. The review revealed MARs dated October 2025 and November 2025 which indicated R5 received valsartan. However, the review revealed no signed medication orders for the medication. 4. In a telephonic interview, E2 reported caregivers administered the aforementioned medications as documented on the MARs. E2 further reported the facility used an electronic system for medication orders. 5. In the telephonic exit interview, the Compliance Officers reviewed the findings with E2 and E3 and E2 and E3 offered no further comment. This is a repeat citation from the complaint inspections conducted on July 15, 2024, and November 2, 2023.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident’s medical record, for one of five sampled residents. The deficient practice posed a risk as the medication could not be verified as administered against a medication order. Findings include: 1. One of the Compliance Officers observed R4’s morning and evening pharmacy-provided multi-dose packs included R4’s duloxetine. 2. A review of R4's medical record revealed an order for “Duloxetine HCL 30 MG – TAKE 1 TAB BY MOUTH TWICE A DAY.” The review further revealed a medication administration record (MAR) dated November 2025 which did not include a place to document the administration of R4’s duloxetine. 3. In a telephonic interview, E2 reported facility personnel administered R4’s duloxetine as ordered but did not document it. E2 reported not knowing why the medication did not populate on the MAR. This is a repeat citation from the complaint inspection conducted on October 18, 2024.

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. A review of facility documentation revealed a policy and procedure (P&P) titled “STORAGE OF MEDICATION." The P&P stated, "Medication is stored in a separate locked room, closet, cabinet, or self contained unit used only for medication storage." 2. The Compliance Officers observed the door leading into unit 11 was not locked. On a stand in R4’s unlocked bedroom, the Compliance Officers observed a bottle of acetaminophen and a bottle of bismuth subsalicylate. 3. The Compliance Officers observed the door leading into unit 16 was not locked. On a nightstand in R2’s unlocked bedroom, the Compliance Officers observed a pharmacy bottle of escitalopram. 4. The Compliance Officers observed the door leading into unit 18 was not locked. On a table in R12’s unlocked bedroom, the Compliance Officers observed an Albuterol Sulfate inhaler. 5. In a telephonic interview, E2 reported the medications found in R2’s, R4’s, and R12’s units should have been stored in a locked area and not accessible in the units. 6. The Compliance Officers observed the door leading into unit 21 was not locked. On a dresser in the common area, the Compliance Officers observed three bottles of ammonium lactate lotion. On a side table in the common area, the Compliance Officers observed a bottle of sodium hypochlorite. 7. In a telephonic interview, E2 reported the medications belonged to R3 and were not supposed to be left out. 8. The Compliance Officers observed the door leading into unit A-4 was not locked. Within unit A-4, the Compliance Officers observed an unlocked shower room. In the shower room, on a shelf in the shower, the Compliance Officers observed three bottles of ketoconazole shampoo. This is a repeat citation from the complaint inspection conducted on July 10, 2025, and an uncorrected citation from the complaint inspection conducted on October 28, 2024.

Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may have caused a resident or other individual to suffer physical injury. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. The Compliance Officers observed two small fences on either side of the walkway to the door of unit 5. However, the Compliance Officers observed one of the fences was broken and detached in several places, exposing sharp edges. The Compliance Officers observed many residents using walkers and motorized wheelchairs. However, the Compliance Officers observed the outdoor common areas and several of the ramps leading into the units had cracks and uneven surfaces. 2. In a series of interviews, R3, R12, and R14 reported struggling to enter the units in wheelchairs due to the ramps having cracks and uneven surfaces. R3 reported R3’s wheelchair had been damaged by the uneven and coarse asphalt of the outdoor common areas. This is a repeat citation from the complaint inspection conducted on July 10, 2025.

Based on documentation review, observation, and interview, the manager failed to ensure garbage and refuse were stored in covered containers. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “ENVIRONMENTAL.” The P&P stated, “Garbage and refuse are stored in covered containers lined with plastic bags and removed from the premises at least once a week.” 2. The Compliance Officer observed garbage in uncovered garbage containers in units 3, 4, 9, 11, 12, 17, and 21, as well as in the bedroom in unit A-4 and near the vending machine in the main building. 3. In a telephonic interview, E2 reported believing the rules only required the garbage cans in bathrooms to be covered and not the garbage cans in bedrooms and common areas. Technical assistance was provided on this rule during the complaint inspection conducted on July 10, 2025.

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 “ENVIRONMENTAL.” The P&P stated, “Poisonous or toxic [materials] stored by the facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications [and] are inaccessible to residents.” 2. The Compliance Officers observed an unlocked medicine cabinet in the bathroom in unit 1. Upon opening the medicine cabinet, the Compliance Officers observed a spray can of air freshener. 3. In an interview, R8 reported the air freshener did not belong to anyone in the unit and R9 stated, “It was here when I got here.” 4. The Compliance Officers observed the door leading into unit A-4 was not locked. Within unit A-4, the Compliance Officers observed an unlocked shower room. In the shower room, the Compliance Officers observed an unlocked cabinet with three spray cans of air freshener inside. 5. In an interview, E3 reported the facility had a designated and locked area to store poisonous or toxic materials. E3 acknowledged the air freshener was not stored in that designated and locked area. 6. The Compliance Officers observed a maintenance cart between building B and the main building. The Compliance Officers observed no personnel within sight. On the cart, the Compliance Officers observed a variety of poisonous or toxic materials, including air freshener, degreaser, disinfectant spray, and two unlabeled bottles. 7. In a telephonic interview regarding the unlabeled bottles, E2 stated, “I know they need to be labeled.” Technical assistance was provided on this rule during the complaint inspection conducted on July 10, 2025, and the complaint and compliance inspection conducted on April 13, 2023; and this is a repeat citation from the complaint inspections conducted on January 20, 2023.

Based on a record review and interviews, the manager failed to ensure that a personnel record for each employee included current documentation of cardiopulmonary resuscitation (CPR) training for one of the two reviewed employee records. 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 the personnel file for E4 revealed that the employee’s Cardiopulmonary resuscitation (CPR) and First Aid (FA) certification was issued on March 28, 2025. However, E4 was hired on December 12, 2024. 2. In an interview, E2 acknowledged E4 worked at the facility without a CPR and First Aid certification from December 12, 2024, to March 28, 2025. 3. In an interview, E2 reported the facility was under the impression they had a grace period to allow the caregiver to go and get the CPR and FA certification.

Based on observation and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. During the environmental inspection with E3, the Compliance Officers observed R4 outside on the courtyard wearing only an incontinent brief, a tank top, and slippers. The resident was visible to male and female residents, visitors, and employees in the area. When approached by the Compliance Officers, the resident was not cognitively aware of their state of dress. 2. In an interview, E3 reported that the caregivers had just bathed R4 and may not have dressed R4 completely. 3. The Compliance Officers observed that the dining room doors were locked and inaccessible to residents. Upon further investigation, the Compliance Officers observed that the facility was attempting to provide lunch for the residents outside, where the temperature was 96°F at the time. Residents were served hot soup while seated at tables and chairs that had been placed outside for the meal. The Compliance Officers requested E3 to allow the residents to come inside the dining room for lunch. 4. In separate interviews, multiple residents reported they were not allowed to use the dining room for meals. 5. In an interview, E3 reported that residents were allowed to use the dining room; however, during Department inspections, the dining room was kept closed. The Compliance Officers informed E3 that inspections may be conducted anywhere in the facility and that residents and their needs come first. 6. In a telephonic interview the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a residents needs or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officers observed that the facility had units for residents, with each unit housing three residents in separate bedrooms. The Compliance Officers observed bedrooms in units 14, 15,16, and 17; however, none of the residents had a bell or other mechanical means to alert the staff of their needs. Upon further investigation, it was identified that none of the residents' rooms were equipped with a bell, intercom, or any other mechanical means for residents to alert employees in the event of a need or emergency. 3. In an interview, E3 acknowledged that the residents’ bedrooms did not have a bell, intercom, or any other mechanical means available to alert employees to a resident’s needs or emergencies. 4. In separate interviews, R3 and R4 reported that if assistance is needed, residents must flag down a staff member in the courtyard. For non-ambulatory residents, they would have to call out to their roommate to get help from a staff member. 5. In a telephonic interview, E2 acknowledged that a bell, intercom, or other mechanical means to alert employees to a residents needs or emergencies was not available in all bedrooms being used by residents.

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 Officers observed multiple ambulatory residents. 3. During the environmental tour, the Compliance Officers observed that the facility had units for residents, with each unit housing three residents in separate bedrooms. The doors leading from each unit to the secured courtyard were equipped with devices intended to alert employees of a resident’s egress to the outside area. However, the door alerts for units 14, 15, and 17 were either turned off or not installed properly. 4. In an interview, E3 reported that the residents often turn off the alerts or take them down. 5. In a telephonic interview, E2 reported that residents often turn off or remove the alerts. E2 acknowledged that a means of exiting the facility to a secure outside area did not monitor or alert employees of a resident’s egress from the facility. This is a repeat citation from the compliance/complaint inspection conducted on February 27, 2024, on-site investigation of complaint May 14, 2024 and July 8, 2025.

Based on observation and interview, the manager failed to ensure medication 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 unsecured medication. Findings include: 1. The Compliance Officers observed multiple ambulatory residents throughout the facility. 2. During the environmental inspection, the Compliance Officers observed that a medication room in Cottage 14 was unlocked. The room contained medications for forty-eight residents. 3. In a telephonic interview, E2 acknowledged that medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. This is a repeat deficiency from the on-site complaint investigation conducted on October 28, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officers observed multiple ambulatory residents. 3. During the environmental inspection with E3, the Compliance Officers observed in the bathroom of Unit 16 that water was actively dripping from an exposed wall-mounted electrical unit, with a white bucket placed below to collect the water. This condition created an immediate risk of electrical shock, fire, and serious physical injury to residents. 4. During the environmental inspection with E3, the Compliance Officers observed that the bathroom floors of units 16 and 17 were warped and damaged from excessive water spilling out of the showers, and residents reported that the facility did not provide waterproof liners. The warped flooring created uneven surfaces that posed a tripping hazard, while the water damage increased the likelihood of mold growth. 5. During the environmental inspection with E3, the Compliance Officer observed that one of the back outside gates was unlocked. Although staff were present in the area, the Compliance Officer was able to open the padlock and exit the facility grounds undetected, walking toward the road while passing stacked furniture and trash cans. This condition created a risk of residents leaving the facility unsupervised and exposed individuals to potential injury from the cluttered pathway. 6. During the environmental inspection with E3, the Compliance Officers observed that most residents used walkers or motorized wheelchairs; however, the ramps leading into the units had cracks and uneven surfaces. R3 was observed struggling to enter a unit using a walker due to the damaged flooring. These conditions created a risk of residents tripping, falling, or being unable to safely access their living areas. 7. In a telephonic interview, E2 acknowledged that the above-mentioned conditions could create a situation that may cause a resident or other individual to suffer physical injury.

Based on observation, documentation review, and interview, the manager allowed more than two individuals to reside in a bedroom. The deficient practice violated a resident's rights. Findings include: 1. A review of Department documentation revealed that the facility’s license was effective April 14, 2022. 2. During the environmental inspection with E3, the Compliance Officers observed that Unit A4 contained three beds, housing three residents, with the beds separated by curtains. 3. In an interview, the Compliance Officers spoke with the three residents and obtained the names of the residents occupying the bedroom. 4. A review of Department documentation revealed that the floor plan submitted to the Department identified Unit A4 as a storage room. 5. In an exit interview, E2 and E3 acknowledged that more than two individuals were allowed to reside in a bedroom.

Based on observation and interview, the manager failed to ensure that each sleeping area had adjustable window covers that provide resident privacy. The deficient practice violated a resident's rights. 1. During the environmental inspection with E3, the Compliance Officers observed that residents’ rooms 14, 15, 16, and 17 did not have functioning shades or blinds. Residents reported that the rooms became excessively hot due to direct sunlight. To cover the windows, some residents resorted to taping black trash bags and other materials over the windows, while others had broken or makeshift coverings that did not provide privacy. 2. In an interview, E3 reported that the facility is working on getting blinds for the residents' rooms.

Based on documentation review, observation, and interview, the manager failed to ensure there was a 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, which provided access to an outside area which 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 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 . During an environmental tour of the facility, the Compliance Officer observed door alerts on all doors leading to an outside area from resident homes in the facility. However, the alerts on doors 21, 20, 12, and 11 were turned off at the time of inspection. 3 . In an interview, E2 reported the residents often turn off the alerts. E2 acknowledged the alerts on doors 21, 20, 12, and 11 were turned off at the time of inspection.