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Based on record review and interview, the manager failed to ensure a resident had a complete service plan no later than 14 calendar days after the resident's date of acceptance, for one of two resident records reviewed. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed an initial service plan dated January 17, 2025. The document was not signed by the resident or resident’s representative; signed by the manager on July 15, 2025; and signed by the nurse on July 14, 2025, which was more than 14 days after R2’s date of acceptance. 2. In an exit interview with E1, the finding was reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, and when initially developed, was signed and dated by the resident or the resident’s representative, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a service plan dated January 17, 2025. However, the resident or the resident's representative did not sign and date the service plan. 2. 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 residency agreement was signed and dated by the manager before or at the time of an individual's acceptance by the assisted living facility, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a residency agreement. However, the residency agreement was not signed or dated by the manager. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure that within five working days after a resident's acceptance by the assisted living facility, the documented agreement was signed by the resident's representative, the resident's legal guardian, or another individual who has been designated by the individual under A.R.S. § 36-3221 to make health care decisions on the individual's behalf, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a residency agreement. However, the residency agreement was not signed or dated by the resident or resident’s representative. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a tour of the facility, the Compliance Officer observed a can of “BAR KEEPERS FRIEND” and a bottle of bleach, unsecured, in the shower of a shared bathroom. 2. Also during the tour of the facility, the Compliance Officer observed a bag of “Kirkland Signature Laundry Detergent Packs”, unsecured in the laundry room, which was accessible to residents. 3. In an interview, E1 acknowledged the toxic materials were unlocked and accessible to residents. E1 also reported the laundry detergent belonged to a resident and was supposed to be secured in the resident’s room. This is a repeat citation from the on-site compliance inspection and investigation of a complaint conducted on January 15, 2025.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During a tour of the facility, the Compliance Officer observed an open and unlocked night stand in R3's bedroom. The door to R3's bedroom was also open and unlocked. The Compliance Officer observed the following medications in the open nightstand drawer: - "Diurex Max Water Pills"; - "Mucinex DM"; - "Equate Redness Reliever" eye drops; and - "Trelegy Elipta" inhaler. 2. In an interview, E1 reported E1 was unaware of the items being in R3's room. E1 reported R3 did not self administer medication and the medications should not be in R3's room. E1 reported R3 leaves the facility independently and has been bringing in things without staff knowledge. E1 reported R3 was provided a 14-day notice to terminate R3's residency agreement due to non-payment. 3. In an interview, E1 acknowledged medications were stored unlocked in R3's room.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed R3's unlocked bedroom. The Compliance Officer observed a bottle of "Equate Witch Hazel" astringent and a bottle of "Lysol AIR SANITIZER", sitting on the nightstand. 2. In an interview, E1 acknowledged the toxic materials were unlocked and accessible to residents.

Based on record review and interview, the manager accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue, for one of three resident records reviewed. The deficient practice posed a risk as R1's primary condition was not a physical health issue and the facility is not authorized to provide behavioral health services. Findings include: Arizona Administrative Code (A.A.C.) R9-10-101.32. states "Behavioral health issue" means "an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors." 1. A review of department documentation revealed a report that stated a resident (R1) was admitted to the facility by the Veterans Administration Hospital (VA). The document said the facility returned (R1) three days later to the VA. 2. A review of documentation titled "Determination For Admission". This document states "Arizona State Regulations R9-10-807.B requires that the following information be provided by a licensed Physician, Nurse Practitioner, Physician's Assistant or Registered Nurse that is dated a least 90 calendar days prior to acceptance into an Assisted Living Facility". This document was signed and dated on August 2, 2024. The Compliance Officer observed the following on the document "Please answer the following questions: Questions #1, 2, 4, 8, & 9 must be checked NO for appropriate placement in ALF. ... 3. Does this person require intermittent nursing services? (i.e. Home Health, Hospice, wound care, foley care, PT, OT) if Yes, please explain: 24/7 supervision for memory/dementia. ... 4. Does this person require continuous behavioral health services? (i.e. 24 hr. Psychiatric care) Yes. 5. Does this person require behavioral care under the direction of a Licensed Behavioral Health Provider? This care may be provided by a trained Caregiver including administering prescribed psychotropic medications and redirection to manage behaviors. YES. ... 9. Does this person's primary condition for which the individual needs assisted living services a behavioral health issue? (R9-10-808.C2.) Yes. 3. In an interview, E1 reported being unaware that the determination for admission documents #4 and #9 marked R1's primary condition as a behavioral health issue and that the facility is not authorized to provide behavioral health services.