Elite Assisted Living 4

Based on observation, 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. The Compliance Officer observed E4 working at the facility. 2. A review of E4’s personnel record revealed E4 was hired as a caregiver. The review revealed a “FALL PREVENTION?RECOVERY INSERVICE” dated February 6, 2025. However, the in-service training was conducted approximately eight months before E4 was hired at this facility. 3. In an interview, E3 reported E4’s personnel record was from another facility owned by the same individuals. E3 confirmed E4 did not receive training regarding fall prevention and fall recovery upon hire at this facility. This is a repeat citation from the compliance inspection conducted on October 12, 2023.

Based on interview and documentation review, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder (EMS). The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. In an interview, E3 reported facility personnel contacted EMS on behalf of R1 once in August 2025 and once in October 2025. 2. A review of facility documentation revealed an incident report which indicated facility personnel contacted EMS on behalf of R1 on August 23, 2025. However, the review revealed no documentation demonstrating what facility personnel provided to EMS or a copy of the documentation provided to EMS. 3. In an interview, E3 reported facility personnel provided EMS with R1’s physician orders. When the Compliance Officer asked if facility personnel printed or kept a copy of the documentation provided to EMS, E3 stated, “No.” 4. A review of facility documentation revealed a “DHS 911 INCIDENT / TRANSFER REPORT” which indicated facility personnel contacted EMS on behalf of R1 on October 20, 2025. However, the document did not include the following: - Whether R1 received medication services and a list of all R1’s prescription and over-the-counter medications, their dosages, and how frequently they are to be administered; - The address of R1's current pharmacy; - A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive; - The name and contact information for R1’s primary care physician and power of attorney or authorized representative; - Basic information about R1’s physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known; - The point-of-contact information for the assisted living home, including the telephone number, if available, cell phone number and email address; and - A copy of R1’s health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living home to plan for R1’s discharge. 5. In the exit interview, the Compliance Officer reviewed the findings and E1, E2, and E3 offered no comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on July 11, 2024.

Based on interview and documentation review, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. In an interview, E3 reported facility personnel contacted EMS on behalf of R1 once in August 2025 and once in October 2025. 2. A review of facility documentation revealed an incident report which indicated facility personnel contacted EMS on behalf of R1 on August 23, 2025. However, the review revealed no documentation demonstrating what facility personnel provided to EMS or a copy of the documentation provided to EMS. 3. In an interview, when the Compliance Officer asked about the facility’s process for providing EMS with the documentation required by this statute, E3 reported facility personnel contacted EMS then filled out a form to give to EMS. E3 confirmed the template form was not filled out until EMS was called. 4. A review of facility documentation revealed no standardized form for R1 and R2 that included the information prescribed in this statute, except for the reason or reasons the emergency responder was requested. 5. In the exit interview, the Compliance Officer reviewed the findings and E1, E2, and E3 offered no comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on July 11, 2024.

Based on interview and documentation review, the manager of an assisted living home failed to maintain a copy of the document provided to the emergency responder (EMS). The deficient practice posed a risk as the designated standards were not followed. Findings include: 1. In an interview, E3 reported facility personnel contacted EMS on behalf of R1 in August 2025. 2. A review of facility documentation revealed an incident report which indicated facility personnel contacted EMS on behalf of R1 on August 23, 2025. However, the review revealed no documentation demonstrating what facility personnel provided to EMS or a copy of the documentation provided to EMS. 3. In an interview, E3 reported facility personnel provided EMS with R1’s physician orders. When the Compliance Officer asked if facility personnel printed or kept a copy of the documentation provided to EMS, E3 stated, “No.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on July 11, 2024.

Based on documentation review, observation, 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 one of three 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." 2. The Compliance Officer observed E4 working at the facility. 3. A review of E4’s personnel record revealed E4 was hired as a caregiver. The review revealed documentation of training and education related to recognizing the signs and symptoms of TB dated February 6, 2025. However, the in-service training was conducted approximately eight months before E4 was hired at this facility. 4. In an interview, E3 reported E4’s personnel record was from another facility owned by the same individuals. E3 confirmed E4 did not receive training and education related to recognizing the signs and symptoms of TB upon hire at this facility. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on July 11, 2024.

Based on documentation review, interview, and record review, the manager failed to ensure an individual authorized by policies and procedures to administer an opioid in treating a patient identified the patient’s need for the opioid before administering an opioid, documented in the patient’s medical record an identification of the patient’s need for the opioid before the opioid was administered, and documented the effect of the opioid administered. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication Findings include: 1. A review of facility documentation revealed an “ELITE OPIOID TREATMENT AND ADMINISTRATION POLICY AND PROCEDURE” which stated: “THE POLICY AND PROCEDURE FOR OPIOID MEDICATIONS IS TO: 1. IDENTIFY THE RESIDENT’S PAIN BEFORE THE PRESCRIBED OPIOID IS ADMINISTERED. 2. MONITOR THE RESIDENT’S RESPONSE TO THE OPIOID; AND 3. DOCUMENT IT IN THE RESIDENT’S MEDICAL RECORD.” 2. In an interview, E3 reported R1 did not have an end-of-life condition or pain associated with an active malignancy. 3. A review of R1’s medical record revealed a current service plan which indicated R1 received medication administration. The review revealed a medication order dated August 12, 2025, for “[O]xyCODONE HCI Oral Tablet 20 MG…Give 1 tablet by mouth every four hours.” The review further revealed a series of medication administration records (MARs) dated between August 2025 and October 2025. The MARs revealed R1 received R1’s oxycodone 20 mg every four hours during waking hours (i.e. between 8:00 AM and 8:00 PM) between 8:00 AM on August 27, 2025, and 4:00 PM on August 30, 2025. However, the review revealed no documentation demonstrating facility personnel identified R1’s need for the opioid before administering it, documented in R1’s medical record an identification of R1’s need for the opioid before administering it, or documented the effect of the opioid. 4. In an interview, E3 reported facility personnel only identified a resident’s need for a medication and documented the aforementioned items if the medication was ordered on an as-needed basis. E3 acknowledged facility personnel were not in compliance with this rule.

Based on documentation review, observation, and interview, the governing authority failed to designate, in writing, a manager who had a certificate as an assisted living facility manager, for one of one total manager. The deficient practice posed a risk as the assisted living facility did not have a certified manager for approximately three weeks. Findings include: 1. A review of Department documentation revealed E1 was the manager. 2. A primary review of the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board) website (conducted in preparation for the inspection) revealed E1’s manager certificate expired on October 22, 2025. 3. During the inspection, the Compliance Officer observed no posted manager's certificate in the facility. However, the Compliance Officer observed a “DELEGATION OF AUTHORITY” which revealed E1 was the manager. 4. In an interview, E3 reported E1 was the current manager of the facility. 5. A secondary review of the NCIA Board website (conducted during the inspection) revealed E1’s manager certificate expired on October 22, 2025. 6. In an interview, when the Compliance Officer informed E3 that E1’s manager certificate had expired, E3 offered no comment. 7. A tertiary review of the NCIA Board website (conducted during the inspection but after informing E3 of the expiration) revealed E1’s manager certificate was then active. 8. In the exit interview, the Compliance Officer reviewed the findings and E1, E2, and E3 offered no comment. 9. In a series of messages, a representative of the NCIA Board confirmed E1’s manager certificate was expired from October 22, 2025, to the date of the inspection, when E1 renewed E1’s manager certificate.

Based on documentation review, observation, and record review, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(A), for one of three sampled employees. 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 review of facility documentation revealed a policy and procedure (P&P) titled “FINGERPRINT CLEARANCE DOCUMENTATION.” The P&P stated: “If the caregiver, assistant caregiver, or volunteer does not hold a current fingerprint card, he or she has twenty days from the hire date to submit the appropriate application to the Department of Public Safety.” 3. The Compliance Officer observed E5 working at the facility. 4. A review of E5's personnel record revealed E5 was hired as an assistant caregiver less than 20 working days before the date of the inspection. The review further revealed an "APPLICATION FOR FINGERPRINT CLEARANCE CARD” dated November 10, 2025. 5. A review of the Department of Public Safety (DPS) website conducted several times between the date of the inspection and December 11, 2025, revealed E5's application was not submitted to DPS. The review confirmed E5 did not apply for a fingerprint clearance card within twenty working days after employment or beginning work.

Based on documentation review, observation, records review, and interview, the manager failed to ensure 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 one of three sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(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 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." The review further revealed a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The webpage stated: "Reading the TST Result: The TST result should be read by a designated, trained HCW 48–72 hours after the TST is placed. If the TST was not read between 48–72 hours, ideally, another TST should be placed as soon as possible and read within 48–72 hours.” 4. A review of facility documentation revealed a personnel schedule which indicated E5 worked on a regular basis in October 2025 and November 2025. 5. The Compliance Officer observed E5 working at the facility. 6. A review of E5's personnel record revealed E5 was hired as an assistant caregiver. The review revealed a “TWO-STEP TUBERCULOSIS (TB) TESTING FORM” which stated: “Both tests must

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for two of two sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-ii) 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…admitted to 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 [and] ii. Determining if the individual has signs or symptoms of tuberculosis." 2. A review of R1's and R2’s medical records revealed R1 and R2 were admitted to the facility more than seven days before the date of the inspection. The review revealed documentation assessing risks of prior exposure to infectious tuberculosis and determining if R1 and R2 had signs or symptoms of TB. However, the assessments were not completed or signed by a medical practitioner, occupational health provider, or local health agency. 3. In an interview, E3 acknowledged the assessments were not completed or signed by a medical practitioner, occupational health provider, or local health agency. 4. In a telephonic interview, E2 reported a nurse usually had the residents complete the assessments. This is a repeat citation from the complaint and compliance inspection conducted on July 11, 2024.

Based on record review, observation, and interview, the manager failed to ensure a resident had a written service plan that, when updated, was signed and dated by the resident or resident's representative, for one of two sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1’s medical record revealed a current service plan. However, the service plan was not signed by R1 or R1’s representative. Instead, R1’s name was typed in next to “Responsible Party (Self-POA)” before the service plan was printed. The date was then written in pen next to R1’s name. 2. The Compliance Officer observed E3 take R2’s service plan to R2 who was sitting in the living room. 3. The Compliance Officer overheard E3 ask R2 to sign R2’s service plan. 4. The Compliance Officer observed R2 sign R2’s service plan. 5. A review of R2's medical record revealed the service plan R2 had signed during the inspection conducted on November 13, 2025. However, the service plan included a typed date of November 11, 2025, as the date R2 signed the service plan. The service plan did not include the correct date R2 signed it. 6. In an interview, E3 confirmed R2’s service plan had just been signed “By [R2]” during the inspection and not on November 11, 2025, as stated on the service plan. 7. In a telephonic interview, E2 reported someone must have added the incorrect date to R2’s service plan before printing it.

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 two 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 R1's medical record revealed a service plan dated August 29, 2025. The service plan stated: “Resident requires staff assistance for all bed mobility and transfers,” “Resident is wheelchair-dependent for mobility and needs hands-on assistance for propulsion and positioning,” “Provide showers 3x weekly,” and “Provide toileting and incontinence care every 2 hours.” The review further revealed documentation of assisted living services (ADLs) provided to R1 dated October 2025. The ADLs indicated R1 received baths daily in October 2025 and assistance with toileting every two hours between the hours of 6:00 AM and 8:00 PM daily in October 2025. 2. In an interview, when the Compliance Officer asked what assistance R1 received with mobility and transferring, E4 reported R1 propelled R1’s own wheelchair and did not receive assistance pushing R1’s wheelchair. E4 reported R1 transferred in and out of R1’s wheelchair alone and did not receive assistance transferring other than during showers. When the Compliance Officer asked when R1 last received a shower by facility personnel, E4 reported E4 had tried to shower R1 when R1 first arrived at the facility. E4 reported R1 had requested E4 wash R1’s hair during each of R1’s scheduled three showers per week. E4 reported E4 told R1 that E4 could not wash R1’s hair during each shower because it was too time consuming and E4 had other residents to care for. E4 reported R1 refused to continue the shower after hearing that. E4 reported R1 did not receive a shower from facility personnel during R1’s more than two month stay at the facility. When the Compliance Officer asked what assistance R1 received with toileting, E4 reported R1 would inform a caregiver when R1 needed to use the restroom and the caregiver would help clean R1 afterward. E4 reported facility personnel did not otherwise assist R1 with toileting and did not check R1’s briefs.

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 two sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a service plan dated August 29, 2025. The service plan stated facility personnel would “Provide showers 3x weekly” and “Provide toileting and incontinence care every 2 hours.” The review further revealed documentation of assisted living services (ADLs) provided to R1 dated October 2025. The ADLs indicated R1 received baths daily in October 2025 and assistance with toileting every two hours between the hours of 6:00 AM and 8:00 PM daily in October 2025. 2. In an interview, when the Compliance Officer asked when R1 last received a shower by facility personnel, E4 reported E4 had tried to shower R1 when R1 first arrived at the facility. E4 reported R1 had requested E4 wash R1’s hair during each of R1’s scheduled three showers per week. E4 reported E4 told R1 that E4 could not wash R1’s hair during each shower because it was too time consuming and E4 had other residents to care for. E4 reported R1 refused to continue the shower after hearing that. E4 reported R1 did not receive a shower from facility personnel during R1’s more than two month stay at the facility. When the Compliance Officer asked what assistance R1 received with toileting, E4 reported R1 would inform a caregiver when R1 needed to use the restroom and the caregiver would help clean R1 afterward. E4 reported facility personnel did not otherwise assist R1 with toileting and did not check R1’s briefs.

Based on record review 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 did not receive medication as ordered. 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 order dated August 12, 2025, for “[O]xyCODONE HCI Oral Tablet 10 MG…Give 2 tablet[s] by mouth every four hours,” and “[O]xyCODONE HCI Oral Tablet 20 MG…Give 1 tablet by mouth every four hours.” The review further revealed a series of medication administration records (MARs) dated between August 2025 and October 2025. The MARs revealed the following: - R1 did not receive R1’s oxycodone 10 mg in August 2025 through October 2025; - R1 did not receive R1’s oxycodone 20 mg on August 12-26, 2025; - R1 received R1’s oxycodone 20 mg every four hours during waking hours (i.e. between 8:00 AM and 8:00 PM) between 8:00 AM on August 27, 2025, and 4:00 PM on August 30, 2025, instead of every four hours as ordered; and - R1 did not receive R1’s oxycodone 20 mg in September 2025 and October 2025. 2. In an interview, E3 reported R1 had complained often about not receiving R1’s oxycodone. E3 reported R1 went to the hospital several times because R1 was seeking oxycodone. When the Compliance Officer pointed out R1 had two orders for oxycodone and facility personnel had not been administering the medication, E3 offered no comment.

Based on record review, interview, and observation, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included dosage, for one of two sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R2’s medical record revealed a current service plan which indicated R2 received medication administration. The review revealed a series of medication administration records (MARs) dated between October 2025 and November 2025. The MARs revealed documentation demonstrating the following: - R2 received one tablet of R1’s desvenlafaxine 100 mg on October 30-31, 2025, and November 1-3, 2025; - R2 received two tablets of R1’s desvenlafaxine 100 mg on November 4-13, 2025; and - R2 received a total of 25 tablets of R1’s desvenlafaxine 100 mg between October 30, 2025, and November 13, 2025. 2. In an interview, E4 reported R2’s physician increased the dosage of R2’s desvenlafaxine from one 100 mg tablet a day to two 100 mg tablets a day. E4 reported R2 arrived at the facility with a pharmacy-provided multi-dose package with some of the tablets already removed from it. E4 reported E4 administered only three tablets from that package before receiving a new one and taking from the new one. 3. The Compliance Officer observed R2’s pharmacy-provided multi-dose packages of desvenlafaxine 100 mg. The Compliance Officer observed 20 tablets had been removed from the packages by facility personnel. In the medication closet, the Compliance Officer observed a medication cup designated for the day after the inspection. Inside the cup, the Compliance Officer observed two of the 20 tablets removed from the R2’s pharmacy-provided multi-dose packages. 4. In an interview, when the Compliance Officer informed E3 and E4 the MARs had 25 tablets documented as administered but the Compliance Officer observed only 20 tablets removed from the pharmacy-provided multi-dose packages by facility personnel, E4 reported believing the medication had been administered as ordered. However, E4 then reported E4 began administering two tablets per day on November 8 or 9, 2025, and not on November 4, 2025, as documented on the MARs.

Based on record review, interview, and observation, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. The deficient practice posed a risk if a 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 order dated August 12, 2025, for the following medications: - “Atorvastatin Calcium Oral Tablet 40 MG…Give 1 tablet by mouth at bedtime;” - “Lidocaine External Patch 4%...Apply to Low back topically two times a day;” - “[O]xyCODONE HCI Oral Tablet 10 MG…Give 2 tablet[s] by mouth every four hours;” and - “[O]xyCODONE HCI Oral Tablet 20 MG…Give 1 tablet by mouth every four hours.” The review further revealed a series of medication administration records (MARs) dated between August 2025 and October 2025. The MARs revealed the following: - R1 did not receive R1’s atorvastatin on October 13-15, 2025; - R1 did not receive R1’s first daily lidocaine patch on August 27-29, 2025, and October 14-20, 2025; - R1 did not receive R1’s second daily lidocaine patch on October 13-26 and 18-19, 2025; - R1 did not receive R1’s oxycodone 10 mg in August 2025 through October 2025; - R1 did not receive R1’s oxycodone 20 mg on August 12-26, 2025; - R1 received R1’s oxycodone 20 mg every four hours during waking hours (i.e. between 8:00 AM and 8:00 PM) between 8:00 AM on August 27, 2025, and 4:00 PM on August 30, 2025, instead of every four hours as ordered; and - R1 did not receive R1’s oxycodone 20 mg in September 2025 and October 2025. 2. In an interview, E3 reported R1 had complained often about not receiving R1’s oxycodone. E3 reported R1 went to the hospital several times because R1 was seeking oxycodone. When the Compliance Officer pointed out R1 had two orders for oxycodone and facility personnel had not been administering the medication, E3 offered no comment. 3. A review of R2’s medical record revealed a current service plan which indicated R2 received medication administration. The review revealed a series of medication orders dated October 27, 2025, for “buPROPion HCI ER…Give 450 mg by mouth one time a day” and “Desvenlafaxine Succinate ER…100 MG…Give 1 tablet by mouth one time a day.” The review further revealed a series of medication administration records (MARs) dated between October 2025 and November 2025. The MARs revealed the following: - R2 did not receive R1’s bupropion 450 mg on November 1-2 and 4, 2025; - Documentation demonstrating R2 received one tablet of R1’s desvenlafaxine 100 mg on October 30-31, 2025, and November 1-3, 2025; - Documentation demonstrating R2 received two tablets of R1’s desvenlafaxine 100 mg on November 4-13, 2025; - Documentation demonstrating R2 received a total of 25 tablets of R1’s desvenlafaxine 100 mg between October

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement a disaster plan and safely evacuate residents during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “EMERGENCY AND SAFETY STANDARDS.” The P&P stated, “4. An evacuation drill for employees and residents: a. Is conducted at least once every six months.” However, the review revealed documentation of an evacuation drill conducted on January 4, 2025, and a second drill conducted more than six months later on July 8, 2025. 2. In a telephonic interview, when the Compliance Officer brought up the gap of more than six months between the two evacuation drills, E2 argued the Compliance Officer was being petty and simply wanted to cite the facility for anything and everything to fill the Compliance Officer’s own pockets with the provider’s money. When the Compliance Officer informed E2 this same issue had been brought up during a previous inspection, E2 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on July 11, 2024.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider (PCP) when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “EMERGENCY AND SAFETY STANDARDS.” The P&P stated: “When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 1. Immediately notifies the resident’s emergency contact and primary care provider.” 2. In an interview, E3 reported R1 went to the hospital two times in August 2025 and once in October 2025. 3. A review of facility documentation revealed two incident reports for the hospital visits in August and a “DHS 911 INCIDENT / TRANSFER REPORT” for the visit in October. However, the three reports did not include notification of R1’s emergency contact and primary care provider. 4. In an interview, E3 reported facility personnel notified R1’s family member when R1 went to the hospital on August 21, 2025, but did not document the notification. When the Compliance Officer asked if facility personnel notified R1’s emergency contact and primary care provider for the incident in October, E4 stated, “No.”

Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented all items required by this rule. The deficient practice posed a potential risk of re-injury. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “EMERGENCY AND SAFETY STANDARDS.” The P&P stated: “When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 2. Documents the following: a. The date and time of the accident, emergency, or injury; b. A description of the accident, emergency, or injury; c. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver; e. The individuals notified by the caregiver or assistant caregiver; and f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.” The review further revealed a P&P titled “QUALITY MANAGEMENT.” The P&P stated, “ALL ACCIDENTS AND INCIDENTS WILL BE COMPLETED ON AN INCIDENT FORM.” 2. In an interview, E3 reported R1 went to the hospital two times in August 2025 and once in October 2025. 3. A review of facility documentation revealed two incident reports for the hospital visits in August and a “DHS 911 INCIDENT / TRANSFER REPORT” for the visit in October. The first report stated R1 went to the hospital on “August 21, 202,” leaving out the rest of the year. The report did not include the full date of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; all individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. The second report revealed R1 went to the hospital on August 23, 2025. However, the report did not include the names of individuals who observed the accident, emergency, or injury and any action taken to prevent the accident, emergency, or injury from occurring in the future. The “DHS 911 INCIDENT / TRANSFER REPORT” revealed R1 went to the hospital on October 20, 2025. However, the report did not include the time of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; and any action taken to prevent the accident, emergency, or injury from occurring in the future. 4. In an interview, E3 reported facility personnel notified R1’s family member when R1 went to the hospital on August 21, 2025, but did not document the notification. When the Compliance Officer asked if the facility had an incident report for the incident in October, E3 and E4 stated, “No.”

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 STANDARDS." The P&P stated: "A manager shall ensure that Elite has the following: 11. Poisonous or toxic materials stored by the assisted living 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 Officer observed a magnet key attached to the wall in the kitchen. The Compliance Officer observed E3 move the magnet key from the wall to an unlocked drawer in the kitchen. The Compliance Officer removed the magnet key from the drawer. The Compliance Officer observed a cabinet under the sink in the kitchen. Using the available magnet key, the Compliance Officer opened the cabinet and observed a variety of poisonous or toxic materials, including all-purpose cleaner with bleach; dishwasher detergent; lime, calcium, and rust remover; multi-surface floor cleaner; powder cleanser with bleach; and wood polish. 3. In an interview regarding the magnet key, E3 stated, "It’s always out.” 4. In the exit interview, the Compliance Officer reviewed the findings and E2 stated, “Got it.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on July 11, 2024.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three sampled caregivers. The deficient practice posed a risk if the employees were not qualified to provide the required services and the Department was provided false or misleading information. Findings include: 1. When the Compliance Officer arrived, E2 and E5 were observed working at the facility as caregivers. E5 reported E5 was the compliance manager and was helping out. 2. A review of E2's personnel record revealed E2 was hired as a caregiver on June 30, 2024. The personnel record contained a caregiver training certificate from the "Alpha Training" (the ALTP #0119) dated November 14, 2012. 3. In an interview, E2 reported E2 first came to Arizona in 2024, from New York, and received caregiver training in New York, and not in Arizona. E2 reported not having been trained in Arizona. E2 reported that an unidentified person had provided a caregiver certificate. According to E2, this unnamed individual had indicated that the certificate would be sufficient. E2 did not disclose the identity of the person who had allegedly supplied the certificate. 4. Review of the https://azcg.tmutest.com/search website revealed no documentation of a caregiver training certificate for E2. 5. A review of facility documentation revealed E2 was scheduled in the facility from June 30, 2024 to present as a live-in caregiver from 12:00 AM to 12:00 AM. 6. A review of the facility policies and procedures revealed a policy titled "Caregiver's Qualifications, Job Description, and Duties and Responsibilities," the policy stated "I.A.1. A caregiver: b. Has documentation of completion of a caregiver training program approved by the Department or the Board of Examiners of Nursing care Institution Administrators and Assisted Living Facility Managers. 7. In a telephonic interview, E4 reported E2's caregiver certificate was verified on the NCIA Board website for caregiver certification verification (https://nciaboard.az.gov/news/caregiver-certificate-verification). However, when questioned about the timeline of the caregiver being in Arizona, E4 acknowledged the caregiver certificate was false and the Department was provided false or misleading information. 8. In an interview, E4 and E5 reported E2 was working at the facility as a caregiver and acknowledged documentation was not available that showed documentation of completing a caregiver training program approved by the Department or the NCIA Board.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation 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 R9-10-113, for three of three employees reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E2's personnel record revealed E2 was hired June 30, 2024. 4. A review of E2's personnel record revealed a negative TB skin test, however, it was read after E2 had begun providing services at the assisted living facility, and no additional documentation of freedom from infectious TB was available for review. 5. A review of E2's and E3's personnel records revealed no documentation for assessing risk of prior exposure to infectious tuberculosis and determining if the individual had signs or symptoms of tuberculosis that was reviewed by a medical practitioner, occupational health provider or local health agency. 6. In an interview, E4 and E5 acknowledged the facility was not in compliance with the rule as specified in R9-10-113.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for three of three residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to 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. Review of R1's, R2's and R3's medical records revealed no documentation for assessing risk of prior exposure to infectious tuberculosis and determining if the individual had signs or symptoms of tuberculosis that was reviewed by a medical practitioner, occupational health provider or local health agency. 3. In an interview, E4 and E5 acknowledged the facility was not in compliance with the rule as specified in R9-10-113.

Based on documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure to cover fall prevention and fall recovery was not available for review. 2. A review of facility documentation revealed a training program to cover fall prevention and fall recovery was not available for review. 3. A review of E1's, E2's and E3's personnel records revealed documentation of in-service education in fall prevention. However, documentation of fall recovery training was not available for review. 4. In an interview, E1 reported the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.