Estancia at Elgin Ranch

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454 and document the actions taken by the manager to prevent the suspected abuse or neglect from occurring in the future. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. In an interview, E1 reported an incident which occurred on January 28, 2026, and involved R1. 4. A review of facility documentation revealed a document titled “Incident Report” and dated January 28, 2026. The document detailed an incident which occurred on January 28, 2026, and involved R1. The document stated the “Incident Type [included] Abuse or Neglect.” However, the document did not include the actions taken by the manager to prevent the suspected abuse or neglect from occurring in the future. Furthermore, the review revealed no documentation demonstrating facility personnel reported the suspected abuse or neglect to a peace officer or to Adult Protective Services. 5. In a telephonic interview, E2 reported R1’s family reported the suspected abuse or neglect and E2 was not aware facility personnel needed to report it. When the Compliance Officer asked if the actions taken by the manager to prevent the suspected abuse or neglect from occurring in the future was included on the aforementioned “Incident Report,” E2 stated, “No, it wasn’t.” 6. In the exit interview, the Compliance Officer reviewed the findings and E1 and E1 offered no further comment. This is a repeat citation from the complaint inspection conducted on June 25, 2025.

Based on documentation review, record review, and interview, the assisted living home that contacted an emergency responder on behalf of a resident failed to provide to the emergency responder a written document that included all of the information required in A.R.S. § 36-420.04.A.1-9, for one of two applicable residents reviewed. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of Department documentation revealed that, according to Gilbert EMS responders, the facility requested an emergency response on behalf of R2 on December 27, 2025. The documentation also stated that "No patient form / paperwork" was provided to EMS responders for R2 during the incident. 2. While on-site, the Compliance Officer requested E2 to provide any recent incident reports and/or documentation of R2 or R3 going to the hospital. E2 provided documentation of an "Incident Report" and an "Emergency Report" for R3 going out to the hospital on January 28, 2026, which met the requirements of A.R.S. § 36-420.04. 3. In an interview, E2 reported there were no incident reports for R2 or any documentation indicating that R2 went out to the hospital. 4. In an interview, E2 stated that E2 could see a note posted in the "internal group chat" stating that E4 sent R2 to the hospital on December 27, 2025. E2 again stated that there was no documentation in R2's medical record to indicate an Incident Report or Emergency Report had been completed for this incident. 5. In an interview, E2 acknowledged that the assisted living home failed to provide the emergency responder with a written document that included the information required in A.R.S. § 36-420.04.A.1-9 on December 27, 2025, for R2. 6. This is a repeat deficiency from the compliance and compliant inspection conducted on May 5, 2025.

Based on record review and interview, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided in the resident’s medical record, for two of two applicable 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 R2's medical record revealed a current service plan dated October 10, 2025, which included the following services: "Afternoon Check In; Brief Change at 6:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM; and Evening Check In." 2. A review of the January 2026 Activities of Daily Living (ADL) sheet for R2 revealed that the Evening Check In was not documented as being provided on January 24, 2026; and the Afternoon Check In, Brief Changes for 11:00 AM, 3:00 PM, and 7:00 PM, and the Evening Check In were not documented as being provided on January 25, 2026 3. A review of R3's medical record revealed a current service plan dated November 17, 2025, which included the following services: "Evening Check In." 4. A review of the January 2026 Activities of Daily Living (ADL) sheet for R3 revealed that the Evening Check In was not documented as being provided on January 24, 2026. 5. In an interview, E3 reported the services were provided but the caregiver was late completing the documentation, at which point the electronic medical records system did not allow for an entry to be made past a certain point. 6. In an interview, E2 and E3 acknowledged the aforementioned services were provided to R2 and R3 but were not documented in the medical records. 7. This is a repeat deficiency from the compliance and compliant inspection conducted on May 5, 2025.

Based on documentation review, record review, and interview, when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the manager failed to ensure that a caregiver or an assistant caregiver documented the incident. The deficient practice posed a risk as there was no documentation of the details of the incident or emergency, including actions taken, individuals notified, and any action taken to prevent the incident or emergency from occurring in the future. Findings include: 1. A review of Department documentation revealed that, according to Gilbert EMS responders, the facility requested an emergency response on behalf of R2 on December 27, 2025. 2. While on-site, the Compliance Officer requested E2 to provide any recent incident reports and/or documentation of R2 going to the hospital. 3. In an interview, E2 reported there were no incident reports for R2 or any documentation indicating that R2 went out to the hospital. 4. In an interview, E2 stated that E2 could see a note posted in the "internal group chat" stating that E4 sent R2 to the hospital on December 27, 2025. E2 again stated that there was no documentation in R2's medical record to indicate an Incident Report or Emergency Report had been completed for this incident. 5. In an interview, E2 acknowledged that the assisted living home failed to complete an incident report for R2 on December 27, 2025. 6. This is a repeat deficiency from the compliance and compliant inspection conducted on May 5, 2025.

Based on documentation review and interview, the manager failed to ensure that a manager who had a reasonable basis, according to A.R.S. § 46-454, to believe abuse had occurred on the premises, the manager complied with all the requirements in R9-10-803(J). The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. A.R.S. § 46-454(A) stated "...other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or the Adult Protective Services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.111 stated "Immediate" means without delay. 3. A review of Department documentation on June 17, 2025, revealed an allegation that R1 was attempting to get out of bed, and one of the caregivers pushed R1 back down on the bed and would not allow R1 to get up. 4. In an interview, E2 reported that on June 18, 2025, E2 was aware of the incident that took place on June 17, 2025. E2 also reported, the incident was not reported to a peace officer or the Adult Protective Services central intake unit by the facility because O1 was making a report to Adult Protective Services. 5. A documentation review revealed there was no evidence of action taken to immediately stop the suspected abuse, neglect, or exploitation. 6. A documentation review revealed there was no documentation of the report required in R9-10-803.J.5. 7. In an interview, E2 acknowledged documentation was not available showing compliance with the requirements in R9-10-803(J).

Based on documentation review, observation, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), which required immediate notification to the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager. Findings include: 1. A review of Department documentation indicated O1's appointment as manager effective December 7, 2021. There was no notification of a new manager appointed. 2. In an on-site compliance investigation, the compliance officer observed E2's manager certificate hanging in the facility. 3. In an interview, E1 reported E2 had been appointed manager effective June 8, 2022. E1 acknowledged the Department was not notified of a change in the manager as required. 4. In an email received by the Department on July 11, 2023, the Department was notified of E2's appointment as manager effective June 8, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's in-service education, for six of six personnel records sampled. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of the facility's policies and procedures (reviewed and approved April 20, 2023) revealed a policy titled, "Personnel." Under the title, "Policy" the document stated, "A minimum of 12 hours of CEU credits will be required for all employees. 2 of these hours will go toward wound care and medication administration. The 2 credit hours will be taken within the first week of hire." 2. A review of E1's, E2's, E3's, E4's, E5's, and E6's personnel records revealed no documented in-service education. 3. The compliance officer requested documented in-service documentation for all personnel members. The compliance officer received documentation of 12 hours of in-service education for E2. However, the 2 hours required for wound care and medication administration were not included. 4. In an interview, E1 acknowledged the required in-service education was not included in E1's, E2's, E3's, E4's, E5's, and E6's personnel records.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. The deficient practice posed a risk if a resident was not assessed and determined to be within the scope of an assisted living facility prior to receiving services. Findings include: 1. A review of R2's medical record (admitted November 2021) revealed documentation dated February 16, 2022, signed by a medical practitioner and documenting R2's needs. However, the document did not indicate R2's level of care. In addition, the documentation indicated R2 required continuous medical services. 2. Further review revealed the documentation was not dated within 90 calendar days before R2's date of admission. 3. In an interview, E1 acknowledged R2's medical record did not contain documentation that was dated within 90 days before the individual was accepted by the assisted living facility. E1 believed there was earlier documentation. However, E1 was unable to find any additional documentation. E1 reported R2 did not require continuous medical services and believed it was mistakenly checked by the medical practitioner.