Eternal Spring of Gilbert

Based on record review and interview, the assisted living center failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section, for two of three sampled residents. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R2's medical record revealed a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 2. A review of R3's medical record revealed a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: The name and contact information for the resident's primary care physician and power of attorney or authorized representative; and The name, address and telephone number of the resident's current pharmacy. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to health and safety as the resident's whereabouts were unknown. Findings include: 1. A review of R2's medical record revealed a service plan dated March 5, 2026, that indicated R2 was diagnosed with late stage dementia and was receiving directed care services. The service plan also revealed that R2 was ambulatory, disoriented to person/place/time, was unable to recognize danger, and was prone to getting into dangerous situations. 2. A review of the facility's documentation revealed an incident report was created on December 31, 2025 detailing an incident when R2 eloped from the facility on December 29, 2025. 3. In an interview, E1 reported the resident eloped from the facility unknowingly and was not physically recognized by staff as a resident when they exited the facility. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(A), for one of eight 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of facility documentation revealed staff schedules for the previous 12 months. The schedules revealed E3 was scheduled for multiple shifts at the facility each month between March 2, 2024, through April 26, 2025. 3. A review of E3's personnel record revealed a fingerprint clearance card which expired on October 19, 2024. E3 had no current, valid fingerprint clearance card from October 19, 2024, to time of inspection. 4. A review of the Department of Public Safety website revealed E3’s fingerprint clearance card had expired on October 19, 2024. 5. In an interview, E1 acknowledged E3 did not have a valid fingerprint clearance card from October 19, 2024, to time of inspection.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, for four of ten sampled residents. 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 R3's, R4’s, R8’s, and R10’s medical records revealed no written service plan was available for review. Based on R3's, R4’s, R8’s, and R10’s date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged no service plan for R3's, R4’s, R8’s and R10’s was available for review.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of ten residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated February 3, 2025, for directed care services. 2. A review of R1's medical record revealed R1 had an incident on April 4, 2025, which left R1 unable to ambulate. 3. In an interview, E1 acknowledged R1’s services plan had not been updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition.

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated at least once every three months for two of ten residents sampled receiving personal care services. Findings include: 1. A review of R5's medical record revealed a service plan dated March 17, 2024, for personal care services. However, no updated service plan was available for review. 2. A review of R6's medical record revealed a service plan dated June 1, 2024, for personal care services. However, no updated service plan was available for review. 3. In an interview, E1 acknowledged R5's and R6’s service plan had not been reviewed and updated at least once every six months.

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated at least once every three months for three of ten residents sampled receiving directed care services. Findings include: 1. A review of R2's medical record revealed a service plan dated June 10, 2024, for personal care services. However, no updated service plan was available for review. 2. A review of R7's medical record revealed a service plan dated October 18, 2024, for personal care services. However, no updated service plan was available for review. 3. A review of R9's medical record revealed a service plan dated May 9, 2024, for personal care services. However, no updated service plan was available for review. 4. In an interview, E1 acknowledged R2's, R7’s, and R9’s service plans had not been reviewed and updated at least once every three months.

Based on record review and interview, the manager failed to ensure a personnel record was established and maintained, for one of two sampled employees. The deficient practice posed a risk as required information could not be verified. Findings include: 1. During the inspection of the facility, the Compliance Officer asked who the Asssited Livning Manager for the facility was and E6 reported E1 was the Asssited Livning Manager for the facility. 2. A review of facility personnel records the Complaince Officer requested the personnel file for E1 and revealed no personnel record for E1 available for review. 3. In an interview, E6 acknowledged there was no personnel record for E1.

Based on record review and interview, the manager failed to ensure a medical record was maintained at the facility, for one of two residents reviewed. Findings include: 1. A review for facility resident dicharge sheet revealed R1 was a resident at the facility. 2. A review of medcial records at the facility revealed no medical record was not available for review for R1. 3. During an interview, E6 acknowledged R1's record was not available.

Based on documentation review, record review, and interview, the assisted living home failed to provide the required documentation to an emergency responder, for one of two sampled residents for whom an emergency responder had been contacted. Findings include: 1. A review of facility documentation revealed an incident report dated January 5, 2025. The incident report indicated R2 had fell with a head injury and transported to the hospital. However, The facility was unable to provide the Compliance Officer with a copy of the emergency responder documentation. 2. In an interview, E6 acknowledged the documentation of what was given to the emergency responder for R2 was not provided for review.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for one of one sampled caregiver. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of facility staff schedule revealed E2 was hired as a caregiver and worked mulitple shifts at the facility for January 2025. 2. A review of E2's personnel record revealed E2 was hired April 2020 and no documented verification of E2's skills and knowledge. 3. In an interview, E6 acknowledged E2's personnel record did not contain documentation of verification of skills and knowledge.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training, for one of one caregivers sampled. The deficient practice posed a risk if E2 were unable to perform CPR. Findings include: 1. A review of facility documentation staff schedules revealed worked the night shift from January 26-30, 2025. 2. A review of E2's personnel record revealed E2 was hired April, 2020. E2's personnel record also revealed a CPR training card issued on November, 2023 from NationalCPRFoundation. No other documentation of CPR training was available for review for E2 3. A review of the website for NationalCPRFoundation stated "National CPR Foundation... We're a Premium Online Certification Provider for Healthcare Providers, Workplace Individuals and the Community." and that the certification consisted of "[...] ten multiple choice questions that cover all of the important aspects of CPR and AED, it can be completed in a few minutes and may be taken as many times as necessary before you pass." 4. In an interview, E6 acknowledged E2 did not have CPR training from November, 2023 until January 29, 2025 and CPR training cards were from online programs that did not include demonstration of the employee's ability to perform cardiopulmonary resuscitation, and documentation of current CPR training, with demonstration, was not available for review.

Based on documentation review and interview, after the manager had a reasonable basis, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation, initiate an investigation of the suspected abuse, neglect, or exploitation, and maintain documentation including all requirements of this rule for at least 12 months after the date the investigation was initiated. The deficient practice posed a risk if a resident was not protected from abuse, neglect, or exploitation. Findings include: 1. A review of facility incident reports revealed no report was created for the incident involving R1 and a caregiver where the caregiver allegedly assaulted R1 2. In an interview, E1 acknowledged being aware of the allegation involving R1 on December 21, 2024. E1 acknowledged the incident was not reported until December 24, 2024, by the facility and not in compliance with A.R.S. \'a7 46-454.

Based on documentation review, record review, and interview, the manager failed to ensure an caregiver or assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for one of one sampled caregiver. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of facility documentation staffing schedules revealed staffing schedules for the previous 12 months. The schedules revealed E2 was scheduled to work at the facility as a caregiver on multiple shifts throughout December 2023-December 2024. 2. A review of E2's personnel records revealed no documented verification of E2's skills and knowledge. 3. In an interview, E1 acknowledged E2's personnel records did not contain documented verification of skills and knowledge.

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 to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of four sampled residents. The deficient practice posed a risk if staff were unable to meet the needs of residents. Findings include: 1. A review of R3's medical records revealed no documentation dated within 90 calendar days before R3 was accepted by the assisted living facility to include whether R3 required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E1 acknowledged R3's medical records did not contain the required documentation.