Everlasting Services at Camelback

Based on observation and interview, the manager failed to ensure that the health, safety, or welfare of a resident was not placed at risk or harmed. Findings include: 1. During an interview with E1, the Compliance Officer observed R2 use the backyard door. The manager immediately followed R2 and directed them back inside the home. R2 seemed upset about being directed back inside the home. 2. The compliance Officer observed that the alarm on the door to the backyard did not chime when R2 went out. Checking the alarm, it was turned on, but the magnet was not lined up correctly to chime. 3. In an interview, E1 reported that they have been directing R2 to use the bathroom in the home and not the side yard, but the issue has not stopped. There were two buckets of feces in the side yard, removed on August 5th, 2025. However, E1 does not know how long R2 was using the buckets. E1 also reported that R4 followed R2's lead and was also going to the bathroom in the side yard. 4. In an interview, E2 reported that since they have been working at the facility, R2 and R4 have had this ongoing issue. 5. In an interview, E1 acknowledged health, safety, or welfare of a resident was placed at risk of harm.

Based on record review, observation, and interview, after having a reasonable basis to believe neglect occurred on the premises, the manager failed to report the suspected neglect of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454. Findings include: 1. A review of R2's and R4's medical records revealed no documentation of any incidents. 2. During an interview with E1, the Compliance Officer observed R2 use the backyard door. The manager immediately followed R2 and directed them back inside the home. R2 seemed upset about being directed back inside the home. 3. In an interview, E1 reported that R2 has a habit of trying and relieving himself on the side of the house using an orange Home Depot bucket and a commode chair that R2 found in the backyard. R2 had shown this type of behavior at least since E1 became the manager in May 2025. R4 was also involved in this type of behavior. E1 acknowledged there was no documentation, investigation, and no action taken by the manager to prevent neglect from occurring in the future. E1 also acknowledged that R2's state-appointed fiduciary and R4's power of attorney were not notified of the ongoing neglect.

Based on observation and record review, the manager failed to ensure a resident was treated with dignity, respect, and consideration. Findings include: 1. During an interview with E1, the Compliance Officer observed R2 use the backyard door. The manager immediately followed R2 and directed them back inside the home. R2 seemed upset about being directed back inside the home. 2. In an interview, E1 reported that R2 has a habit of trying and relieving himself on the side of the house using an orange Home Depot bucket and a commode chair that R2 found in the backyard. E1 is worried that neighbors would see R2 exposing himself. R2 had shown this type of behavior at least since E1 became the manager in May 2025. E1 acknowledged that R2 was not treated with dignity, respect, and consideration.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. Review of Department documentation revealed the facility was licensed for the directed level of care. 2. The Compliance Officer observed that the door leading to the backyard had an alarm. However, when the door was opened, the alarm did not sound. The alarm was not set up correctly and was not able to chime. 3. In an interview, E1 acknowledged that the alarm was not set up correctly and the door was not controlled or able to alert employees of the egress of the resident from the facility. This is a repeat deficiency from the compliance inspection conducted on May 12, 2023, and the complaint investigation conducted on January 17, 2025.

Based on documentation review, record review, and interview, the manager failed to implement tuberculosis (TB) infection control activities that included baseline screening; obtaining documentation of freedom from infectious TB; annually obtaining documentation of the individual's freedom from symptoms of infectious TB (for an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201 1201); annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. A review of the facility’s documentation revealed there was no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis. 2. A review of E2’s, E3's, E4’s, and E6’s personnel records revealed that there was no documentation of a baseline screening available for review. 3. In an interview, E8 reviewed E2’s, E3's, E4’s, and E6’s personnel records. E8 acknowledged that the above required documentation was not available for review at the time of the survey.

Based on record review and interview, the manager failed to ensure individuals employed by the facility completed Documentation of a negative Mantoux skin test or other tuberculosis screening test that is recommended by the U.S. Centers for Disease Control and Prevention (CDC) for three of eleven sampled employees. Findings include: 1. According to the CDC’s website (https://www.cdc.gov/tb/hcp/testing-diagnosis/tuberculin-skin-test.html), reflected “Two-step testing if the first TB (tuberculosis) skin test result is negative, a second TB skin test should be done 1 to 3 weeks later”. 2. A review of E2’s, E4's, and E6’s medical records revealed there was no documentation that a second TB test was completed. 3.In an interview, E8 acknowledged there was no documentation of a second test for E2, E4, and E6.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of seven personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) 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. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 2. A review of personnel records revealed there was no documentation of verification that E3 was not on the adult protective services registry. 3. A review of the facility's work schedule dated February 2025 and April 2025 revealed E3 was scheduled to work on various days. 4. In an interview, E8 acknowledged there was no documentation of verification that E3 was not on the adult protective services registry.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board) for one of seven caregivers sampled. Findings include: 1. A review of E7's personnel record revealed a caregiver training certificate issued from Sunshine Care Training Program with program license number ALTP0085, issued December 15, 2018. 2. A review of the NCIA Board website revealed ALTP0085 Sunshine Care Training Program expired May 31, 2012. A review of the tmuniverse website revealed that E7 did not have a valid caregiver training certificate. Any caregiver training certificate issued after 2013 would be listed on the tmuniverse website. 3. A review of documentation revealed a work schedule dated April 2025 which reflected E7 was the only employee scheduled to work April 1, 2025 from 8pm to 8am, April 5, 2025 from 8am to 8pm, April 9, 2025 from 4pm to 8am, and April 12, 2025 from 8am to 8pm. 4. In an interview, E8 reported being unaware that E7's caregiver certification was not valid, and acknowledged E7 was scheduled to work alone as a caregiver.

Based on observation, record review and interview, the manager failed to ensure before providing personal care services or directed care services to a resident, a caregiver provided documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults, for two of seven caregivers sampled. 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 E6's and E7's personnel records revealed expired first aid and CPR training certifications. E6's certification expired February 13, 2025, and E7's certification expired May 28, 2023. 2. In an interview, E1 acknowledged E6's and E7's first aid and CPR training certifications were expired, and there was no additional documentation available for review.

Based on the record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for four of the seven caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E4's, E5's, E6's, and E7's personnel records revealed no documented verification of E4's, E5's, E6's, and E7's skills and knowledge. 2. A review of the facility's work schedule dated April 2025 reflected E4, E5, E6, and E7 were scheduled to work various days and times in the facility. 3. In an interview, E8 reviewed E4's, E5's, E6's, and E7's personnel records and acknowledged that the personnel records did not include documented verification of skills and knowledge, despite being scheduled to work various days in April.

Based on the record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that was specific to the duties to be performed by the caregiver or assistant caregiver for two of seven sampled personnel. Findings include: 1. A review of E4's and E6's personnel records revealed there was no documentation of orientation completed by E4 and E6. 2. In an interview, E8 acknowledged E4's and E6's personnel records did not have documentation of orientation.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the 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, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During a facility tour with E1, the Compliance Officer observed the living room door leading to outside area to have a device above the door, however the device was not operable when the door was opened and closed by the compliance officer. The front door did not have an alert or control, when opened and closed by the compliance officer. 3. In an interview, E2 acknowledgd the living room door leading to outside area and the front door of the facility did not have an alert or controlwhen opened and closed by the compliance officer. had a device or mechanism to control or alert employees of the egress of a resident from the facility to the courtyard. 3. In an interview, E1 acknowledged the patio doors leading to the courtyard did not control or alert employees of the egress of a resident from the facility to the courtyard. E1 reported the facility had cameras and sufficient staffing to monitor the courtyard.

Based on documentation review, observation, and interview, the manager failed to ensure meals and snacks for each day were planned using the applicable guidelines in http://www.health.gov/dietaryguidelines/2015.asp. Findings include: 1. During a review of the Dietary guidelines for Americans 2015, the guidelines state: "Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level. A healthy eating pattern includes: \'b7 A variety of vegetables from all of the subgroups-dark green, red and orange, legumes (beans and peas), starchy, and other \'b7 Fruits, especially whole fruits \'b7 Grains, at least half of which are whole grains \'b7 Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages \'b7 A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products \'b7 Oils". 2. During the on-site compliant investigation conducted on January 17, 2025, the compliance officer observed the residents being served fish sandwhich, fries water or juice. 3. During a review of the facility's menu dated January 15, 2025 through January 21, 2025 indicated the residents were to be served the following meal on January 17, 2025: - Breakfast: three pancakes, bacon, jello, coffee or water; - Lunch: Hot dog, pudding, chip, water or juice; - Dinner: fish sandwhich, fries water or juice. The meau was not complaint with dietary guidelines for Americans 2015. 4. During an interview, E1 reported the residents are usually served a bigger meal during lunch, and acknowledged the residents were not served a variety of vegetables, fruit, or a protein for dinner.

Based on observation and interview, the manager failed to ensure each resident sleeping area included clean linen, mattress pads, large enough sheets, pillow cases, bedspread, waterproof mattress covers as needed, and blankets. Findings include: 1. During the environmental tour, the Compliance Officer(CO) observed R4 to not have a sheet on R4's bed and R4's bed cover to be ripped. The CO observed the pillows on R6's bed to have no pillow case for four pillows. 2. In an interview, R2 reported that disposable bed underpads were left all night. 3. In an interview, E1 acknowledged R4 did not have a sheet on R4's bed and R4's bed cover to be ripped. The CO observed the pillows on R6's bed to have no pillow case for four pillows.

Based on documentation review, observation, and interview, the manager failed to ensure the 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, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away 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 was authorized to provide directed care services. 2. The Compliance Officer observed two ambulatory residents. 3. A review of facility policies and procedures revealed a policy titled "Residents that wander" with a review date of January 1, 2022. The policy stated: "Procedure: Potential for wandering will be addressed during the assessment and documented as a safety precaution in the resident folder if needed. Any potential wandering will be monitored by staff in the home and during activities..." 4. During the environmental inspection of the facility, the Compliance Officer observed a door leading to an outside area in the front yard allowing residents to be at least 30 feet away from the facility. The Compliance Officer observed the door to the front yard was a lockable door, from the inside, and allowed residents access to the outside area. The Compliance Officer observed the door leading to the front yard contained an alarm, however, the alarm did not alert employees to the egress of a resident when the door was opened. 5. During the environmental inspection of the facility, the Compliance Officer observed a door leading to an outside area in the back yard allowing residents to be a least 30 feet away from the facility. The Compliance Officer observed the door to the back yard was a lockable door, from the inside, and allowed residents access to the outside area. The Compliance Officer observed the door leading out to the back yard contained an alarm, however, the alarm did not alert employees to the egress of a resident when the door was opened. 6. In an interview, E2 reported the alarms were broken. E2 reported the alarms broke the day prior to the survey. 7. In an interview, E1 reported alarms are used on the doors to control and alert employees of the egress of a resident from the facility. E1 acknowledged the doors leading to the outside areas did not control or alert employees of the egress of a resident from the facility at the time of the survey.