Everlasting Services at Estrella Center

Based on documentation review and interview, the assisted living home failed to maintain a copy of the document provided to the emergency responder as prescribed in A.R.S. § 36-420.04.A.1-9, for two of two applicable residents reviewed. The deficient practice posed a risk as the designated standards were not followed and the department was unable to ensure compliance with the applicable statute. Findings include: 1. A review of facility documentation revealed several incident reports for the month of February 2026 for both R2 and R3, in which EMS services were requested. 2. Further review of facility documentation revealed the facility had created and maintained the required pre-filled standardized EMS Transport forms and all of the necessary attachments for R2, R3, and the other residents. However, there were no copies of the EMS Transport forms that were completed at the time of each of the incidents that included the date and reason for the EMS request. 3. In an interview, E1 and E2 were certain that the EMS Transfer forms and required attachments were provided to emergency responders for each of the incidents involving R2 and R3, as that was part of the facility's standard process when a resident required EMS services. In addition, E1 and E2 were able to confirm with E3 that E3 provided EMS responders with the required paperwork for the incident in question involving R2. However, E1 stated that E1 was not aware of the requirement to make and maintain a copy of the specific EMS Transfer forms provided to EMS responders at the time of the incident/transfer, and therefore, had not made or maintained copies. 4. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.

Based on observation and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm, for one of one applicable resident reviewed. Findings include: 1. While on-site, the Compliance Officer observed the main entrance of the facility to be secured from the inside and outside, requiring an individual at the front desk to push a button to allow the door to open. Staff members with badges could also badge themselves out, which allowed the doors to open as well. 2. In an interview, E1 explained that R1 must have walked out the door when someone else was walking in or walking out, likely visitors or family members of other residents. R1 was personal care and required a POA/Guardian to sign R1 out and to accompany R1 on any outings; therefore, R1 should not have been able to leave the facility unaccompanied. Although R1 was not injured during this incident, R1's health, safety, and welfare were placed at risk of harm. E1 explained that this incident was a shock to the care staff, and that due to this incident, R1's level of care will be increased to directed care and R1 will be moved to a secure area of the building. 3. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided. 4. This is a repeat deficiency from the complaint inspection conducted on October 6, 2025.

Based on record review, documentation review, and interview, the manager failed to provide written notification to the Department of a resident’s elopement, within 24 hours of the elopement being discovered. Findings include: 1. A record review of an incident report dated January 5, 2026 revealed, R1 was discovered missing at 09:00 AM. Upon review of security camera it was discovered that R1 eloped from the facility at 6:00 PM on January 4, 2026. The incident report stated, "[E1] submitted complaint to DHS at 4:46pm notifying of elopement." However, a review of Department records revealed written notification to the Department was not provided. 2. In an interview, E2 acknowledged the manager failed to provide written notification to the Department of a resident’s elopement, within 24 hours of the elopement being discovered.

Based on documentation review, record review, and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454. 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) 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 (A.A.C.) R9-10-101(111) states, "'Immediate' means without delay." 3. A review of Department documentation revealed an altercation had occurred between R1 and R2 on December 17, 2025. 4. A review of facility documentation revealed a document titled "Resident Emergency Transfer Record," dated December 17, 2025. The document revealed R1 was "taken out by Emergency Medical Technicians (EMTs) for further evaluation..." 5. A review of facility documentation revealed a report dated December 17, 2025. The documentation indicated E1 was made aware of an allegation of abuse immediately following the incident. However, documentation of the immediate notification of a peace officer or Adult Protective Services (APS) was not available for review. 6. In an exit interview, the findings were reviewed with E1 and E2. E1 reported adult protective services was not notified of the incident, and no additional information was provided.

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 three caregivers sampled. Findings include: 1. A review of documentation contained work schedules dated December 1, 2025, through December 7, 2025; December 8, 2025, through December 14, 2025; December 15, 2025, through December 21, 2025; and December 22, 2025, which reflected that E6 and E7 were scheduled to work as caregivers on various days. 2. A review of E6’s personnel record revealed a caregiver training certificate issued by "Arizona Caregiver Services" with program license number ALTP0131, issued November 10, 2009. E6’s record contained an undated verification from the NCIA Board's website, which reflected ALTP0131 expired January 31, 2009. 3. A review of the NCIA Board’s website stated ALTP0131 expired January 31, 2009. 4. A review of E7’s personnel record did not contain documentation of completion of a caregiver training program approved by the Department or the NCIA board. 5. In an interview, E1 acknowledged there was no documentation to reflect that E6 and E7 were issued documentation of completion of a caregiver training program approved by the Department or the NCIA board. E1 reported E6 worked as an assistant caregiver, despite the facility's work schedule reflecting E6 was scheduled to work as a caregiver.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver’s or assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services, and according to policies and procedures, for two of six caregivers' records reviewed. Findings include: 1. A review of documentation contained a policy titled “Employee Orientation” which stated “all caregivers, managers, and assistant caregivers (if applicable) skills and knowledge are verified and documented during new employee orientation and completed before providing assisted living services, which may include but not limited the following: (See facility new employee orientation)… Credentials verified: i.e caregiver certified, managers certification etc”. 2. A review of documentation contained work schedules dated December 1, 2025, through December 7, 2025; December 8, 2025, through December 14, 2025; December 15, 2025, through December 21, 2025; and December 22, 2025, which reflected that E6 and E7 were scheduled to work as caregivers on various days. 3. A review of E6’s personnel record revealed a caregiver training certificate issued by "Arizona Caregiver Services" with program license number ALTP0131, issued November 10, 2009. E6’s record contained an undated verification from the Arizona Nursing Care Institution Administrators and Assisted Living Facility Manager board website (NCIA Board), which reflected ALTP0131 expired January 31, 2009. 4. A review of the NCIA Board’s website stated ALTP0131 expired January 31, 2009. 5. A review of E7’s personnel record did not contain documentation of orientation or any other documentation that E7's skills and knowledge were verified before the caregiver provided physical health services. 6. In an interview, E1 acknowledged that E6’s skills and knowledge were not verified according to the above policy and procedure, and documentation of verification was documented in E6’s personnel record. Despite E6’s lack of verification, E6 continued to work on various days. 7. In an interview, E1 reviewed E7’s personnel record and acknowledged that there was no documentation that E7's skills and knowledge were verified at the time of the survey. This is a repeat deficiency from the complaint investigation and compliance inspections conducted on April 11, 2024, and May 8 and 9, 2025.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for two of three sampled residents. The deficient practice posed a risk as the Department was provided with false or misleading information. Findings include: 1. A review of R1’s medical record revealed a service plan dated June 30, 2025. R1's service plan revealed R1 would be provided the following assistance: dressing and undressing, and grooming on every day and evening shift. 2. A review of R1’s medical record contained documentation of services provided dated December 2025, which stated R1 was not provided dressing assistance on the day shift on December 22, 2025, and December 29, 2025; and on the evening shift on December 10, 2025, December 16, 2025, December 22, 2025, and December 23, 2025. R1’s documentation reflected that grooming was not provided on December 16, 2025, December 25, 2025, and December 29, 2025. 3. A review of R2’s medical record contained documented titled “Progress Notes” which reflected “[R2] was taken to Banner ER” dated December 16, 2025; and “[R2] returned from hospital stay with two antibiotics” dated December 22, 2025. 4. A review of R2’s medical record contained documentation of services provided, which reflected that R2 was aided with activities of daily living between December 17, 2025, through December 21, 2025, despite R2 being unavailable, and was admitted into the hospital. 5. In an interview, E1 reviewed R1’s and R2’s medical records and acknowledged that the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services appropriately. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on May 8 and 9, 2025.

Based on documentation review, record review, observation, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to the physical health, safety, and overall welfare of the residents. Findings include: 1. Review of Department documentation revealed the facility was licensed for directed care. 2. Review of R1’s medical record revealed an incident report which stated, “Was called over by the caregivers to assess [R1]. Was told [R1] was acting strange. Upon assessing [R1], it was obvious that [R1] was intoxicated, and [R1] confirmed that [R1] was and where [R1] got [R1’s] hands on the hand sanitizer. Stated that [R1] got the hand sanitizer from another resident and let me know where to find it.” The report later revealed, “911 was called and [R1] was taken to the hospital for an evaluation.” 3. The Compliance Officer observed two unlocked housekeeper carts that contained the following: - A spray bottle of Odoban, - Two spray cans of Lisol; and - Two spray bottles of Windex. 4. The Compliance Officer observed an unlocked telecom room that contained the following: - Two spray cans of Scrub Free bathroom cleaner, - A bottle of Fabuloso, - A bottle of Bona hard surface cleaner, - A bottle of Spic Span disinfecting all purpose cleaner and glass cleaner; and - A bottle of Cloralen Bleach 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of Department documentation revealed the facility was licensed for directed care. 2. The Compliance Officer observed two unlocked housekeeper carts that contained the following: - A spray bottle of Odoban, - Two spray cans of Lisol; and - Two spray bottles of Windex. 3. The Compliance Officer observed an unlocked telecom room that contained the following: - Two spray cans of Scrub Free bathroom cleaner - A bottle of Fabuloso - A bottle of Bona hard surface cleaner - A bottle of Spic Span disinfecting all purpose cleaner and glass cleaner. - A bottle of Cloralen Bleach 4. Review of the facility’s policy and procedures revealed a policy titled, “Cleaning Supplies: Poisonous or toxic materials,” which stated, “2. Locked area separate from food preparation/ storage areas, dining areas, and medications. 3. Not accessible to residents,” 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. A review of R2’s and R3’s medical records revealed service plans which indicated R2 and R3 were to receive personal care services. 2. The Compliance Officer observed call buttons in R2’s and R3’s bathrooms. However, the Compliance Officer observed no bells, intercoms, or other mechanical means to alert employees to R2’s and R3’s needs or emergencies in R2’s and R3’s bedrooms. 3. In an interview, E1 reported all bathrooms contained call buttons. However, E1 acknowledged R2’s and R3’s bedrooms did not have bells, intercoms, or other mechanical means to alert employees to R2’s and R3’s needs or emergencies.

Based on record review, observation, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. A review of R1’s medical record revealed a service plan which indicated R1 was to receive directed care services. 2. The Compliance Officer observed a call button in R1’s bathroom. However, the Compliance Officer observed no bell, intercom, or other mechanical means to alert employees to R1’s needs or emergencies in R1’s bedroom or on R1’s person. 3. In an interview, when the Compliance Officer asked how R1 summoned assistance, R1 reported R1 had to leave R1’s room to go find a caregiver. 4. In an interview, E1 reported all bathrooms contained call buttons. However, E1 acknowledged R1’s bedroom did not have a bell, intercom, or other mechanical means to alert employees to R1’s needs or emergencies.