Family Matters Care

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established, documented, implemented, and completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. Findings include: 1 . A review of R2's medical record revealed that documentation of a completed service plan was not available for review at the time of inspection. Based on the resident's date of acceptance, this documentation was required. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to develop and administer a training program for all staff regarding fall prevention and fall recovery, for one of three personnel sampled. Findings include: 1 . A review of facility documentation revealed documentation of a training program regarding fall prevention and fall recovery, including initial and continued competency training, was not available for review at the time of inspection. 2 . A review of E3's personnel record revealed documentation of fall prevention and fall recovery training was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided. This is a repeat deficiency from an inspection conducted on February 24, 2025.

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section. Findings include: 1 . A review of R1's and R2's medical records revealed that documentation of a maintained standardized form for the emergency responder was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S § 36-411 for three of three employees sampled. Findings include: 1 . A review of E1's and E2's personnel records revealed that documentation of an annual Adult Protective Services (APS) registry check was not available for review at the time of inspection. 2 . A review of E3's (provided direct supportive services) personnel record revealed that documentation of a fingerprint clearance card was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation required by policies and procedures, for one of three employees sampled. Findings include: 1 . A review of facility documentation revealed a policy titled "Orientation, In-Service Trainings for Employees." The policy stated, "Schedule and provide new employee and volunteer orientation sessions as appropriate to ensure the proper orientation of all staff." 2 . A review of E3's personnel record revealed that documentation of a completed orientation was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. Findings include: 1 . A review of R2's medical record revealed a negative TB test. However, documentation of a signs and symptoms screening and risk assessment was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan was reviewed and updated at least once every three months for a resident receiving directed care services. Findings include: 1 . A review of R1's medical record revealed the latest completed service plan dated August 21, 2025. However, documentation of a completed service plan after August 21, 2025 was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two residents sampled. Findings include: 1 . A review of R1's and R2's medical records revealed documentation of an orientation completed was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure there was a means of exiting the facility for a resident that monitors or alerts employees of the egress of a resident 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 . During an environmental inspection of the facility, the Compliance Officers observed an alert placed on the door of the facility leading to the garage. However, when the Compliance Officer opened the garage door, the alert was turned off. 2 . During an environmental inspection of the facility, the Compliance Officers observed a sliding glass door leading to the backyard. The door had half of an alert system in place. However, the other half of the alert system was not there, making the alert not able to function. 3 . A review of facility documentation revealed no monitoring system for the garage door or the back door. 4 . In an interview, E1 reported no monitoring system for the garage door or the back door. 5 . In an exit interview, the findings were discussed with E1 and no additional information was provided. This is a repeat deficiency from an inspection conducted on February 24, 2025.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed medication for E2 sitting on a bathroom counter in a resident room. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a door to a resident room. The door was propped open with a dumbbell, and had no handle. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a resident's sleeping area was not used as a passageway to another sleeping area. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a bed located in the closet of the master bathroom of a resident's room. 2 . In an interview, E2 reported sleeping in the closet to be closer to a resident who needs more assistance at night. 3 . In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure the swimming pool was locked when the swimming pool was not in use. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed that the gate latch for the pool was unlocked at the time of the inspection. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided. This is a repeat deficiency from inspections conducted on June 23, 2023, and February 24, 2025.

Based on observation, 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 provides physical health services, for two of two caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of E1's and E2's personnel records revealed E1 and E2 were hired as caregivers. 2. A review of E1's and E2's personnel records revealed no documentation to indicate E1's and E2's skills and knowledge were verified before E1 and E2 provided physical health services. 3. In an interview, E1 acknowledged E1's and E2's skills and knowledge were not verified and documented before E1 and E2 provided physical health services.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two residents sampled. The deficient practice posed a risk if residents were unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1's and R2's medical record revealed no documentation to indicate R1 and R2 were oriented to exits from the assisted living facility. 2. In an interview, E1 reported the documentation must have been misplaced, but was unable to locate the documentation during the inspection. E1 acknowledged E1 failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked. Findings include: 1. The surveyor reviewed the facilities June 2023 personnel scheduled provided by E1. The schedule is dictated on a monthly calendar to include the name of the caregivers working each day; however, the calendar does not include the hours worked for the caregivers. 2. During an interview, E1 acknowledged the calendar used by the facility to document the caregiver's work schedule did not include the hours worked by each caregiver. 3. During an interview, E2 acknowledged the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked. Technical assistance was provided during the compliance inspection conducted May 18, 2022.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of the two residents sampled. Findings: 1. Review of R1's personal care service plan dated June 1, 2023, revealed the following services to be provided to R1, "complete bath 2 x weekly." However, R1's medical record for June 2023 revealed no documentation of the identified service provided. 2. During an interview with E1, E1 reported United Health Hospice provided R1 with the identified service weekly. E1 acknowledged R1's medical record did not include documentation of the service provided. 3. During an interview, E2 contacted United Health Hospice by telephone. E2 was notified no documentation was provided to the facility to reflect the identified service was completed. E1 acknowledged that R1's medical record revealed no documentation of complete bath 2 x weekly. E1 acknowledged the manager failed to ensure a caregiver documented the services provided in the resident's medical record.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record. Findings include: 1. A review of R1's medical record revealed a signed medication order for Potassium CL Microtab 20 mg, take two tablets by mouth every day signed May 19, 2023. 2. A review of R1's medication administration record revealed R1's May and June record revealed no documentation the identified medication was administered to R1. 3. The compliance officer observed R1's seven day pill dispenser contained the identified medication. 4. In an interview, E1 reported E1 forgot to add the identified medication to R1's medication administration record. E1 reported E1 has administered the medication in compliance with the medication order. E1 acknowledged E1 had not documented the medication administered in R1's medical record. 5. In an interview, E2 acknowledged the manager failed to ensure medication administered to a resident was documented in the resident's medical record.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. Findings include: 1. During the facility tour with E1, the surveyor observed Semaglutide/Cyancocobalamin 1 ml vial located in the facilities refrigerator door. The medication was unlocked and accessible to residents. The refrigerator did contain a locked medication box that stored the residents' medications. 2. During an interview, E1 reported the medication belonged to E1. E1 acknowledged the medication was stored unlocked. 3. During an interview, E2 acknowledged the manager failed to ensure medications stored by the facility were stored in a locked area.

Based on observation, documentation review, and interview, the manager failed to ensure food was protected from potential contamination and was safe for human consumption. Findings include: 1. During a facility tour with E1, the surveyor observed the kitchen refrigerator shelf had hamburger blood spread throughout the shelf where the facility's food was stored. 2. In an interview, E1 reported E1 de-thawed hamburger meat and the blood from the meat leaked onto the kitchen shelf. E1 acknowledged the hamburger blood was left on the shelf with the stored food. 3. In an interview, E2 acknowledged the food stored in the kitchen refrigerator was not protected from potential contamination.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility's documentation identified the facility's work schedule identified as the following: 6 am-6 pm 6 pm-6 am 2. A documentation review of the facility's disaster drills revealed a disaster drill was conducted on the following dates: May 29, 2023, at 4 pm May 23, 2023, at 11 am February 15, 2023, at 3 pm February 12, 2023, at 10 am December 17, 2022, at 4 pm December 15, 2022, at 10:33 am September 13, 2022, at 4 pm September 10, 2022, at 10 am 3. In an interview, E2 reviewed the identified disaster drills and acknowledged the drills were only conducted on the first shift. E2 reported no additional drills were available for review. E1 acknowledged the disaster drills were not conducted on each shift at least once every three months.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented. Findings include: 1. A review of R2's medical record revealed documentation indicating R2 received orientation to exits from the assisted living facility and the route to be used when evacuating the assisted living facility was not provided for review. 2. In an interview, E2 reviewed R2's medical record. E2 reported E2 believed E2 provided R2 with the orientation to the facility and E2 did not document this in R2's record. E2 acknowledged R2's record did not reveal documentation R2 received orientation to exits from the assisted living facility and the route to be used when evacuating the assisted living facility was not provided for review.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During a facility tour with E2, the compliance officer observed two oxygen cylinders sitting upright, but unsecured, next to an oxygen tank in a stand located in R1's bedroom closet. The compliance officer observed seventeen oxygen cylinders sitting upright, but unsecured, in the facility garage. 2. During an interview, E2 acknowledged the manager failed to ensure oxygen containers were secured in an upright position.

Based on observation and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents. Findings include: 1. During the facility tour with E2, the compliance officer observed two bottles of Charcoal Lighter Fluid in the backyard patio area. The combustible liquid was not locked and was accessible to the residents. 2. In an interview, E2 acknowledged combustible liquids were not locked and were accessible to residents.

Based on observation and interview, the manager failed to ensure a swimming pool gate was locked when the swimming pool was not in use. Findings include: 1. During a facility tour with E2, the compliance officer observed a swimming pool in the back yard. The pool was not in use by residents or personnel members. However, the pool gate was unlocked. 2. In an interview, E2 acknowledged the pool gate was unlocked and acknowledged the swimming pool was not in use.