Grace & Mercy Assisted Living

Based on record review and interview, the manager failed to ensure that a written service plan was established, documented, and implemented for a resident receiving behavioral care, including review by a medical practitioner or behavioral health practitioner, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated December 1, 2025, and indicated R2 required behavioral care. However, the service plan did not include review by a medical practitioner or behavioral health practitioner. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 3. Technical Assistance was provided on this rule during the compliance inspection on December 16, 2025.

Based on observation, record review, documentation, and interview, the manager failed to ensure that, before providing assisted living services to a resident, a caregiver provided current documentation of first-aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of two personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Upon arrival at the facility, the Compliance Officers were greeted by E2. E2 was alone with four residents. 2. During the inspection, the Compliance Officers observed E2 providing services to R1. 3. A review of E2's personnel record revealed E2 was hired as a caregiver on October 11, 2021. Further review revealed an expired CPR and First Aid card with an expiration date of September 2025. However, there was no documentation of a current CPR and First Aid Card. 4. A review of the facility’s February 2026 personnel schedule revealed E2 worked alone from February 1, 2026, to February 5, 2026; February 8, 2026, to 2026; February 17, 2026, to February 19, 2026; and February 23, 2026, to February 24, 2026. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan included documentation of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of the three residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. During an environmental inspection, the Compliance Officers observed R1 with a catheter. 2. A review of R1’s medical record revealed a service plan dated December 16, 2025. The service plan indicated R1 received personal care services. The service plan did not indicate that R1 had a catheter and needed assistance emptying the catheter. 3. In an interview, E1 reported that R1 moved in with the catheter. The catheter was just recently changed on February 23, 2026. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. This is an uncorrected deficiency from the compliance inspection on December 16, 2025.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that included for a resident who required behavioral care: the psychosocial interactions or behaviors for which the resident required assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors, for one of two residents sampled. Findings include: 1. A review of R2’s medical record revealed a service plan, dated December 1, 2025, that indicated R2 required behavioral care. However, the service plan did not include the psychosocial interactions or behaviors for which the resident required assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. 2. In an interview, E1 reported that R2 requires behavioral care. E1 also reported that the service plan did not have the required requirements for residents receiving behavioral care. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. Technical Assistance was provided on this rule during the compliance inspection on December 16, 2025.

Based on observation, record review, and interview the manager failed to ensure that a caregiver or assistant caregiver provided a resident with the assisted living services in the resident’s service plan; was only assigned to provide the assisted living services the caregiver or assistant caregiver had the documented skills and knowledge to perform; provided assistance with activities of daily living (ADL's) according to the resident’s service plan; encouraged a resident to participate in activities planned according to subsection (E); and documented the services provided in the resident’s medical record, for three of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. During the environmental inspection, the Compliance Officers observed that E2 was providing R1 with a bed bath. Also, R1 had a catheter. 2. A review of R1’s medical records revealed the following: A current service plan dated December 16, 2025, which indicated R1 receives showers but not bed baths, and did not indicate that R1 had a catheter. A document titled “Activities of Daily Living,” which indicated the catheter is being emptied every two hours, and R1 receives partial baths. 3. In the interview, R1 reported that R1 receives bed baths and the care staff empties R1’s catheter. 4. In an interview, E1 reported that the care staff assisted R1 with emptying the catheter and provided bed baths. 5. During the inspection, the Compliance Officers observed that R2 dressed R2’s self. In addition, R2 changed R2’s brief R2’s self, then handed the plastic grocery bag with the solid brief to the care staff to throw away. 6. A review of R2’s medical records revealed the following: A current service plan dated December 1, 2025, which indicated that R2 needed max assistance with dressing and toileting. The service plan indicated incontinence care changes every two hours and as needed. A document titled “Activities of Daily Living,” which indicated “self” for “assist with clothing,” and that the care staff is helping with incontinence care. 7. In an interview, R2 reported that R2 gets dress R2’s self and takes care of R2’s briefs. 8. In an interview, E1 reported that R2 is independent, including with dressing and brief changes. 9. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of two residents sampled. The deficient practice posed a risk as the medication administered could not be verified against a medication order. Findings Include: 1. A review of R1’s medication administration record (MAR) revealed the following: “Hydrochlorothiazide 25 mg - take 1 tablet by mouth once daily in the morning.” “Lisinopril 5 mg - take 1 tablet by mouth once daily for hypertension.” “Pantoprazole SOD DR 40 mg - take one tablet by mouth at bedtime.” “Senna 8.6 mg Tablet - take 2 tablets by mouth twice a day.” 2. A review of R1’s medical record revealed no signed order for “Hydrochlorothiazide 25 mg,” “Lisinopril 5 mg,” “Pantoprazole SOD DR 40 mg,” and “Senna 8.6 mg Tablet.” 3. In an interview, E1 acknowledged that the medication was administered without a signed medication order. 4. A review of R2's medical record revealed the following: A current written service plan dated December 1, 2025. This service plan indicated R2 received medication administration. A medication list dated February 24, 2026. However, the medication list was not signed by a medical practitioner. Medication Administration Record (MAR) for February 2025, signed that medications were administered. 5. In an interview, E1 reported that medications were administered to R2 and that the medication lists were not signed by a medical practitioner. 6. In an exit interview, the findings were reviewed 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 a medication administered to a resident that included the strength, for one of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A review of R2's medical record revealed a current written service plan dated December 1, 2025. This service plan indicated R2 received medication administration. 2. A review of R2's medical record revealed the following: A medication order signed and dated by a medical practitioner on May 29, 2025, for “Benztropine mesylate 0.5 mg.” A medication order signed and dated by a medical practitioner on December 11, 2025, for “Dextromethorphan HBR/bupropion 45 mg -105 mg” and “Docusate sodium 100 mg.” 3. A review of R2’s February 2026 medication administration record (MAR) revealed no strength documented for the following medications: “Benztropine mesylate 0.5 mg.” “Dextromethorphan HBR/bupropion 45 mg -105 mg.” “Docusate sodium 100 mg.” 4. The Compliance Officers observed the following medication bottles: “Benztropine mesylate 0.5 mg.” “Dextromethorphan HBR/bupropion 45 mg -105 mg.” “Docusate sodium 100 mg.” 5. In an interview, E1 acknowledged that the MAR did not have the strength documented for “Benztropine mesylate 0.5 mg,” “Dextromethorphan HBR/bupropion 45 mg -105 mg,” and “Docusate sodium 100 mg.” 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 7. This is an uncorrected deficiency from the compliance inspection on December 16, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure the facility obtained a written determination from a behavioral health professional or medical practitioner, at least once every six months, stating the resident's needs were met by the facility and the resident's needs were within the facility's scope of services, for one of three residents reviewed who received behavioral care. The deficient practice posed a health and safety risk to the resident if the facility retained a resident who received behavioral care and the resident's needs were not met. Findings include: 1. R9-10-101(22) defines "Behavioral care" as limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate, including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services are provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors. 2. A review of R2's medical record revealed a service plan for personal care dated December 1, 2025. This service plan revealed R2 had a diagnosis of Schizophrenia and indicated R2 received behavioral care services. 3. A review of R2's medical record revealed no written determination from R2's medical practitioner stating R2's needs were met by the facility, and R2's needs were within the facility's scope of services. 4. During an interview, E1 reported that R2 had a psychiatrist, had psychosocial behaviors requiring assistance, and received administration of psychotropic medications. 5. During an interview, E1 acknowledged that R2's behavioral health professional or medical practitioner did not provide a written determination every six months. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 7. This is a repeat deficiency from the compliance inspection on February 24, 2023, and uncorrected from the compliance inspection on December 16, 2025.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R1’s medical record revealed a signed medication list, dated September 11, 2025, which included “Nifedipine ER 30 mg tablet - take one tab PO twice a day.” 2. A review of R1’s medication administration record (MAR) for February 2026 revealed that R1 was administered one tablet of “Nifedipine ER 30 mg tablet” once a day. However, the medication order indicated that R1 was to receive “Nifedipine ER 30 mg tablet” twice a day. 3. In an interview, E1 acknowledged that R1 was only getting one “Nifedipine ER 30 mg tablet” daily. 4. A review of R2’s medical record revealed the following: A medication order signed and dated by a medical practitioner on May 29, 2025, for “Benztropine mesylate 0.5 mg - take 1 tablet by oral route 2 times every day.” A medication order signed and dated by a medical practitioner on December 11, 2025, for “Pravastatin sodium 80 mg - take 1 tablet by oral route every day” and “Famotidine 40 mg - take 1 tablet by oral route every day at bedtime.” 5. A review of R2’s medication administration record (MAR) for February 2026 revealed the following: “Benztropine mesylate - take 1 tab PO 1x QD.” “Pravastatin sodium 10 mg Tab Take 1 tab PO QD.” “Famotidine 20 mg Tab Take 1 tab PO 2xQD.” 6. In an interview, E1 reported that the MAR is the most accurate. E1 reported that all medication is administered based on the MAR, and E1 does not use medication organizers. 7. In an interview, E1 acknowledged that “Benztropine mesylate” is only given once a day. E1 acknowledged that R2 is only getting 10 mg of “Pravastatin sodium.” E1 acknowledged that “Famotidine 20 mg” is given twice a day instead of 40 mg at bedtime per the order. 8. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 9. This is a repeat deficiency from the compliance inspection on February 24, 2023, and uncorrected from the compliance inspection on December 16, 2025.

Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was accurately documented in the resident's medical record for two of two residents reviewed. The deficient practice posed a health and safety risk to the resident if a caregiver did not know whether a medication was administered. Findings include: 1. A review of R1's medical record revealed the following: A current written service plan dated December 16, 2025. This service plan indicated R1 received medication administration. No medication order for “Senna 8.6 mg.” 2. A review of R1’s medication administration record (MAR) for February 2026 revealed that “Senna 8.6 mg” had been administered twice a day from February 1, 2026, to February 23, 2026. 3. In an interview, E1 reported that “Senna 8.6 mg” was being signed off for February even though it was not being administered. 4. A review of R2's medical record revealed the following: A current written service plan dated December 1, 2025. This service plan indicated R2 received medication administration. A medication order signed and dated December 11, 2025. 5. A review of R2’s medication administration record (MAR) for February 2026 revealed that there were two sections for “Clozapine 100mg.” Both sections of “Clozapine 100mg” had been administered twice a day from February 1, 2026, to February 23, 2026. 6. In an interview, E1 reported that there should only be one section of “Clozapine 100mg.” The second section was an error. E1 reported that “Clozapine 100mg” was given per the mediation order. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 8. This is a repeat deficiency from the compliance inspection conducted on February 24, 2023.

Based on observation and interview, the manager failed to ensure that medications stored by the facility were stored in a locked area. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. Upon arrival at the facility, the Compliance Officers were greeted by E2. E2 left to find E2’s phone and was never near the kitchen table. 2. During the inspection, the Compliance Officers observed two peach medication capsules with "0.4mg" written on them and one khaki green medication capsule left on the kitchen table. In addition, the Compliance Officers observed ambulatory residents. 3. In an interview, E1 reported that the medication capsules are R3’s medication. E1 and E2 open the capsules up and sprinkle R3’s medication on the food. E1 acknowledged that the capsules were left on the table. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. This is a repeat deficiency from the compliance inspection on February 24, 2023, the complaint inspection on February 3, 2025, and an uncorrected deficiency from the compliance inspection on December 16, 2025.

Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were free from conditions or situations that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to a resident. Findings include: 1. During an environmental inspection, the Compliance Officers observed the following: Boxes of wood flooring were leaning against the wall in the dining room and hallway. A box of tile against the wall next to the residents' bathroom. A fan cord lying across the floor in front of R1’s room. A pile of cut wood flooring near the entrance of a resident's room. A piece of cut wood flooring that was not glued down in front of the residents' bathroom door. 2. The Compliance Officers observed several ambulatory residents. 3. In an interview, E1 reported that E1 is having the flooring redone. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. This is a repeat deficiency from the compliance on July 9, 2024, and uncorrected from the compliance inspection on December 16, 2025.

Based on documentation review, record review, and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A.R.S. § 36-420.04.A.1-9 states, “Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: (...).” 2. A review of R1’s, R2’s, and R3’s medical records revealed no standardized form to provide to emergency responders. 3. In an interview, E1 acknowledged that a standardized form for emergency responders for R1, R2, and R3 was not completed. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment. 2. In an interview, E1 acknowledged that the annual assessment of the facility's TB risk assessment was not completed. 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 a caregiver or an assistant caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of two employees sampled. The deficient practice posed a risk if the employees were unable to meet residents' needs. Findings include: 1. A review of E2's personnel record revealed E2’s hire date of June 11, 2021. However, the record revealed no documentation showing E2 had received orientation specific to the duties to be performed. 2. A review of the facility’s policies and procedures revealed a policy titled "Employee Annual Evaluation.” The policy and procedure stated, "New employee orientation is required to be completed by all new employees and volunteers before starting to provide assisted living services to the residents." 3. 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 that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one of three residents sampled. The deficient practice posed a TB exposure risk to residents.  Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R3's medical record revealed no evidence of freedom from TB. Based on R3's admission date, this documentation was required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. Technical Assistance was given on this rule on February 24, 2023.

Based on observation, record review, and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of three residents reviewed. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed. Findings include: 1. Upon arrival to the facility, the Compliance Officers observed R2 sitting in the living room. R2 asked E1 about breakfast. E1 informed R2 that E1 had to puree R2’s food. 2. During the environmental inspection, the Compliance Officers observed E1 feeding R2. 3. A review of R2's medical record revealed a service plan dated December 16, 2025. The service plan indicated R2 received personal care services, and R2 was on a regular diet. 4. In an interview, E1 reported that R2’s diet had changed. E1 acknowledged that the service plan was not updated with the change. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that, when initially developed, was signed and dated by the resident or the resident's representative, and the manager, for two of three residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1’s medical record revealed the following: A current written service plan dated December 10, 2025. The service plan indicated that R1 received medication administration. The current service plan was not signed by the resident's representative. 2. A review of R2’s medical record revealed the following: A current written service plan dated December 16, 2019. The service plan indicated that R4 received medication administration. The current service plan was not signed by the manager, the nurse or medical practitioner, or the resident, or the resident's representative. 3. In an interview, E1 acknowledged that the service plans for R1 and R2 needed to be signed by the resident representative and the nurse or medical practitioner. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of a medication administered to a resident that included the date and time of administration; the name, strength, dosage, and route of administration; the name and signature of the individual administering the medication; and an unexpected reaction a resident had to the medication, for one of three residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A review of R2's medical record revealed a current written service plan dated December 16, 2025. This service plan indicated R2 received medication administration. 2. A review of R2's medical record revealed medication orders signed and dated by a medical practitioner on December 31, 2024, for the following: “Mirtazapine 30 mg Tab: Take one tablet by mouth at bedtime for mood and for sleep.” “Quetiapine Fumarate 25 mg Tab: Take one tablet by mouth at bedtime.” 3. A review of R2’s December 2025 medication administration records (MARs) revealed the following: “Mirtazapine 15 mg Tab take 1 tab PO QHS” listed the wrong strength. Quetiapine Fumarate 25 mg Tab: Take half a tablet by mouth at bedtime,” listed the wrong dosage. 4. The Compliance Officers observed the following medication bottles: “Mirtazapine 30 mg Tab.” “Quetiapine Fumarate 25 mg tab.” 5. In an interview, E1 acknowledged that the MAR had the wrong strength for “Mirtazapine 30 mg Tab” and the wrong dosage for “Quetiapine Fumarate 25 mg tab.” 6. 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 that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for one of three residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record did not include documentation of R1's notification of the availability of vaccinations for flu and pneumonia. Based on R1's date of admission, this documentation was required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is a repeat deficiency from the compliance inspection on February 24, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure the facility obtained a written determination from a behavioral health professional or medical practitioner, at least once every six months, stating the resident's needs were met by the facility and the resident's needs were within the facility's scope of services, for one of three residents reviewed who received behavioral care. The deficient practice posed a health and safety risk to the resident if the facility retained a resident who received behavioral care and the resident's needs were not met. Findings include: 1. R9-10-101(22) defines "Behavioral care" as limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors. 2. A review of R2's record revealed a service plan for personal care dated December 16, 2025. This service plan revealed R2 had a diagnosis of Schizophrenia and indicated R2 received behavioral care services. 3. A review of R2's medical record revealed a written determination from R2's medical practitioner, signed and dated September 30, 2019. However, the medical practitioner did not indicate that R2 required behavioral care services. No further documentation was available stating R2's needs were met by the facility, and R2's needs were within the facility's scope of services, at least once every six months. 4. During an interview, E1 reported that R2 had a psychiatrist, had psychosocial behaviors requiring assistance, and received administration of psychotropic medications. 5. During an interview, E1 acknowledged that R2's behavioral health professional or medical practitioner did not provide a written determination every six months. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 7. This is a repeat deficiency from the compliance inspection on February 24, 2023.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for two of three residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a signed medication list, dated September 11, 2025, which included “Nifedipine ER 30 mg tablet - take one tab PO twice a day.” 2. A review of R1’s medication administration record (MAR) for December 2025 revealed that R1 was administered one tablet of “Nifedipine ER 30 mg tablet” once a day. However, the medication order indicated that R1 was to receive “Nifedipine ER 30 mg tablet” twice a day. 3. In an interview, E1 acknowledged that R1 was only getting one “Nifedipine ER 30 mg tablet” daily. 4. A review of R2’s medical record revealed a signed medication list, dated December 5, 2025, which included “Senna Plus 8.6-50 mg tablet - twice a day - 2 tabs.” 5. A review of R2’s MAR for December 2025 revealed that “Senna Plus 8.6-50 mg” was not listed on the MAR. 6. A review of R2’s medication organizer revealed that “Senna Plus 8.6-50 mg” was in the morning slot. 7. In an interview, E1 acknowledged that “Senna Plus 8.6-50 mg” was not listed on the MAR and was only being administered in the morning. 8. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 9. This is a repeat deficiency from the compliance inspection on February 24, 2023.

Based on observation and interview, the manager failed to ensure that medications stored by the facility were stored in a locked area. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During the environmental inspection, the Compliance Officers observed the following: In the kitchen, one cabinet with a hole where the locking mechanism used to be. The cabinet contained R2’s “Albuterol Aulfate HFA 90 mcg per actuation” and “Nystatin Topical Powder.” In a resident's room, a bottle of “Nyamyc Topical Powder.” 2. The Compliance Officers observed several ambulatory residents. One resident walked into the kitchen. 3. During an interview, E1 acknowledged that medications were stored unlocked. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. This is a repeat deficiency from the compliance inspection on February 24, 2023, and the complaint inspection on February 3, 2025.

Based on record review and interview, the manager failed to ensure that a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility, for one of three residents sampled. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1's medical record revealed no documentation of orientation to the exits of the facility. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 3. This is a repeat deficiency from the compliance inspection on July 9, 2024.

Based on record review and interview, the manager failed to ensure that when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider for one of three residents sampled. The deficient practice posed a health and safety risk. Findings include: 1. While reviewing resident medical records, E1 reported that R2 had an incident approximately one month ago where R2 had difficulty breathing. E1 called 911, and R2 was hospitalized. 2. A review of R2’s medical record revealed discharge paperwork from the hospital dated December 5, 2025. 3. In an interview, E1 reported that E1 did not contact R2's primary care provider regarding R2's hospitalization. E1 reported that E1 still needed to contact R2's primary care provider to review R2's medication changes made upon discharge.. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of three residents. The deficient practice posed a health and safety risk. Findings include: 1. A review of R2’s medical record revealed discharge paperwork dated December 5, 2025. 2. In an interview, E1 reported that R2 was having a medical emergency and E1 called 911. R2 was transported to the hospital. 3. In an interview, E1 acknowledged that there was no documentation of the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were cleaned and disinfected according to policies and procedures to prevent, minimize, and control illness or infection. The deficient practice posed a risk as the facility had not implemented its established policy and procedure to reinforce and clarify standards expected of employees. Findings Include: 1. During an environmental inspection of the facility, the Compliance Officers observed the following: A chunk of fecal matter on the windowsill of R3’s room. The door frame in the bathroom connected to R3’s room had dry waste stains and fingerprints going up and down the door frame. The button for flushing the toilet had dry waste and other stains on it. 2. A review of the facility's policies and procedures, reviewed and signed by E1, titled “Emergency, Safety and Environmental Standards.” The policy stated, “The facility shall be cleaned and disinfected daily to prevent, minimize, and control illness or infection. The manager will develop a regular housekeeping schedule for the facility that shall be followed by the caregiver(s) on duty.” 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were free from conditions or situations that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed O1 working outside on the side gate. The Compliance Officers observed O1 plugging in a table saw in the outlet by the backdoor. The Compliance Officers observed the table saw on the ramp with the cord stretched from the outlet, with O1 not in sight. 2. The Compliance Officers observed several ambulatory residents. One resident went outside to smoke. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is a repeat deficiency from the compliance on June 9, 2024.

Based on observation and interview, the manager failed to ensure that toxic materials were stored 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. During an environmental inspection of the facility, the Compliance Officers observed the following: In the residents' bathroom cabinet that had a lock that was disengaged, a can of “Natural Breeze Air Freshener” and a bottle of “Kroger Isopropyl Alcohol.” In the residents’ bathroom, a can of “Wizard Double Action Air Freshener.” 2. In an interview, E1 acknowledged that cleaning supplies were not locked up. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is a repeat deficiency from the compliance inspection on July 9, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure there was a 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, that allowed the resident to be at least 30 feet away from the facility, and controlled or alerted 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. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed four residents moving freely around the house. Two residents were sitting in the common area, and two residents were outside. 3. The Compliance Officer observed a common area with a glass patio door leading to the backyard patio that did not control or alert employees of the egress of a resident. The door was open with residents outside. The residents opened and shut the door multiple times, the back-door alert was not functioning and was attached to the door frame with clear tape. 4 . In an interview, E1 reported that the air conditioning maintenance company was out to the house the day before and attached a portable unit to the back door. E1 acknowledged that the alert on the back door of the facility was not able to alert an employee of egress from the facility.

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 ivestigation 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 documentation revealed no incident report for R2. 2. In an interview, R2 reported E2 was helping R2 back to R2's room and E2 had pinched R2's back due to E2 being frustrated with R2 needing to much redirection. 3. In an interview, E1 acknowledged R2 reported E2 had pinched the back of R2 and E1 acknowledged the incident had not been reported by the facility in compliance with A.R.S. \'a7 46-454.

Based on documentation 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 and assistant caregivers. 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 schedules for January 2025 revealed E2 worked at the facility Monday- Friday 24 hours a day. 2. A review of E2's (hired as a caregiver) personnel records revealed no documented verification of E2's skills and knowledge. 3. A review of facility personnel record revealed no personnel record and no documented verification of skills and knowledge for E2. 4. In an interview, E1 acknowledged E2's personnel records did not contain documented verification of skills and knowledge.

Based on documentation review, record review, and interview, the manager failed to maintain a personnel record for each employee which included the items required by this rule, for one of one employees sampled. The deficient practice posed a risk as required information could not be verified for an employee. Finding include: 1. During the environmental inspection of the facility, the Compliance Officer observed E2 at the facility. 2. A review of facility documentation revealed staffing schedules for the month of January 2025, Monday through Friday 24 hours day. 3. A review of E2 personnel record revealed no orientation was documented or provide by the end of the inspection. 4. In an interview, E1 acknowledged E2 personnel record did not contain orientation documentation.

Based on interview, observation the manager failed to ensure a resident was treated with dignity, respect, and consideration. Findings include: 1. In an interview, R2 reported E2 would yell and get frustrated with R2 when providing services to R2. R2 reported E2 tells R2 that they are annoying. The Compliance Officer noticed when R2 was talking about E2 they were shaking R2's voice was cracking and R2 was whispering so that one could hear what R2 was saying to not get in trouble with E1 or E2. 2. During the environmental inspection of the facility, the Compliance Officer asked E2 when the light bulb in R2 room had gone out, E2 responded by saying "Yesterday", the Compliance Officer then responded by saying "Well the resident had said it has been a while since the light bulb was out". E2 then turned towards the resident and made an "uh" sound towards the resident to say, "Why are you saying that "Then E2 proceeded to take E2's left hand and slap it into E2 right hand very aggressively while facing R2. 3. In an interview, E1 and E2 reported R2 was one of the residents who needed more attention than the other residents and maybe they need to hire more caregivers so they can give E2 a break from work.

Based on observation, record review, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for three of three sampled residents who received medication administration. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R1, and R2 at the facility during the time of inspection. 2. A review of R1's and R2's medical records revealed R1 and R2 were receiving directed care services and medication adminsitration services. 3. A review of R1's medical record revealed a medication administration record (MAR). The MAR revealed the MAR had not been filled out for Febraury 2025. 4. A review of R2's medical record revealed a medication administration record (MAR). The MAR revealed the MAR had not been filled out for Febraury 2025. 5 In an interview, E1 and E2 acknowledge the MAR had not been filled out for Febraury 2025 for R1 and R2.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the unsecured medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed 2 boxes of "Lantus (Insulin Glargine)100 Units Milliliters" in the kitchen refrigerator. The refrigerated medications were stored in a self-contained unit used only for medication storage. However, the unit had the key in the keyhole and was not locked at the time of the observation. 2. In an interview, E1 acknowledged the aforementioned medications were stored in a unit used only for medication storage, but the unit was not locked at the time of the observation.

Based on record review and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E1's personnel record revealed no documentation indicating E1 completed fall prevention and fall recovery training. 2. Review of E2's personnel record revealed no documentation indicating E2 completed fall prevention and fall recovery training. 3. During an interview, E1 acknowledged documentation was not available showing E1 and E2 completed a training in fall prevention and fall recovery. This is a repeat deficiency from the compliance inspection conducted February 24, 2023.

Based on a documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility's policy and procedure manual revealed no documentation indicating the policies and procedures were reviewed at least once every three years. 2. During an interview, E1 acknowledged documentation was not available showing the policies and procedures were reviewed at least once every three years an updated as needed.

Based on a 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 required in R9-10-818(B) for one of two residents sampled. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency. Findings include: 1. A review on R1's medical record revealed no documentation of R1's orientation to exits from the facility. 2. In an interview, E1 reported they forgot to document R1's orientation to exits from the facility. E1 acknowledged R1's orientation was not available during the inspection.

Based on observation and interview, the manager failed to ensure that 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 pathway in the backyard that led to the side gate that exited to the front yard. The pathway was blocked with a long blue mattress and three wheelchairs. 2. In an interview, E1 acknowledged the pathway was blocked and the facility was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility 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. During an environmental inspection of the facility, the Compliance Officers observed in a common bathroom, a bottle of Lysol Toilet Bowl cleaner unlocked under the bathroom sink. 2. In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area and inaccessible to residents.