House of Hope Assisted Living LLC

Based on record review, documentation review, and interview, the health care institution failed to ensure a training program for all staff regarding fall prevention and fall recovery, which included initial training and continued competency, was implemented. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E2’s and E3’s personnel record revealed evidence of documentation indicating E2 and E3 had received ongoing training in fall prevention and fall recovery in May 2024. However, evidence of documentation indicating E2 or E3 had received additional training in fall prevention and fall recovery since May 2024 was unavailable for review. 2. A review of facility documentation revealed a fall prevention and fall recovery program compliant with A.R.S. § 36-420.01. The program stated, “All House of Hope employees are required to review fall prevention yearly.” 3. In an interview, E1 acknowledged E2 and E3 had not completed annual fall training as required.

Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities, including annual training and education for employees, related to recognizing the signs and symptoms of TB. Findings include: 1. A review of E2's and E3’s personnel records revealed evidence of documentation of training in recognizing signs and symptoms of TB in 2023. However, evidence of documentation of training after 2023 was unavailable for review. 2. In an interview, E1 admitted they had not received training in recognizing the signs and symptoms of TB annually as required.

Based on document review, observation, record review, 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 and safety of a resident. Findings include: 1. A review of Department documentation revealed the facility was licensed at the directed care level. 2. During a tour of the facility, the Compliance Officer observed R1 to be ambulatory, without assistance. The Compliance Officer observed two separate sets of French doors, each equipped with locking door handles, which required a key to open, and an electronic mechanism designed to alert caregivers of the egress of a resident. Each mechanism was turned off, and the locks were not engaged. When the Compliance Officer opened each set of doors, there was no alert. On separate occasions, the Compliance Officer observed both E1 and E2 redirect R1, who appeared to be wandering. 3. A review of E2’s and E3’s personnel records revealed evidence of documentation of fall prevention and fall recovery training conducted in May 2024. However, evidence of documentation of continued competency training since May 2024 was unavailable for review. 4. A review of facility documentation revealed a fall prevention and recovery program, which indicated facility employees were required to maintain continued competency on an annual basis. 5. A review of facility documentation revealed an incident report, dated July 24, 2025, documenting a fall by R3, in which the resident suffered a bruise to their right ear, bruising to their right side, and a skin tear. A second incident report, dated July 30, 2025, documented R3’s refusal to get out of bed due to “pain,” and being “unable to get up.” The incident report also documented R3’s “left hip swollen and toes bruised.” The report indicated R3 was transported to the hospital. 6. In an interview, E1 acknowledged R3’s injuries documented on July 30, 2025, were dissimilar to those documented on July 24, 4045. E1 advised E1 suspected R3 may have had an undocumented fall during the night of July 29, 2025, because that was the last shift E2 worked. E1 said E2 had been terminated on August 1, 2025, because E2 was “always late or calling off work,” and E2 refused to keep their fingernails short, which E1 felt posed a safety risk to residents.

Based on documentation review, observation, and interview, the manager failed to ensure the location where the most recent Department inspection report and any resulting plan of correction may be viewed. Findings include: 1. A review of facility documentation revealed the most recent on-site compliance inspection at the facility had been conducted on August 26, 2024. Documentation revealed citations were issued, and a corresponding plan of correction had been submitted. 2. During a tour of the facility, the Compliance Officer observed the location where the most recent Department inspection report and corresponding plan of correction could be reviewed was not conspicuously posted. 3. In an interview, E1 acknowledged the location where the most recent Department inspection report and corresponding plan of correction could be reviewed was not conspicuously posted. Technical assistance regarding the requirement in R9-10-803(D)(4) was provided on August 26, 2024.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident’s date of occupancy. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(A)(2)(a)(i-ii) states: “a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, baseline 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 [TB], ii. Determining if the individual has signs or symptoms of [TB].” 2. A review of R1’s and R2’s medical records revealed evidence of documentation of a negative TB skin test. However, evidence of baseline screening for signs, symptoms, and risk of exposure to TB was unavailable for review. 3. In an interview, E1 acknowledged R1 and R2 had not provided evidence of freedom from infectious TB, including baseline screening, as specified in R9-10-113, before or within seven calendar days of their respective dates of occupancy.

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, which monitored 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 the license issued by the Department revealed the facility was authorized to provide directed care services. 2. While at the facility, the Compliance Officer observed R1 to be ambulatory, without assistance. On separate occasions, the Compliance Officer observed both E1 and E2 redirect R1, who appeared to be wandering. 3. During a tour of the facility, the Compliance Officer observed two separate sets of French doors, which led to a secure area behind the facility. Each set of doors was equipped with an electronic door chime, designed to alert caregivers of the egress of a resident. Each mechanism was turned off, and the locks were not engaged. When the Compliance Officer opened each set of doors, there was no alert. Batteries for the electronic door chimes were replaced and made operational while the Compliance Officer was on-site. 4. In an interview, E2 advised there was no monitoring system for the doors, other than the attached electronic chimes. E1 agreed there was a means of exiting the facility, which allowed residents to be at least 30 feet away from the facility, but did not monitor or alert employees of the egress of a resident.

Based on documentation review, observation, record review, and interview, the governing authority failed to designate a manager who had either a temporary or permanent manager's certificate from the Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers, which posed a health and safety risk. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable rules. Findings include: 1. A review of department documentation revealed the following: "09/21/2023, Notification [E1] is no longer the on-site manager effective 09/19/2023. see attached", and " 7/25/2024, online sub of late fees were received 07/02/2024. CO will need to check the manager's expiration at the next inspection". 2. A review of department documentation revealed the following: " September 18, 2023, To: Arizona Department of Health Services, Re: Termination of Management, Manager license number: 008853. This Letter is to inform the department that, as of September 19, 2023, I [E1], located at 1938 W. Riverview, Tucson AZ 85704, License No. AL11914H. For questions regarding this matter. I can be reached via cell 520-743-6548, Attentively [E1]". 3. On August 26, 2024, after entering the facility, the Compliance Officer asked caregiver E2, if the manager was on-site, and who is the manager. E2 stated [E1], however [E1] was not on-site. E2 proceeded to call E1. E2 reported that [E1] is on the way to the facility. During a tour of the facility the Compliance Officer observed E1's manager's license posted on the wall. 4. When E1 arrived at the facility the Compliance Officer asked E1 if E1 was still the manager. E1 reported "yes". The Compliance Officer told E1 that the department received a letter stating E1 was no longer the manager on 09/21/2023, A response was never given to the Compliance Officer. 5. In an online search of the Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers website the Compliance Officer observed the license number assigned to E1 had been Suspended due to disciplinary action. 6. The Compliance Officer asked E1 if E1 knew of the suspension. E1 stated "yes". E1. E1 showed the compliance officer a letter from the Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA). The letter stated the following: "Consent Agreement and Order for Stayed Suspension, Probation and Continuing Education". This document was an agreement between the NCIA board and E1. The document stated "Suspension: Respondent's Certificate Number ALM-009953 is immediately suspended, but the suspension is stayed as long as the terms of the Order are met with Probationary period specified below: Probation. Respondent's Certificate Number ALM-008853 is placed on a term of probation for a period of three (3) months from the effective date of this Order. During the probationary period, Respondent shall complete the following". E

Based on record review, observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. A review of R1's medical record revealed R1 was supervisory level of care and self-administers own medications. 2. A review of R1's medical record revealed R1's doctor signed the following document "Medication Management and Administration". The document stated the following: "A resident who has been certified by their primary physician to be mentally and physically capable of self-administration or managing their own medication and treatments maybe allowed to do so. Manager shall ensure that caregivers will: ... Management 1. All medications must be stored in a locked cabinet. 2. Container or area that is inaccessible to other residents". 3. During the facility tour the Compliance Officer observed when entering R1's room the door was unlocked. In R1's room R1 was storing medication under the bed in an unlocked box. The Compliance Officer asked R1 if the box can be locked R1 stated no. The Compliance Officer observed the box was unable to be locked. The Compliance Officer asked R1 if R1 locks the door when R1 leaves the room. R1 stated no I always leave it unlocked. 4. In an interview, E1 reported being unaware R1's medications were in an unlocked room and a unlocked box under R1's bed.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and were inaccessible to residents. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. During an environmental tour the Compliance Officer observed in an open and unlocked garage the following poisonous or toxic materials: - three (3) 1-gallon containers of "O'Reilly Dex-cool Compatible Antifreeze & Coolant"; - one (1) plastic gallon container with no label, just hand-written "Weed Killer"; and - one (1) green and one (1) pink metal gasoline containers with gas. 2. A review of the facility's policy and procedures revealed "Facility Safety (818-820)". ... "11). Poisonous and toxic chemicals will be kept locked where they're inaccessible to residents and away from food storage, preparation, medications, and dining area. 12). Flammable, combustible, and hazardous material will be stored in their original containers or a safety container in a locked area that is inaccessible to residents". 3. In an interview, E1 and E2 acknowledged poisonous and toxic materials, and flammable, combustible, and hazardous materials stored by the assisted living facility, were not in a locked area and inaccessible to residents.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers, for one of four caregivers sampled, which posed a health and safety risk to the residents if the employee was not trained. Findings include: 1. The Compliance Officer observed E2 opened the door to let the Compliance Officer into the facility. E2 stated, "I need to go toilet a resident". The Compliance Officer observed E2 take R4 to the restroom. 2. A review of department documentation the Compliance Officer observed E2's name on a previous roster with E2 listed as an assistant caregiver. 3. In an interview, E2 acknowledged E2 was an assistant caregiver and not a certified caregiver. E2 reported being the only staff member in the house. E2 acknowledged providing care to residents without the supervision of a caregiver. 4. The Compliance Officer observed the facility had a census of six residents. 5. A review of E2's personnel record revealed a date of hire as an assistant caregiver of July 20, 2021. 6. In an interview with R1, R2, R3, R4, and R5 all reported E2 provides them with assistance in bathing, dressing, and giving them their medications. 7. In an interview, E1 acknowledged E2 was working as an assistant caregiver for the facility and did not have documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers.

Based on documentation review, and interview, the manager failed to ensure before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults for three of four 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 E1's personnel record revealed E1 was the Manager of the facility and a hire date of August 1, 2021. The personnel record revealed a CPR and first aid card from the American Red Cross with an expiration date of July 23, 2023. 2. A review of E2's personnel record revealed E2 worked as an assistant caregiver and had a hire date of July 20, 2021. The personnel record revealed a CPR and first aid card from the American Red Cross with an expiration date of July 23, 2023. 3. A review of E4's personnel record revealed E4 was the owner of the facility and worked as a caregiver. E4's hire date was June 15, 2021. The personnel record revealed a first aid and CPR card from the American Red Cross with an expiration date of July 23, 2023. No other documentation was provided to the Compliance Officer during the on-site inspection. 4. In an interview, E1 acknowledged E1, E2, and E4's CPR and first aid certifications had expired.

Based on record review, observation, and interview, the manager of a facility providing directed care services failed to ensure a means of exiting the facility providing access to an outside area, and alerting 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 the license issued by the Department revealed the facility was licensed to provide directed care. 2. During the environmental inspection the Compliance Officer observed no sound alerted employees of the egress of a resident when exiting the back door which led into the courtyard and garage. The Compliance Officer observed when entering the open garage the garage gate had been left open and unsecured. The Compliance Officer was able to walk out into the street and the surrounding neighborhood. The Compliance Officer walk into the courtyard which was left unsecured due to the garage gate being left open. The Compliance Officer walked around the facility which had a walking area that circled the facility. Two metal security doors had been left unlocked and the Compliance Officer was able to access three residents rooms. The Compliance Officer observed these rooms had french doors which led into the resident's rooms. The Compliance Officer observed when entering each of these rooms the following: room number two's door was unlocked and did not alert an employee of the egress of a resident, room number three's door was unlocked and did not alert an employee of the egress of a resident, and room number four's door was unlocked and did not alert an employee of the egress of a resident. 3. In an interview, E1, acknowledged the garage gate had been left open and the doors did not have any means to alert employees of a resident's egress.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan in the event of an emergency. Findings include: 1. A review of the facility's staffing schedules revealed two shifts: - 7:00 am - 6:00 pm (first shift), and - 6:00 pm - 7:00 am (second shift). 2. A review of documentation titled, "Disaster drill log Q3 months every shift" revealed the following information: - July 6, 2023, (first shift), - July 14, 2023, (first shift), - January 4, 2023, (second shift), - October 15, 2022, (second shift), and - July 17, 2022, (first shift). There was no additional documentation or evidence to indicate a disaster drill was conducted on each shift at least once every three months and documented. 3. In an interview, E1 acknowledged disaster drills for employees were not conducted on each shift at least once every three months and documented. Technical assistance was given on the last compliance survey completed June 20, 2022.