Joy & Care Assisted Living Home

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, R3's, and R4's medical records revealed no documentation of the completed emergency responder patient information documentation required in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1) through (9). 3. In an interview, E1 acknowledged that the information required in A.R.S. § 36-420.04 were not prepared in a standardized emergency responder patient information packet as required. 4. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. Technical assistance was provided on this Rule during the inspection conducted on June 17, 2024.

Based on interview, and record review, the manager failed to ensure that an assisted living home maintained a copy of the document provided to the emergency responders and documentation of the actions required for a period of two years after the date of the emergency. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. In an interview, E1 reported that R1 was sent out to the hospital on September 30, 2025, for vomiting by emergency medical services (EMS). However, a copy of the documentation provided to the emergency responders on September 30, 2025, was not available for review. 2. A review of R1’s medical record revealed no incident reporting was available regarding R1 being transported by EMS on September 30, 2025, at the time of inspection. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. Technical assistance was provided on this Rule during the inspection conducted on June 17, 2024.

Based on documentation review and interview, the health care institution failed to ensure the health care institution documented and implemented tuberculosis (TB) infection control activities required in R9-10-113(A)(2)(d). The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of facility documentation revealed that an annual assessment of the health care institution’s risk of exposure to infectious TB was not available for review. 2. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. Technical assistance was provided on this Rule during the inspection conducted on June 17, 2024.

Based on observation, record review, and interview, for two of two residents sampled, who received opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident's health and safety if the facility did not appropriately assess and monitor opioid administration for a resident. Findings include: 1. During the environmental inspection, R1's medications were observed at the facility, and included "OXYCODONE HCL 5 MG TABLET.” 2. A record review of R1's medical record revealed a service plan for personal care and medication administration services. A review of R1's medication order revealed "OXYCODONE HCL 5 MG TABLET Take 1 tablet by mouth every six hours for pain.” A review of R1's medication administration record (MAR) included documentation that R1 received the OXYCODONE HCL 5 MG medication daily from August 2025 to present. The medical record did not include documentation of an identification of the need for the opioid before the opioid was administered, nor did it include monitoring of the effect of the opioid administered. R1's medical record did not include documentation of an active malignancy or an end-of-life condition. 3. During the environmental inspection, R3's medications were observed at the facility, and included "Tramadol 50 mg 1 PO BID Pain PRN," and "Tramadol 100 mg 1 PO QHS Pain PRN." 4. A record review of R3's medical record revealed a service plan for directed care and medication administration services. A review of R3's medication order revealed "Tramadol 50 mg 1 PO BID Pain PRN," and "Tramadol 100 mg 1 PO QHS Pain PRN." A review of R3's MAR included documentation that R3 received the TRAMADOL HCL 50 medication daily from October 2025 to present. The medical record did not include documentation of an identification of the need for the opioid before the opioid was administered, nor did it include monitoring of the effect of the opioid administered. R3's medical record did not include documentation of an active malignancy or an end-of-life condition. 5. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for two of two employees sampled. The deficient practice posed a safety risk to residents. Findings include: 1. 1. ARS § 36-411(C)(3-4) states: "C. Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to: [...] (3) Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency may not hire the potential employee. (4) On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency shall take action to terminate the employment of that employee." 2. A review of E2's and E3’s personnel records revealed no documentation of good faith efforts to verify that each employee was not on the adult protective services registry pursuant to section 46-459. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program that, at a minimum, included the frequency of submitting a documented report to the governing authority. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management Program Including Incident Reports." This policy stated, "In order to provide quality and safe services to the facility residents, the manager shall ensure that: 1. Facility personnel will document and evaluate incidents at the facility to ensure quality services are provided. 2. A copy of each filled out form regarding the incident, accident, emergency, unusual occurrence, or event that puts the resident in danger, including incidents regarding opioid-related adverse reactions or other negative outcomes a resident experiences, or opioid-related deaths, will be placed in the QOS Folder and the Quality of Service Monthly Recording Form. Information collected is to be used to accurately report and evaluate services provided to residents as per procedure below. 3. Facility may use a survey tool (Quality of Service Monthly Recording Form) to help in identifying and collecting information. Data and reports collected are used to identify a concern..." 2. A review of the facility’s documents revealed that no documentation of any quality management program was available for review. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on documentation review, interview, and record review, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was incomplete documentation identifying the staff present each day to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a series of work schedules dated between August, September, and October 2025. However, most of the required work schedules, which were to be maintained for at least 12 months after the last date on the documentation and were to include the caregivers and assistant caregivers working each day along with their hours, were not available for review, and the schedules that were available did not include all hours worked by each caregiver or assistant caregiver. 2. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. This is a repeat citation from an inspection conducted on June 16, 2024.

Based on record review and interview, the manager failed to ensure that a complete personnel record was available for two of four personnel sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. A review of the Department's documentation revealed that E1 was the facility's assisted living manager and held an active assisted living manager license. 2. The Compliance Officers requested E1’s, E2’s, E3’s, and E4’s personnel records; however, they revealed that there were no personnel records for E1 or E4. 3. A review of the facility’s work schedule documentation from August 2025 to October 2025 revealed that E4 worked as a caregiver and appeared on the schedule on August 1, 8, and 31, 2025; September 7, 14, 21, and 28, 2025; and October 5, 2025, from 7 a.m. to 7 p.m. However, no personnel record was available for E4. A review of the website https://azcg.tmutest.com/ revealed that E4 had completed a caregiver training program. 4. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. This is a repeat citation from an inspection conducted on June 16, 2024.

Based on record review and interview, the manager failed to ensure a service plan included a summary of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for two of four residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. A review of the R1's medical records revealed discharge documentation from another healthcare institution, the document stated R1's diagnosis “CHARCOTS JOINT, LEFT ANKLE AND FOOT(M14.672), OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC)(G47.33), HYPOTHYROIDISM, UNSPECIFIED(E03.9), DEPRESSION, UNSPECIFIED(F32.A), CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE(I50.30), UNSPECIFIED GLAUCOMA(H40.9), HYPERLIPIDEMIA, UNSPECIFIED(E78.5), UNSPECIFIED MYELOPATHY(G95.9), PRESSURE ULCER OF BACK, UNSPECIFIED, UNSPECIFIED(LEA36D), I50, PRESSURE ULCER OF RIGHT BUTTOCK, UNSTAGEABLE(L89.403), PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE(L89.150), UNSPECIFIED OPEN WOUNDS OF LEFT UPPER ARM, SUBSEQUENT ENCOUNTER(S41.102D), PRESSURE-INDUCED DEEP TISSUE DAMAGE OF LEFT BUTTOCK(L89.326), DEPENDENCE ON RENAL DIALYSIS(Z99.2), LYMPHEDEMA, NOT ELSEWHERE CLASSIFIED(189.0), ILEOSTOMY STATUS(723.2), ATTENTION TO ILEOSTOMY(Z43.2), NON-PRESSURE CHRONIC ULCER OF OTHER PART OF LEFT FOOT WITH BONE INVOLVEMENT WITHOUT EVIDENCE OF NECROSIS(L97.525), UNSPECIFIED OPEN WOUND, LEFT LOWER LEG, SUBSEQUENT ENCOUNTER(S81.802D), UNSPECIFIED OPEN WOUND, RIGHT LOWER LEG, SUBSEQUENT ENCOUNTER(S81.801D), PRESSURE ULCER OF SACRAL REGION, STAGE 2(L89.32), CHRONIC PAIN(R52), ACQUIRED ABSENCE OF RIGHT LEG BELOW KNEE(Z89.511), CELLULITIS OF LEFT UPPER LIMB(L03.114), HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE(131.2), GENERALIZED ANXIETY DISORDER(F41.1), CHRONIC PAIN SYNDROME(G89.4), PAROXYSMAL ATRIAL FIBRILLATION(I48.0), PRESSURE ULCER OF LOWER BACK, STAGE 2(L89.320), OTHER CLOSED FRACTURE OF LOWER END OF LEFT ULNA, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING(S52.502D), DISPLACED MALLEOLAR FRACTURE OF LEFT LOWER LEG, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING(S82.402D), FRACTURE OF UNSPECIFIED PART OF SCAPULA, LEFT SHOULDER, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING(S42.102D), CHRONIC PULMONARY EMBOLISM(I27.82), MEDICALLY NONCOMPLIANT(Z91.19), CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED(J44.9), INFECTION AND INFLAMMATORY REACTION DUE TO OTHER CARDIAC AND VASCULAR DEVICES, IMPLANTS, AND GRAFTS, INITIAL ENCOUNTER(T82.7XXA), CANDIDAL SEPSIS(B37.7), UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION(E43), UNSPECIFIED BACTERIAL PNEUMONIA, UNSPECIFIED LUNG(186.9), BACTEREMIA(R78.81), OTHER SPECIFIED COMPLICATION OF VASCULAR PROSTHETIC DEVICES, IMPLANTS AND GRAFTS, SUBSEQUENT ENCOUNTER(T82.858D), TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE(E11.22), TYPE 2 DI

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident, for one of three residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include: 1. In an interview, E1 reported that the staff repositioned R1 every two to three hours and PRN. 2. A review of R1's medical record revealed a current service plan for personal care services dated August 13, 2025. The service plan stated: "R1 was admitted to redness to bilateral buttocks and right front, healing wound to coccyx. R1 is at high risk for skin breakdown d/t impaired mobility, urinary incontinence and medical comorbidities. R1 is A/O x3. Positioned to obtain a discomfort when R1 is repositioned on R1 left or right side. Has been re-educated on the importance of relieving weight to R1 buttocks. R1 prefers to sit upright in R1 bed despite teaching. R1 controls bed positions independently and often reverts bed to upright sitting position. Preventative measures are in place." The service plan also included R1 needs full assistance Uses Assistive devices: Hoyer, W/C (high back reclining) and other – Specify: Half side rails in bed to aid in bed mobility. However, there was no documentation of the need for repositioning. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's service plan included the psychosocial interactions or behaviors for which the resident required assistance; the psychotropic medications ordered for the resident; the planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and the goals for changes in the resident's psychosocial interactions or behaviors, for one of one resident reviewed who required behavioral care. The deficient practice posed a risk as a service plan directs the services to be provided to a resident. Findings include: 1. R9-10-101(29) defines "Behavioral care" a. means 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; and b. Does not include court-ordered behavioral health services. 2. A review of R4's medical record revealed a service plan for personal care dated July 07, 2025. A review of R4's medical record revealed documentation of a diagnosis of "Bipolar disorder, Depression, Anxiety, Insomnia". In addition, the medical record revealed R4 received administration of psychotropic medications, including Lamotrigine, Duloxetine, Donepezil, Melatonin, and Amitriptyline. However, R4's written service plan did not include the following required components: -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. 3. In an interview, E1 acknowledged that R4 received behavioral care, and the service plan did not include the required components. 4. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan for one resident sampled, who required behavioral care, was reviewed by a medical practitioner or behavioral health professional. The deficient practice posed a health and safety risk if the facility was unable to meet the needs of the resident. Findings include: 1. A review of R4's medical record revealed a service plan for personal care dated July 07, 2025. A review of R4's medical record revealed documentation of a diagnosis of "Bipolar disorder, Depression, Anxiety, Insomnia". In addition, the medical record revealed R4 received administration of psychotropic medications, including Lamotrigine, Duloxetine, Donepezil, Melatonin, and Amitriptyline. 2. A review of R4's medical record revealed a service plan for personal care dated July 07, 2025. This service plan was not signed to indicate that it was reviewed by a medical practitioner or behavioral health professional. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record for five of six residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2’s, R3’s, R4’s, R5’s, and R6's medical records revealed activities of daily living (ADL) sheets for August, September, and October 2025. The ADL sheets documented that services were provided according to the residents’ service plans; however, the Compliance Officer was unable to verify whether a caregiver or assistant caregiver provided the services, as the ADL sheets used only a tick mark indication rather than staff initials. Although each ADL sheet included a key with staff names and initials, the staff did not use the initials to indicate who provided the services during those months. 2. In an interview, E2 acknowledged that the services documented on the ADL sheets for R2, R3, R4, R5, and R6's could not be verified as to whether a caregiver or assistant caregiver provided them. The ADL sheets used only a tick mark indication rather than staff initials, and staff did not use the key with staff names and initials to indicate who provided the services during those months, as provided in the ADL sheet. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. Technical assistance was provided on this Rule during the inspection conducted on June 17, 2024.

Based on record review and interview, for one of one resident receiving transportation, the manager failed to ensure an evaluation of the resident was conducted before and after the transport, information from the resident's medical record was provided to a receiving health care institution, the date and time of the transport. The deficient practice posed a health and safety risk to a resident if an evaluation of the resident was not initiated, and the required documentation was not in the resident's record and available for review. Findings include: 1. During an interview, E1 reported R1 was transported to a Dialysis clinic three times a week: Tuesday, Thursday, and Saturday, and the transportation was coordinated by E1 or the facility. 2. A review of R1’s medical record did not include the required documentation for transport to the dialysis clinic, including an evaluation of the resident before and after the transport and any communication with an individual at the receiving health care institution. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on observation, interview, and record review, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk, as it violated a resident's rights. Findings include: 1. Upon arriving at the facility, the Compliance Officers observed several residents sitting at the breakfast table. Multiple residents reported that E2 would not give them any sugar for their cereal. When E2 was asked whether there was a reason the residents could not have sugar, E2 reported that they had never asked for it. However, when the residents then asked E2 for sugar, E2 still did not provide any sugar. 2. During the environmental inspection of the facility, the Compliance Officers observed R2 attempting to enter R2’s bedroom, but the door was blocked, and R2 was unable to open it. The door had been blocked by another resident’s bed, which had rolled in front of it. The Compliance Officers asked E2 for assistance in helping R2, and E2 opened the door. E2 then told R2 that they could not close the door to the room. R2 became upset and told E2 that they were going to close the door. R2 reported that E2 had pushed the bed in front of the door so R2 could not enter the room. R2 also reported that E2 had made R2 walk to the living room to receive medication because E2 would not bring the medication to R2’s bedroom. R2 further reported that E2 had ignored residents when they asked questions and had slammed items on the table. R2 reported that the bedsheet on their bed frequently fell off, and E2 did not replace it. R2 also reported that E2 had been rough when transferring R3 to their wheelchair. 3. In an interview, R5 reported that they had been waiting for E2 to come and change their brief and get them showered and dressed for the day; however, R5 reported that they had been waiting a long time. E2 then entered R5’s bedroom and stated, “Get up, you need to get up and get changed,” in an aggressive voice. E2 then brought R5 out of the room while R5 was only wearing a top and briefs, and left R5 in the wheelchair in the common hallway while E2 went to assist another resident who was in the bathroom at the time. The Compliance Officers requested E2 to put a towel over R5's lap so R5 would not be exposed in front of residents and visitors. 4. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on record review and interview, for five of six residents sampled, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident. The deficient practice posed a risk if services provided to a resident could not be verified. Findings include: 1. A review of R2's medical record included a service plan for personal care services and showed that R2 received assisted living services from the facility, documented in an ADL chart dated October 2025, including but not limited to the following: “Fluid Intake – Yes Bathing – 2x wk Dressing – Yes Make-up / Hair Care – Shampoo 1x/wk Nail Care – PRN Bowel Movement – S-M-L Condition Check – Skin Night Assurance” However, documentation was not available to show these services were provided from October 15th to the present, and Night Assurance was not documented from October 1 to the present. 2. A review of R3's medical record included a service plan for personal care services and showed that R3 received assisted living services from the facility, documented in an ADL chart dated October 2025, including but not limited to the following: “Fluid Intake – Yes Dressing – Yes Make-up / Hair Care – + Shampoo 1x/wk Oral Care – Yes Nail Care – PRN Toileting – Yes Continence Care – Yes Bowel Movement – S-L-M Condition Check – Yes (Skin) Recreation / Activities Night Assurance Linen Change – 1x/wk” However, documentation was not available to show these services were provided from October 17th to the present, and Night Assurance was not documented from October 1 to the present. 3. A review of R4's medical record included a service plan for personal care services and showed that R4 received assisted living services from the facility, documented in an ADL chart dated October 2025, including but not limited to the following: “Fluid Intake – Yes Bathing – 2x/wk Make-up / Hair Care – + Shampoo 1x/wk Nail Care – PRN Continence Care – Yes Bowel Movement – S-L-M Condition Check – Skin Recreation / Activities Night Assurance" However, documentation was not available to show these services were provided from October 15th to the present, and Night Assurance was not documented from October 1 to the present. 4. A review of R5's medical record included a service plan for personal care services and showed that R5 received assisted living services from the facility, documented in an ADL chart dated October 2025, including but not limited to the following: “Fluid Intake – Yes Bathing – 2x/wk Make-up / Hair Care – + Shampoo 1x/wk Nail Care – PRN Continence Care – Yes Bowel Movement – S-L-M Condition Check – Skin Recreation / Activities Night Assurance” However, documentation was not available to show these services were provided from October 15th to the present, and Night Assurance was not documented from October 1 to the present. 5. A review of R6's medical record included a service plan for personal care services and showed that R6 received assisted living servi

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for two of two residents sampled who required vaccination for influenza (flu) and pneumonia. 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 licensee 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 R3’s medical record revealed no documentation that R3 was offered the flu and pneumonia vaccines in 2024, and this documentation was required based on R3’s acceptance date. 3. A review of R4’s medical record revealed no documentation that R4 was offered the flu and pneumonia vaccines in 2024, and this documentation was required based on R4’s acceptance date. 4. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on documentation review, record review and interview, the manager failed to ensure that a behavioral health professional or medical practitioner completed and signed a written determination, 30 days prior to acceptance or before the resident begins receiving behavioral care and at least once every six months thereafter, stating that the resident’s behavioral health needs could be met by the facility and were within the facility’s scope of services, for one of one residents sampled who were receiving behavioral care. The deficient practice posed a health and safety risk by potentially retaining a resident whose needs were not properly assessed or supported by the facility. Findings include: 1. R9-10-101(29) defines "Behavioral care" a. means 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; and b. Does not include court-ordered behavioral health services. 2. A review of R4's medical record revealed a service plan for personal care dated July 07, 2025. A review of R4's medical record revealed documentation of a diagnosis of "Bipolar disorder, Depression, Anxiety, Insomnia". In addition, the medical record revealed R4 received administration of psychotropic medications, including Lamotrigine, Duloxetine, Donepezil, Melatonin, and Amitriptyline. However, no documentation indicating that R4's behavioral health professional or medical practitioner examined R4 30 days prior to acceptance or before R4 began receiving behavioral care, signed and dated a determination stating R4's needs were being met by the facility, and reviewed that the facility's scope of services was available. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections for one of three sampled residents who received personal care services. The deficient practice posed a health risk to the resident if skin maintenance was not provided to ensure the health and safety of R1. Findings include: 1. A review of R1's medical record revealed a current service plan for personal care services dated August 13, 2025. The service plan stated: "R1 was admitted to redness to bilateral buttocks and right front, healing wound to coccyx. R1 is at high risk for skin breakdown d/t impaired mobility, urinary incontinence and medical comorbidities. R1 is A/O x3. Positioned to obtain a discomfort when R1 is repositioned on R1 left or right side. Has been re-educated on the importance of relieving weight to R1 buttocks. R1 prefers to sit upright in R1 bed despite teaching. R1 controls bed positions independently and often reverts bed to upright sitting position. Preventative measures are in place." However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. In an interview, E1 reported that the service plan was missing a page about the resident's skin maintenance portion and acknowledged that R1's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on documentation review, observation, and interviews, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, which provided access to a secured outside area that monitored or alerted employees of the resident’s egress from the facility. This 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 Officers observed multiple ambulatory residents. 3. During the environmental inspection, the Compliance Officers observed a door in the kitchen that led to the backyard. The outside area allowed residents to be at least 30 feet away from the facility. However, the door was not monitored and did not have a mechanism to alert employees to the egress of a resident to the outside area. 4. A review of facility documentation revealed a policy titled "Environmental and Physical Safety," the policy stated "5. Exit doors and windows to the outside that a wandering resident may exit through will be alarmed to alert employees in the event of a resident is wandering." 5. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. This is a repeat deficiency from the inspections conducted on June 17, 2024, and September 26, 2024.

Based on record review, documentation review, and interview, the manager failed to ensure a medication was administered in compliance with the medication order for one of four residents whose medications were reviewed. This deficient practice posed a risk if the resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R2's medical record revealed a current service plan that included personal care services and medication administration. 2. A review of R2’s medical record revealed a written medication order dated October 7, 2025, for “Amitriptyline 20 mg 1 PO QHS.” A review of the Medication Administration Record (MAR) for October 2025 revealed the order for "Amitriptyline 20 mg 1 PO QHS" started on October 15, 2025, but was not documented as administered. However, a review of the physical medication bottle revealed "AMITRIPTYLINE HCL 25 MG TAKE 1 TABLET BY MOUTH AT BEDTIME." 3. In an interview, E3 reported that the medication was provided; however, E2 did not sign off on the MAR, and E3 acknowledged that the milligrams on the signed medication order did not match the milligrams on the physical medication bottle. 4. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record for five of six residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R2's medical record revealed a signed medication list, which included the following medications: -Pantoprazole 40 mg 1 PO Q12 7a–7p -Sodium Chloride 1 GM (2) Tab PO 8am -Gabapentin100 mg PO BID 8a–8p -Venlafaxine 75 mg 1 PO QD AM -Melatonin 3mg 1 PO QHS -Duloxetine 20 mg (2) Cap PO QD Time Advice -Amitriptyline 20 mg 1 PO QHS However, a review of R2's medication administration record (MAR) for October 2025 did not include documentation of all aforementioned medications administered to R2 from October 14, 2025 night to the present. 2. A review of R3's medical record revealed a signed medication list, which included the following medications: -Loratadine 10 mg 1 Tab P.O Q.D -Lidocaine Patch 4% on 12 Hrs. Apply Top -Tramadol 50 mg 1 P.O BID PRN Pain -Tramadol 100 mg 1 P.O Q.H.S PRN Pain -Miralax Powder 17 m Capful in 8 oz Liq Drink PRN Constipation -Trazadone 100 mg 1 P.O Q.H.S -Sertraline 25 mg 1 P.O Q.H.S (Nightly) -Melatonin 10 mg 1 P.O Q.H.S -Quetiapine (Seroquel) 25 mg 1 P.O Q.H.S -Trazadone (HCL) 100 mg 1 P.O Q.H.S However, a review of R3's medication administration record (MAR) for October 2025 did not include documentation of all aforementioned medications administered to R3 from October 16, 2025, to the present. 3. A review of R4's medical record revealed a signed medication list, which included the following medications: -Omeprazole 40 mg 1 Cap PO QD -Lamotrigine 150 mg 1 PO QD -Duloxetine 60 mg 1 Cap PO QD -Aspirin 81 mg 1 PO QD -Lactulose On Dose 10 mg/15 mL 60 mL PO Q8 hr TID -Prevent UTI Leuocarnitine 330 mg 1 PO BID -Sodium Chloride 1 GM 1 PO BID -Claritin 10 mg 1 PO QD -Propranolol 10 mg 1 PO QD Hold if Pulse < 60 BP Before Given/hold -Lisinopril 5 mg 1 PO QHS Hold if BP below BP Before Med -Memantine 5 mg 1 PO QHS -Donepezil 5 mg 1 PO QHS -Melatonin 3 mg 1 Tab SL QHS -Atorvastatin 10 mg 1 PO QHS -Tylenol 500 mg 1 PO Q8h -Pain Headache PRN Amitriptyline 25 mg 1 PO QHS -Xifaxan 550 mg 1 PO BID However, a review of R4's medication administration record (MAR) for October 2025 did not include documentation of all aforementioned medications administered to R4 from October 17, 2025, to the present. 4. A review of R5's medical record revealed a signed medication list, which included the following medications: -Lisinopril 40 mg 1 PO QD — Hold if SBP < 80 or Pulse < 50 -Meclizine 12.5 mg 1 PO QD AM -Simvastatin 10 mg 1 PO QHS -Buspirone HCL 5 mg 1 PO BID 9A–9P Anxiety -Pantoprazole Sod 40 mg 1 PO QD 1 hr before eats 7 AM -Sertraline HCL 150 mg 1 PO QHS -Nifedipine ER 10 mg 1 PO QD — Hold if SBP < 80 or Pulse < 50 -Dulcolax 10 mg Softgel 1 PO QD PM — Hold if loose stool However, a review of R5's m

Based on documentation review, observation, and interview, the manager failed to ensure medication stored by an assisted living facility 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 medication. Findings include: 1. A review of Department documentation revealed the facility is licensed for directed care service. 2. The Compliance Officers observed ambulatory residents at the facility. 3. During the environmental inspection of the facility, the Compliance Officers observed two medication cups for two residents on the counter in the kitchen area, which was accessible to residents at the facility. 4. During the environmental inspection of the facility, the Compliance Officers also observed a medication cabinet in the kitchen area, and next to the medication cabinet was the key to open the medication cabinet, which was accessible to residents at the facility. The medication cabinet contained medication for the five residents at the facility. 5. During the environmental inspection of the facility, the Compliance Officers observed unlocked medication in the kitchen refrigerator. The medication in the kitchen refrigerator contained the following medications, which were accessible to residents at the facility; -"LATANOPROST 0.005% EYE DROPS" -"TIMOLOL MALEATE 0.5% EYE DROPS" -2 boxes of "insulin glargine-yfgn100 units/mL (U-100)" 6. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers did not observe a current food menu posting. The food menu posted was from the prior month of September 2025. 2. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. This is a repeat deficiency from an inspection conducted on June 17, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure food was stored free from spoilage, filth, or other contamination and was safe for human consumption. Findings include: 1. A review of Department documentation revealed the facility was licensed for directed care services. 2. The Compliance Officers observed ambulatory residents at the facility. 3. During the environmental inspection of the facility, the Compliance Officers observed five old, blackened bananas on the kitchen counter that were spoiled and not safe for human consumption. 4. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. The deficient practice posed a risk for potential foodborne illnesses. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a refrigerator in the kitchen area. The refrigerator had a broken oven thermometer on the door of the refrigerator. 2. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. Technical assistance was provided on this rule during the inspection on June 17, 2024.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future, for one of one residents sampled who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. In an interview, E1 reported that R1 was sent out to the hospital on October 01, 2025, for vomiting by emergency medical services (EMS). 2. A review of R1's medical record revealed no incident reporting about R1 being transported out by EMS on October 01, 2025. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a potential illness risk to residents. Findings Include: 1. During the environmental inspection of the facility, the Compliance Officers observed a used adult brief soaked with urine on the floor in R5’s bedroom next to the bed. 2. In an interview, E2 was asked if that was a used adult brief on the floor. E2 did not answer the question and continued working. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk. Findings include: 1. During the facility inspection, the Compliance Officers observed R5 lying in bed. One side of the bed had a half bedrail in the upright position, and the other side was pushed against the wall. A wheelchair was placed on the open side of the bed, blocking access and preventing R5 from safely getting off the bed. 2. During the facility inspection, the Compliance Officers observed a sheet of fiberglass insulation in the closet of R5’s bedroom. E1 reported that the maintenance worker had made repairs to the home and had left the fiberglass insulation in R5’s closet. 3. In an interview, the Compliance officer questioned R5 about the bedrails, and R5 reported that R5 could not move the rails up or down, and could not move around them. 4. A review of the facility documentation revealed an evacuation path posted, and in that plan, one of the designated emergency exits was a double door leading to the backyard. However, this door was blocked with five recliner chairs, making the exit inaccessible during an emergency. Technical assistance on this issue was previously provided during an inspection on June 17, 2024. 5. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a pest control program compliant with Arizona Administrative Code (A.A.C.) R3-8-201(C)(4) was implemented and documented. Findings include: 1. A.A.C. R3-8-201(C)(4) states: "4. An individual may not provide pest management services at a...health care institution...unless the individual is a certified applicator in the certification category for which services are being provided." 2. The Compliance Officers requested documentation of a pest control program; however, no documentation was available for review to demonstrate a pest control program compliant with A.A.C. R3-8-201(C)(4) was available at the time of the inspection. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the facility 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. A review of department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officers observed multiple ambulatory residents. 3. During the environmental inspection of the facility, the Compliance Officers observed two bottles of "Pinalen" and two gallon bottles of “Awesome Bleach” in an unlocked cabinet under the kitchen sink. The cabinet did have a locking device; however, it was not working at the time, and the toxic materials were accessible to residents at the facility. 4. During the environmental inspection of the facility, the Compliance Officers observed a bottle on the kitchen cabinet of “Great Value All-purpose Cleaner with Bleach”. The toxic materials were accessible to residents at the facility. 5. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. Technical assistance was provided on this rule during the inspection on June 17, 2024.

Based on observation and interview, the manager failed to ensure the bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed there were no paper towels in a dispenser or a mechanical air hand dryer available for one of the bathrooms in a common area used by residents, personnel and visitors. 2. In an interview, E1 acknowledged the bathroom accessible from the common area did not contained paper towels in a dispenser or a mechanical air hand dryer. 3. In an exit interview, the findings were reviewed with E1, E3, and E5, and no additional information was provided. Technical assistance was provided on this rule during the inspection on June 17, 2024, and this is a repeat citation from the inspection completed on September 26, 2024.

Based on observation and interview, the manager failed to ensure the bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control. Findings include: 1. During the environmental tour, the Compliance Officer observed there were no paper towels in a dispenser or a mechanical air hand dryer available for one of the bathrooms in a common area used by residents, personnel and visitors. 2. In an interview, E1 and E2 acknowledged the bathroom accessible from the common area did not contained paper towels in a dispenser or a mechanical air hand dryer. Technical assistance was provided on this Rule during the compliance inspection conducted on June 17, 2024.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location 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 facility staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed the door leading out to the backyard from bedroom 3. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door was not equipped with a device that alerted caregivers of the egress of a resident. 3. During the environmental tour, the Compliance Officer observed a door located in the kitchen leading to the back yard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 4. A review of facility documentation revealed a policy titled "Environmental and Physical Safety," the policy stated "5. Exit doors and windows to the outside that a wandering resident may exit through, will be alarmed to alert employees in the event of a resident is wandering." 5. In an interview, E1 reported that the devices were installed after the compliance inspection conducted on June 17, 2024, and was unaware when the devices fell. E1 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility. This is an uncorrected deficiency form the compliance inspection conducted on June 17, 2024.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for six of eight residents sampled. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. A review of R1's medical record revealed written service plans for directed care services dated June 10, 2024 and September 04, 2024. However, these service plans did not include a signature and date from the resident or representative. 2. A review of R2's medical record revealed written service plans for directed care services dated April 01, 2024 and July 01, 2024. However, these service plans did not include a signature and date from the resident or representative. 3. A review of R3's medical record revealed a current written service plan for personal care services dated July 01, 2024. However, this service plan did not include a signature and date from the resident or representative. 4. A review of R4's medical record revealed written service plans for directed care services dated June 27, 2024 and August 26, 2024. However, these service plans did not include a signature and date from the resident or representative. 5. A review of R5's medical record revealed a current written service plan for directed care services dated July 01, 2024. However, this service plan did not include a signature and date from the resident or representative. 6. A review of R6's medical record revealed a current written service plan for personal care services dated July 10, 2024. However, this service plan did not include a signature and date from the resident or representative. 7. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, R5's and R6's service plans did not include a signature and date from the resident or representative. Technical assistance was provided on this Rule during the compliance inspection conducted on June 17, 2024.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the manager, for five of eight 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 a written service plan for directed care services dated for June 10, 2024. However, this service plan did not include a signature and date from the manager. 2. A review of R2's medical record revealed a current written service plan for directed care services dated for July 01, 2024. However, this service plan did not include a signature and date from the manager. 3. A review of R3's medical record revealed a current written service plan for personal care services dated for July 01, 2024. However, this service plan did not include a signature and date from the manager. 4. A review of R4's medical record revealed a current written service plan for directed care services dated for August 26, 2024. However, this service plan did not include a signature and date from the manager. 5. A review of R6's medical record revealed a current written service plan for personal care services dated for July 10, 2024. However, this service plan did not include a signature and date from the manager. 6. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, and R6's service plans did not include a signature and date from the manager.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of eight residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a current written service plan, which indicated R1 received medication administration. 2. A review of R1's medical record revealed signed medication orders dated September 24, 2024 for the following medications; - Levothyroxine 75mg (1) PO QD AM - Protonix 40mg (1) PO QD AM - Gabapentin 100mg (2)Tabs PO QHS - Mirtazapine 15mg (1) PO QHS - Donepezil 10mg (1) PO QHS 3. A review of R1's medical record revealed a September 2024 medication administration record (MAR). This MAR did not include documentation that the aforementioned medications were provided on September 25, 2024. 4. In an interview, E1 and E2 reported the medications were administered per the medication orders and acknowledged R1's MAR did not include documentation the medications were administered.

Based on observation, documentation review and interview, the manager failed to ensure policies and procedures were implemented for discarding medication. The deficient practice posed a risk as the standards expected of employees were not followed. Findings include: 1. During the environment tour, the Compliance Officer observed the following medication belonging to R7 (Discharged Date: 2021); - "NYSTATIN 1000000U/GM Cream" - "SERTRALINE HCL 50 MG" - "ACITRETIN 10 MG CAP" - "Mirtazapine 15 mg TAB" 2. A review of facility documentation revealed a policy titled "Part IV - Disposal (discarding) of Medication including Opioids and Narcotics, medication recall." The policy stated "1. On a monthly basis the facility manager or manager designee will check all medication in the facility to identify and locate any discontinued medication, expired medication, including medication of deceased residents. 2. Such medication will be disposed of by facility manager ... c. Disposed of by mixing the pills with hot water and cooking flour, closing the container's lid on securely, and shaking. Then scrape the label off of the container and toss in trash." 3. In an interview, E1 acknowledged the medications were not discarded per the policies and procedures.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training for two of two sampled personnel. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention," the policy stated, "All employees upon hire will take part in an in-service training program regarding Fall Prevention and Fall Recovery, which will include initial training and continued competency training at least every 12 months." However, the policy and procedure did not include documentation of fall recovery. 2. A review of E2's (hired 2024) personnel record revealed initial training in fall recovery was not available for review. 3. A review of E3's (hired 2024) personnel record revealed initial training in fall recovery was not available for review. 4. In an interview, E1 acknowledged E2's and E3's personnel records were not in compliance with A.R.S. \'a7 36-420.01. 5. Technical assistance was provided on this Rule during the compliance inspection conducted January 9, 2023.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for two of four sampled caregivers. The deficient practice posed a risk if the employees were not qualified to provide the required services and the Department was provided false or misleading information. Findings include: 1. When the Compliance Officer arrived, E2 and E3 were observed working at the facility as caregivers. E1 arrived to the facility at 11:00 AM. 2. A review of E2's personnel record revealed E2 was hired as a caregiver on March 5, 2024. The personnel record contained a caregiver training certificate from the Foundation for Senior Living Assisted Living Training Course (the ALTP # was not legible) dated January 15, 2024. However, this training program was only in operation December 16, 1998 - August 2, 2013 per NCIA Board records. No other documentation of completing a caregiver training program approved by the Department or the NCIA Board was available. Therefore, E2 was not qualified to be left alone with the residents based on the lack of caregiver training. 3. A review of the NCIA verification of caregiver training portal (https://azcg.tmutest.com) revealed E2 had not completed a caregiver training program after August 3, 2013. 4. In an interview, E1 reported E1 never verified E2's caregiver certificate. 5. A review of E3's personnel record revealed E3 was hired as a caregiver on May 6, 2024. The personnel record contained a caregiver training certificate from Arizona Desert Rose Caregiver & Manager Training (ALTP # 0058) dated November 30, 2023. However, this training program was only in operation October 28, 2002 - June 12, 2006 per NCIA Board records. No other documentation of completing a caregiver training program approved by the Department or the NCIA Board was available. Therefore, E3 was not qualified to be left alone with the residents based on the lack of caregiver training. 6. A review of the NCIA verification of caregiver training portal (https://azcg.tmutest.com) revealed E3 had not completed a caregiver training program after August 3, 2013. 7. In an interview, E1 reported E1 never verified E3's caregiver certificate. 8. A review of the facility policies and procedures revealed a policy titled "Employees and Volunteer Qualifications," the policy stated "2. A caregiver: b. Provides documentation of Completion of a caregiver training program approved by the Department or by the NCIA Board." 9. In an interview, E1 reported E2 and E3 were working at the facility as caregivers and acknowledged documentation was not available that showed documentation of completing a caregiver training program approved by the Department or the NCIA Board.

Based on observation and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. When the Compliance Officer arrived, E2 and E3 were the only personnel members working at the facility. 2. During the environmental tour, the Compliance Officer observed there was no personnel schedule posted for the month of June. The Compliance Officer requested to see the personnel schedule for the month of June, however, E2 and E3 were not able to provide the documentation. 3. In the exit interview, E1 acknowledged documentation was not maintained of the caregivers working each day, including the hours worked for the month of June.

Based on observation, record review, documentation review, and interview, the manager failed to ensure at least the manager or caregiver was present at the assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet resident needs. Findings include: 1. The Compliance Officer arrived at 10:00 AM, and E2 and E3 were observed working at the facility as caregivers. E1 arrived to the facility at around 11:00 AM. 2. A review of E2's personnel record revealed E2 was hired as a caregiver on March 5, 2024. The personnel record contained a caregiver training certificate from the Foundation for Senior Living Assisted Living Training Course (the ALTP # was not legible) dated January 15, 2024. However, this training program was only in operation December 16, 1998 - August 2, 2013 per NCIA Board records. No other documentation of completing a caregiver training program approved by the Department or the NCIA Board was available. Therefore, E2 was not qualified to be left alone with the residents based on the lack of caregiver training. 3. A review of the NCIA verification of caregiver training portal (https://azcg.tmutest.com) revealed E2 had not completed a caregiver training program after August 3, 2013. 4. A review of E3's personnel record revealed E3 was hired as a caregiver on May 6, 2024. The personnel record contained a caregiver training certificate from Arizona Desert Rose Caregiver & Manager Training (ALTP # 0058) dated November 30, 2023. However, this training program was only in operation October 28, 2002 - June 12, 2006 per NCIA Board records. No other documentation of completing a caregiver training program approved by the Department or the NCIA Board was available. Therefore, E3 was not qualified to be left alone with the residents based on the lack of caregiver training. 5. A review of the NCIA verification of caregiver training portal (https://azcg.tmutest.com) revealed E3 had not completed a caregiver training program after August 3, 2013. 6. In an interview, E1 reported E2 and E3 were working at the facility as caregivers and acknowledged documentation was not available that showed documentation of completing a caregiver training program approved by the Department or the NCIA Board. In addition, E1 acknowledged E2 and E3 were at the facility with six residents at the time of the inspection with no other staff present. E1 acknowledged neither a manager or caregiver was present at the facility when the Compliance Officer arrived.

Based on observation, record review and interview, the manager failed to ensure a personnel record for each employee included documentation of all requirements in R9-10-806(C)(1), for two of four personnel sampled. The deficient practice posed a risk as the required information could not be verified for E1 and E4. Findings include: 1. A review of departments documentation revealed E1 was the Assisted Living Manager. 2. During a review of personal records, the Compliance Officer requested to review E1's personnel record, however, no personnel record for E1 was available for review at the time of the inspection. 3. In an interview, E1 reported E1's personnel record was not available at the facility to review. 4. In an interview, E1 reported E4 was the back-up caregiver. 5. During a review of personal records, the Compliance Officer requested to review E4's personnel record, however, no personnel record for E4 was available for review at the time of the inspection. 6. In an interview, E1 reported E4's personnel record was not available at the facility to review. 7. In an exit interview, E1 acknowledged a personnel record was not maintained for E1 and E4.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility, for six of six sampled residents. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1, R2, R3 an R5's medical records revealed no documentation of residency agreements were available for review at the time of inspection. 2. In an interview, E1 reported the residency agreements were available, however, E1 was not able to locate the documentation at the time of inspection. 3. A review of R4's medical records revealed a residency agreement. However, the agreement stated it was between R4 and a different assisted living facility, not "AL12059_JOY & CARE ASSISTED LIVING HOME." 4. A review of R6's medical records revealed a residency agreement. However, the agreement stated it was between R6 and a different assisted living facility, not "AL12059_JOY & CARE ASSISTED LIVING HOME." 5. In an interview, E1 reported R4's and R6's residency agreements were from the previous owner and E1 failed to make new residency agreements after the change of ownership. 6. In an interview, E1 acknowledged documentation of R1, R2, R3 an R5's residency agreements were not available for review. In addition, E1 acknowledged R4's and R6's did not have a residency agreement with this facility.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. \'a7 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. During the environmental tour, the Compliance Officer observed medical records for all residents were stored on a counter top in the kitchen. 3. During the inspection, E1 arrived at the facility carrying a tote bag containing resident and personnel records. E1 stated that all documentation required for the inspection was in the bag and that E1 personally maintains these records. However, when asked to produce the requested documents, E1 was unable to do so. 4. In an interview, E1 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location 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 facility staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed three ambulatory residents. 3. During the environmental tour, the Compliance Officer observed the front door leading to the street from the facility. However, the door was not secured and the door chime was not functioning. 4. During the environmental tour, the Compliance Officer observed the door leading out to the backyard from bedroom 3. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door was not equipped with a device that alerted caregivers of the egress of a resident. 5. During the environmental tour, the Compliance Officer observed a door located in the kitchen leading to the back yard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 6. A review of facility documentation revealed a policy titled "Environmental and Physical Safety," the policy stated "5. Exit doors and windows to the outside that a wandering resident may exit through, will be alarmed to alert employees in the event of a resident is wandering." 7. In an interview, E1 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. During the environmental tour, the Compliance Officer observed a food menu dated May 05, 2024 - May 11, 2024. 2. In an interview, E2 and E3 were unaware of a new menu. 3. In the exit interview, E1 acknowledged the food menu was not conspicuously posted at least one calendar day before the first meal on the food menu was served.

Based on documentation review and interview, the manager failed to ensure the disaster plan required was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed evidence of a disaster plan. However, evidence of documentation of an annual disaster plan review was unavailable for review. 2. A review of facility policies and procedures (reviewed February 14, 2022) revealed a policy "Disaster plan, Relocation, Records, Medication, Food and Water," the policy stated "8. The disaster plan is reviewed and the review is documentation at least once every 12 months ..." 3. In an interview, E1 acknowledged there was no documentation available for review at the time of the inspection to indicate the disaster plan was reviewed at least once every 12 months. 4. Technical assistance was provided on this Rule during the compliance inspection conducted January 9, 2023.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a health and safety risk to residents and employees, if the employees were unable to implement the evacuation plan. Findings include: 1. A review of Department documentation revealed AL12059 was licensed in January 2022. 2. A review of facility documentation revealed a form titled "Evacuation Drill." The form reported "An evacuation drill for employees and residents is conducted at least once every six months and includes all individuals on the premises ..." Evacuation drills for employees and residents were conducted on the following dates: - November 14, 2022 - May 02, 2023 - November 01, 2023 Additionally, the form did not indicate which employees participated in the evacuation drill. 3. In an interview, E1 reported to being unaware that employees were required to participate in evacuation drills. E1 acknowledged that evacuation drills for both employees and residents were not conducted at least once every six months.

Based on observation, documentation review, and interview, the manager failed to ensure a cat was vaccinated against rabies. The deficient practice posed a health and safety risk to residents, if an animal was not vaccinated against rabies. Findings include: 1. During the environmental tour, the Compliance Officer observed O1 in a shared bedroom, bedroom two. 2. A review of facility documentation revealed a pet record for O1 containing a rabies vaccination record from Humane Society of Central Arizona dated "Status Date: September 15, 2020 - Expiry Date: February 16, 2021." However, no documentation was available to show that O1's rabies vaccination was up to date. 3. A review of the facility's policies and procedures revealed a policy titled, "Control and Sanitation of Pets." Under the title "Procedure" the policy stated, "Cats: 1. Must maintain current vaccination against rabies." 4. In an interview, E1 acknowledged the facility did not have updated documentation the O1 was vaccinated against rabies.