Jubilee in the Desert Assisted Living

Based on record review and interview, the manager of an assisted living home failed to maintain a copy of the document provided to the emergency responder (EMS), which included the items listed 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 the resident. Findings include: 1. A review of R1’s medical record revealed a standardized form missing reasons the emergency responder was requested on behalf of the resident; the name, address and telephone number of the resident's current pharmacy; the name and contact information for the resident's primary care physician; the point-of-contact information for the assisted living center or assisted living home; and a copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living home to plan for the resident's discharge. 3. A review of R2’s medical record revealed a standardized form missing reasons the emergency responder was requested on behalf of the resident; the name, address and telephone number of the resident's current pharmacy; the name and contact information for the resident's primary care physician; the point-of-contact information for the assisted living center or assisted living home; and a copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living home to plan for the resident's discharge. 4. A review of R3’s medical record revealed no EMS documentation. 5. A review of R4’s medical record revealed no EMS documentation. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that 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 to the resident. Findings include: 1. A review of the facility’s documentation revealed a document titled “ Report of Unusual Occurrence.” The following was revealed: On November 3, 2025, at 10:00 am, “R2 was sent to the ER per request of R2’s pcp,” and 911 was called. On October 18, 2025, at 12:15 pm, “R2 complained of abdominal pain and wanted to go to the ER,” and 911 was called. On December 1, 2024, at 1:00 pm, “Went in to have R3 sign documents. R3 was unable to use right side of body, had sloped night side of mouth and slurred speech. Call 911 for suspected stroke.” On October 1, 2024, at 9:10 am, “Called 911 to treat infected foot per R3 request and hospice.” 2. A review of R2’s medical record revealed no copy of the document given to Emergency Services (EMS) for the incident on October 18, 2025, at 12:15 pm and November 3, 2025, at 10:00 am. 3. A review of R3’s medical record revealed no copy of the document given to EMS for the incident on October 1, 2024, at 9:10 am, and December 1, 2024, at 1:00 pm. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental tour, the Compliance Officers observed two ambulatory residents. 2. During the environmental tour, the Compliance Officers observed the following poisonous and toxic materials in an unlocked linen closet: - one spray bottle "OdoBan Disinfectant Fabric & Air Freshener Spray" - two spray bottle of "Comet Classic All Purpose Cleaner with Bleach" - one canister of "The Works Classic Clean Toilet Bowl Cleaner" 3. During the environmental tour, the Compliance Officers observed a box of hair color "Clairol Natural Instincts Demi-Permanent Hair Color Creme, 6A Light cool Brown, Hair Dye, 1 Application" in a second unlocked linen closet down the hallway. 4. During the environmental tour, the Compliance Officers observed an unlocked caregiver room/laundry room through the kitchen hallway. The following poisonous and toxic materials were observed: - one spray canister of "WD-40" - one spray bottle of "OdoBan Disinfectant Fabric & Air Freshener Spray" - one spray bottle of "Simple Green\'ae Original - 24 oz Spray Bottle" - one spray bottle of "Windex\'ae Original Blue, Spray Bottle, 23 fl oz" - one spray bottle of "Comet Classic All Purpose Cleaner with Bleach" - one canister of "Rust-Oleum Universal Black Stainless-Steel Metallic Spray Paint 11 oz" - one canister of "Liquid Nails Heavy Duty Construction and Remodeling Adhesive" - one spray bottle of "CLR Outdoor Furniture Cleaner, Cleans and Protects Outdoor Surfaces" - one jug of "1 Gal. Eucalyptus Disinfectant and Odor Eliminator, Fabric Freshener, Mold Control, Multi-Purpose Cleaner Concentrate" 5. A review of facility documentation revealed a policy titled "Environmental and Physical Plant Safety," the policy stated "15. Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dinning areas, and medications and are inaccessible to residents." 6. In an interview, E1 and E2 acknowledged poisonous and toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.

Based on observation, documentation review, and interview, the manager failed to ensure the swimming pool was entirely enclosed by a wall or fence at least five feet in height. The deficient practice posed a health and safety risk. Findings include: 1. During the environmental tour, the Compliance Officers observed two ambulatory residents. 2. During the environmental tour, the Compliance Officers observed a swimming pool in the backyard. The Compliance Officers observed the swimming pool was only partially enclosed by a wall or fence. The placement of the pool fencing allowed direct egress from three windows in the living room/common area into the pool area. 3. A review of Department records revealed the facility was originally licensed July 03, 2019, therefor an exception from the Department before October 1, 2013 would not apply. 4. A review of facility documentation revealed a policy titled "Swimming Pool Safety," the policy stated "2. Swimming pools will be enclosed by a wall or fence, at least 5 feet height (measured on the exterior of the wall or fence) with openings no greater than 4 inches across, has no horizontal openings, and is not a chain-link. ..." 5. In an interview, E1 acknowledged there was no wall or fence entirely enclosing the swimming pool.

Based on documentation review, observation and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area from which a resident may 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 the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the environmental tour, the Compliance Officers observed two ambulatory residents. 3. During the environmental tour, the Compliance Officers observed an open door leading to the back yard. 4. During the environmental tour, the Compliance Officers observed the back yard did not allow residents to be at least 30 feet away from the facility. The Compliance Officer measured the distance from the back of the facility to the wall in the back yard to be approximately 18 feet. The door leading out to the back yard had a chime that was intended to alert employees to the egress of a resident to the outside area. However, the chime did not work. 5. During the environmental tour, the Compliance Officers observed a gate in the back yard leading to the front yard. The gate was locked and did not allow a resident to exit to a location at least 30 feet away from the facility. 6. A review of facility documentation revealed a policy titled "Whereabouts of a Resident." The policy stated "Exit doors and windows to the outside of the facility that a resident might exit through will be alarmed to alert employees in the event that a resident wandering. Facility personnel will check daily to ensure the alarms are functioning correctly." 7. In an interview, E2 reported the door was open for O1 to come in and out of the facility. 8. In an interview, E1 reported the battery of the door chime needed to be replaced. 9. In an interview, E1 acknowledged the facility did not have a means of exiting to an outside area that allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees to the egress of a resident from the facility.