La Paz Assisted Living III

Based on record review and interview, the assisted living home failed to ensure a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed documentation of a standardized emergency responder patient information form completed as required by Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9). However, the following were not included in the documentation: - A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. - A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. - Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 2. In an interview, E1 acknowledged the information required in A.R.S. § 36-420.04 was not prepared in a standardized emergency responder patient information form as required.

Based on observation and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. The deficient practice posed a risk if no individual on-site was designated to act on behalf of the governing authority in the management of the assisted living facility. Findings include: 1. During a facility tour, the Compliance Officer observed a posting in the dining room which stated, "Designation of Manager by the Governing Authority." The designation listed four employees, however E5 was not listed. 2. A review of the facility's personnel schedule for June 2025 revealed E5 had not been documented to have worked at the facility at any time. However, the work schedule revealed a single caregiver was present at the facility on each shift. 3. A review of R2's medical record revealed a medical administration record (MAR) dated June 2025. The MAR indicated E5 had administered medications to R2 on June 1, 2025, June 8, 2025, June 15, 2025, June 22, 2025 and June 29, 2025. 4. In an interview, E1 acknowledged the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. E1 reported E5 was an "as needed" worker who had been covering some shifts during the previous month. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on May 23, 2023 and the on-site compliance inspection conducted on June 11, 2024.

Based on observation, document review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services or behavioral health services for one of three personnel members sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: A review of E5's personnel record revealed documentation of verification of E5's skills and knowledge was not available for review. In an interview, E1 reported E1 did not have E5's personnel record on site, but had scanned and printed E5's personnel file for the Compliance Officers to review. E1 acknowledged documentation of verification of E5's skills and knowledge had not been provided for review.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked 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. A review of R2's medical record revealed a medical administration record (MAR) dated June 2025. The MAR indicated E5 had administered medications to R2 on June 1, 2025, June 8, 2025, June 15, 2025, June 22, 2025 and June 29, 2025. 2. A review of the facility's personnel schedule for June 2025 revealed E5 had not been documented to have worked at the facility at any time. 3. In an interview, E1 acknowledged the facility failed to maintain documentation of the caregivers and assistant caregivers working each day, including the hours worked by each.

Based on record review and interview, the manager failed to ensure a caregiver received orientation before providing assisted living services to a resident. Findings include: A review of E5's personnel record revealed documentation of orientation was not available for review. In an interview, E1 acknowledged documentation of E5's orientation had not been provided for review.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy, for one of two sampled residents. A review of R2's medical record revealed, based on R2's date of occupancy, completed TB documentation was required. A review of R2's medical record revealed documentation of a single Mantoux skin test (TST). However, the TST induration had been read 26 hours after the injection of the tuberculin serum. Online research at cdc.gov revealed the time frame for reading a TST result is between 48 to 72 hours after injection of the serum. In an interview, E1 acknowledged R2's documentation of freedom from infectious TB included a TST with an invalid read date.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f) at least once every 6 months for a resident receiving personal care services and at least once every three months for a resident receiving directed care services, for two of two residents reviewed. The deficient practice posed a risk if there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a current service plan for directed care services, updated on June 21, 2025, more than three months after the previous service plan dated March 15, 2025. 2. A review of R2's medical record revealed a current service plan for personal care services, updated on May 3, 2025, more than six months after the previous service plan dated September 23, 2024. 3. In an interview, E1 acknowledged the service plans for R1 and R2 had not been updated within the required timeframe. 3. A review of R2's only service plan revealed it had been completed on June 15, 2023, and that R2 was receiving supervisory care services. On the first page of the service plan at the top in the center, it stated, "Next due Date: 6/15/2024." However, the only service plan on record was from June 15, 2023. 4. There were no service plans on record for R3. E1 and E2 stated R3 received personal care services, which would mean that R3 should have had at least four service plans on record based on R3's admission date. 5. In an interview, E1 acknowledged the service plans for R1 and R2 were past due and that there should have been service plans on record for R3.

Based on record review and interview, the manager failed to ensure a service plan, for one of one sampled resident receiving directed care services, included the requirements in R9-10-814(F)(1) or documentation of the resident's weight. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 21, 2025, for directed care services. However, the service plan did not include documentation of skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, and did not include documentation of R1's current weight at the time the service plan had been updated. The service plan form included both sections, however, they had been left blank. 2. In an interview, E1 acknowledged R1's service plan did not include all required components.

Based on 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. During an environmental tour of the facility, the Compliance Officers observed a refrigerator, located in the kitchen, was accessible to residents. Inside the refrigerator, the Compliance Officers observed a metal box with a combination lock, labeled, "narc's." However, the box had been left open and unlocked at the time of the inspection. Inside the box, the Compliance Officers observed containers of Morphine, Lorazepam, and Aplisol. 2. In an interview, E1 acknowledged medications stored by the facility had not been stored in a locked area.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a cabinet below the sink in a common bathroom accessible to all residents. The cabinet had a magnetic lock, however, the lock appeared to be stuck open. Inside the cabinet, the Compliance Officer observed containers of, "All purpose Cleaner with Bleach.” 2. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on May 24, 2022, the on-site compliance and complaint inspection conducted on May 23, 2023, and the on-site compliance inspection conducted on June 11, 2024

Based on documentation review, record review, and interview, the assisted living center failed to maintain a copy of the documentation provided to an emergency responder, for one of one sampled residents for whom an emergency responder had been contacted. Findings include: 1. A review of facility documentation revealed an incident report for R1 dated March 5, 2024. The incident report stated R1, "Was sent out to the ER." 2. The Compliance Officer requested to review the facility's copy of the documentation which had been provided to the emergency responder after R1's incident. However, the documentation was not provided for review. 3. In an interview, E1 acknowledged a copy of the documentation given to the emergency responder for each resident was not available for review as required by ARS 36-420.04.

Based on observation and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. The deficient practice posed a risk if no individual on-site was designated to act on behalf of the governing authority in the management of the assisted living facility. Findings include: 1. During a facility tour, the Compliance Officer observed a posting in the dining room which stated, "Designation of Manager by the Governing Authority." The designation listed seven employees, however E4 was not listed. 2. A review of the facility work schedule for May 2024 revealed the following: - E4 worked alone on the 7 pm to 7 am shift on May 7,8,14,15,21,22,28, and May 28, 2024. 3. In an interview, E1 acknowledged the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on May 23, 2023.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the kitchen counter. The cabinet had a magnetic lock, however, cabinet had not been fully closed and the lock had not engaged. Inside the cabinet, the Compliance Officer observed containers of, "Pine-sol," "Lysol," and, "Jazzle bleach." 2. During an environmental inspection of the facility, the Compliance Officer observed spray bottle of, "Great Value Cleaner with Bleach," on top of the a refrigerator in the kitchen area. 3. In an interview, E1 and E2 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on May 24, 2022 and the on-site compliance and complaint inspection conducted on May 23, 2023.

Based on observation and interview, the manager failed to ensure a current toxicology reference guide was available for use by personnel members. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested the facility's toxicology reference guide. However, a toxicology reference guide was not provided for review. 2. In an interview, E3 acknowledged the facility's toxicology reference guide had not been provided for review within two hours after a Department request.

Based on observation, documentation review, and interview, the manager failed to ensure a food menu was maintained for at least 60 calendar days after the last day included on the food menu. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not available during the on-site inspection, and was not provided to the Department within two hours after a Department request. Findings include: 1. The Compliance Officer observed the posted menus were not dated and did not include substitutions. 2. The Compliance Officer requested to review the menus for the last 60 days. However, no menus were provided for review. 3. In an interview, E3 acknowledged menu substitutions and historical menus for the previous 60 days had not been provided for review within two hours after a Department request.

Based on observation and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. Findings include: 1. Upon arriving at the facility, the Compliance Officer observed two caregivers, E1 and E2, working at the facility. The Compliance Officer observed the manager was not present at the facility. 2. During a facility tour, the Compliance Officer observed a posting in the dining room which stated, "Designation of Manager by the Governing Authority." The designation listed five employees, however E1 and E2 were not listed. 3. In an interview, E3 reported E1 and E2 were both newly hired caregivers who had not yet been designated. E3 acknowledged the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. Findings include: 1. On May 23, 2023 at 9:45 am, the Compliance Officer requested the following documents during the on-site inspection: - Resident medical record for R1; - Employee records for E1 and E2; - Resident activity calendars for the last 12 months; - Menus for the last 60 days; - Documentation of the hours worked by each caregiver and assistant caregiver for the previous 12 months; - A drug reference guide and a Toxicology reference guide; - A Therapeutic diet manual; - Smoke detector tests for the previous 12 months; - Disaster drills for the previous 12 months; - Evacuation drills for the previous 12 months; - Pet vaccination and license records; - Pest control program documentation; - First aid kit; - Personal funds records; - Quality Management reports; - Transportation logs; - Maintenance logs; - Annual disaster plan review; and - Incident reports involving elopements. However, this documentation was not provided, except for R1's chart, of which incomplete records were provided as follows: - For R1, a service plan and documentation of freedom from infectious tuberculosis were not provided for review. 2. In an interview, E1 reported E1 was fairly new at the facility and could not locate these records. E1 called E3 and reported E3 would be bringing all of the records requested. 3. At 12:00 p.m., the Compliance Officer advised E1 more than two hours had elapsed and the time to submit documentation had ended. 4. At 12:20 pm, E3 arrived at the facility. The Compliance Officer observed E3 was carrying a single binder. 5. In an interview, E3 reported the binder contained employee records and the rest of the documents were on-site. The Compliance Officer advised E3 more than two hours had elapsed since the time of the request and additional documents, including the employee records, would not be reviewed. E3 acknowledged the requested documentation had not been provided within two hours after a Department request.

Based on documention review and interview, the manager failed to ensure the quality management report required in R9-10-804(2) and the supporting documentation for the report was maintained for at least 12 months after the date the report was submitted to the governing authority. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested to review the facility's quality management report and supporting documentation for the report. However, a quality management report was not available for review. 2. In an interview, E3 acknowledged a quality management report had not been provided for review within two hours after a Department request.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least 12 months of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not provided during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed E1 and E2 working at the facility upon arrival at 9:35 a.m. 2. The Compliance Officer requested to review a daily staffing schedule maintained for at least 12 months of the caregivers working each day, including the hours worked by each. However, the requested documentation was not provided for review. 3. In an interview, E3 acknowledged documentation of the caregivers working each day, including the hours worked by each for the previous 12 months had not been provided within two hours after a Department request.

Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained, for two of two personnel records reviewed. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not available during the on-site inspection, and was not provided to the Department within two hours after a Department request. Findings include: 1. The Compliance Officer observed E1 and E2 working in the facility when the Compliance Officer arrived at the facility for an unannounced inspection. 2. A review of E1's personnel record revealed a personnel record was not available for review. 3. A review of E2's personnel record revealed a personnel record was not available for review. 4. In an interview, E3 reported E1 and E2 had personnel files. E3 acknowledged the personnel files for E1 and E2 had not been provided for review within two hours after a Department request.

Based on observation and interview, the manager failed to ensure a current therapeutic diet manual was available for use by personnel members. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested the facility's therapeutic diet manual. However, a therapeutic diet manual was not provided for review. 2. In an interview, E3 acknowledged the facility's therapeutic diet manual had not been provided for review within two hours after a Department request.

Based on documentation review, observation, interview, and record review, the manager failed to discharge an individual who needed services which were not within the assisted living facility's scope of services. Findings include: 1. A review of facility documentation revealed a document titled, "Scope of Services" which stated, "Services provided by this facility include the following...Directed Care Services - programs and services, including personal care services, provided to persons who are incapable of recognizing danger, summoning assistance, expressing need, or making basic care decisions...Health care services specific to individuals who are confined to a bed or chair, wandering, and individuals with dementia and psychiatric behaviors. This facility cannot accept residents who are exit seeking nor have behaviors that endanger themselves or others." 2. During a facility tour, the Compliance Officer observed R2 was a current resident of the facility. 3. In an interview, E2 reported R2 was a nurse and tries to care for the other residents, but becomes stressed if the other residents are difficult. E2 reported R2 eloped from the facility by climbing out a window. E2 reported R2's roommate at the time was causing R2 a lot of stress and since then R2 has a new roommate which is working better. E2 reported sometimes R2 will start talking about needing to visit R2's sibling, which is not something R2 can actually do, and this is a warning that they need to help R2 de-stress and keep a close eye on R2, because R2 will start trying to leave the facility. E2 reported locks have been placed on all doors and there has not been another actual elopement with the other services that are in place, but R2 continues to be exit seeking when agitated. 4. A review of R2's medical record revealed a service plan for supervisory care services, dated December 10, 2022. The service plan stated, "Mental State: Has significant memory and/or judgment impairments requiring verbal cueing, monitoring and redirection to perform activities of daily living.....Behavioral/Cognitive Status: Wanders, Restless, Wandering, Exit Seeking, Potential for Elopement..." 5. In an interview, E3 acknowledged the facility had retained a resident with exit seeking behaviors, and acknowledged the facility's scope of services does not include the provision of services to individuals with exit seeking behaviors.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan for supervisory care services, dated December 10, 2022. The service plan stated, "Mental State: Has significant memory and/or judgment impairments requiring verbal cueing, monitoring and redirection to perform activities of daily living.....Behavioral/Cognitive Status: Wanders, Restless, Wandering, Exit Seeking, Potential for Elopement..." 2. In an interview, E3 reported they do not allow R2 to leave the facility unattended and reported they had contacted law enforcement for assistance when R2 climbed out of a window. E3 acknowledged R2's service plan failed to indicate R2 was receiving directed care services.

Based on documentation review and interview, the manager failed to maintain at least 12 months of activity calendars after the last scheduled activity. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not available during the on-site inspection, and was not provided to the Department within two hours after a Department request. Findings include: 1. The Compliance Officer requested activity calendars for the past 12 months. However, past activity calendars were not provided for review. 2. In an interview, E3 acknowledged the activity calendars for the past 12 months had not been provided within two hours after a Department request.

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. Findings include: 1. During a tour of the facility, the Compliance Officer observed a posting on a refrigerator in the kitchen. The posting stated, "..for [R3] it is important that [R3] takes [their] meds at the same time every day.... 7am, 3pm, 7pm, 11pm because of his Parkinson's Disease. Also, [R3's] blood pressure is to be checked at 7am, 3pm, 11pm before giving [R3] the Nifedipine pill that is in the bottle. If Systolic Blood Pressure is lower than 100 don't give it...." 2. In an interview, E1 acknowledged the posting included protected health information and R3's name and was a medical record. E1 acknowledged R3's medical record was not protected from unauthorized use.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for one of two residents sampled. The deficient practice posed a TB exposure risk to residents, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R2's medical record revealed documentation of freedom from infectious TB was not available for review. 2. In an interview, E3 reported R1 had documentation of freedom form infectious TB, however, the documentation was not provided for review within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's service plan and updates, for one of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not in the medical record during the inspection, and was not provided to the Department within two hours after a Department request. Findings include: 1. A review of R1's medical record revealed a service plan was not available for review. 2. In an interview, E3 reported R1 had a service plan, however, the documentation was not provided for review within two hours after a Department request.

Based on observation and interview, the manager failed to ensure a current drug reference guide was available for use by personnel members. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested the facility's drug reference guide. However, a drug reference guide was not provided for review. 2. In an interview, E3 acknowledged the facility's drug reference guide had not been provided for review within two hours after a Department request.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3\'b0 F, which posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. During the facility tour with E1, the Compliance Officer observed two similar refrigerators in the kitchen of the facility. However, neither refrigerator contained a thermometer. The Compliance Officer observed a digital display on each refrigerator reading, "38F." After opening the doors, the readout did not change. A button next to the readout allowed the number to be changed between "46F" and "34F", and was the temperature setting of the refrigerators, not the actual temperature inside the refrigerators at the time of the inspection. 2. In an interview, E3 acknowledged the refrigerators in the kitchen did not have thermometers.

Based on observation and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) 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, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested to review the facility's annual disaster plan review. However, the facility's annual disaster plan review was not provided for review. 2. In an interview, E3 acknowledged documentation of an annual review of the facility's disaster plan had not been provided for review within two hours after a Department request.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested documentation of disaster drills conducted during the twelve months prior to the inspection. However, documentation of disaster drills was not available for review. 2. In an interview, E3 acknowledged documentation of disaster drills had not been provided for review within two hours after a Department request.

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 deficiency practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested documentation of evacuation drills conducted during the twelve months prior to the inspection. However, documentation of evacuation drills was not available for review. 2. In an interview, E3 acknowledged documentation of evacuation drills had not been provided for review within two hours after a Department request.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of R1's medical record revealed an incident report dated May 3, 2023. The incident report indicated R1 fell, had a head injury and a dislocation, and was transported to the hospital by emergency medical services. The incident report indicated R1's responsible party was notified immediately. However, the incident report indicated R1's physician was not notified. 2. In an interview, E3 acknowledged the provided incident report for R1 indicated R1's primary care provider was not immediately notified of the incident.

Based on observation and interview, a manager failed to ensure a rechargeable fire extinguisher had a tag attached specifying the date of the last servicing and the identification of the person who serviced the fire extinguisher. Findings include: 1. During a facility tour, the Compliance Officer observed a rechargeable fire extinguisher mounted on an island in the kitchen. However, the fire extinguisher did not have a tag attached specifying the date of the last servicing and the identification of the person who serviced the fire extinguisher. 2. In an interview, E3 acknowledged the fire extinguisher did not have an attached tag specifying the date of the last servicing and the identification of the person who serviced the fire extinguisher.

Based on observation and interview, the manager failed to ensure smoke detectors were tested at least once a month. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested documentation of monthly testing of the facility's smoke detectors. However, documentation was not provided for review. 2. In an interview, E3 acknowledged documentation of monthly testing of the facility's smoke detectors had not been provided for review within two hours after a Department request.

Based on documentation review and interview, the manager failed to ensure a pest control program in compliance with R3-8-201(C)(4) was not implemented and documented. The deficient practice posed a risk as the facility standards were not documented, were not available during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested documentation of the facility's pest control program. However, documentation was not available for review. 2. In an interview, E3 acknowledged documentation of the facility's pest control program had not been provided for review within two hours after a Department request.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the kitchen counter. The cabinet had a magnetic lock, however, the lock was missing a screw and was hanging down where it would not engage. Inside the cabinet, the Compliance Officer observed a container of Bleach. 2. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the kitchen counter. The cabinet did not have a lock. Inside the cabinet, the Compliance Officer observed a package of "Lysol Automatic Toilet Bowl Cleaner." 3. During an environmental inspection of the facility, the Compliance Officer observed a mirrored cabinet in a shared bathroom. The cabinet did not have a lock. Inside the cabinet, the Compliance Officer observed a container of "Chamosyn Ointment multipurpose moisture barrier." The barrier cream label stated, "If swallowed, get medical help of contact a Poison Control Center right away." 4. In an interview, E3 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on May 24, 2022.

Based on observation, record review and interview the manager failed to ensure a dog residing at the facility was licensed consistent with local ordinances. The deficiency practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Finding include: 1. The Compliance Officer observed a dog was present in the facility during the inspection. 2. The Compliance Officer requested and was not provided with documentation of a Pima County license for the dog. 3. In an interview, E3 acknowledged a license for the dog had not been provided for review within two hours after a Department request.

Based on observation, record review and interview the manager failed to ensure a dog residing at the facility was vaccinated against rabies. The deficiency practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Finding include: 1. The Compliance Officer observed a dog was present in the facility during the inspection. 2. The Compliance Officer requested and was not provided with documentation of a rabies vaccination for the dog. 3. In an interview, E3 acknowledged documention of rabies vaccination for the dog had not been provided for review within two hours after a Department request.