Living Waters Assisted Living LLC

Based on documentation review, record review, and interview, the governing authority failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “HEALTH CARE INSTITUTIONS; FALL PREVENTION AND FALL RECOVERY; TRAINING PROGRAMS.” The P&P stated, in its entirety: “Policy Statement: In compliance to ARS 36-420.01 We have included fall prevention and fall recovery training for all our staff prior to providing services to our residents. This will be included in their orientation training. Fall prevention and fall recovery training will be part of the personnel requirement to complete at least once every 12 months. Procedures: A. All staff will have an initial training that will be included during orientation. Fall prevention and fall recovery training materials to be use[d] will be from Arizona Training Solutions or Relias Online Training Video and/or materials from the department's AZ Fall Prevention Coalition. B. Administrator and or the designee will conduct the orientation training using the training materials from the departments, Arizona Training Solutions and/or online Relias Training Video. Orientation will be mandatory for all newly hired personnel. C. After orientation, all staff will be required to have an ongoing training that will cover fall prevention and fall recovery at least once every 12 months. Ongoing training will be provided by one of the training centers mentioned above. Completion of training will be documented in their personal file.” 2. A review of E1’s personnel record revealed E1 was hired as a caregiver in 2023. The review revealed no documentation demonstrating E1 received training regarding fall prevention and fall recovery from the administrator with orientation upon starting employment, as required by P&Ps. The review revealed E1 did not receive training regarding fall prevention until November 20, 2024, more than one year after E1’s date of starting employment. The review further revealed no documentation demonstrating E1 received training regarding fall recovery upon starting employment or any time thereafter. 3. A review of E2’s personnel record revealed E2 was hired as the manager. The review revealed no documentation demonstrating E2 received training regarding fall prevention and fall recovery from the administrator with orientation upon starting employment, as required by P&Ps. The review revealed E2 received trainings from Relias on “Slips, Trips, and Falls Prevention” on October 28, 2024; “About Falls” on November 12, 2024; and “Identifying Fall Risk in Assisted Living” on November 13, 2024; all after E2’s starting date of employment. 4. A review of E3’s personnel record revealed E3 was hired as a caregiver. The review revealed documentation demonstrating E3 did not receive training regarding fall prevention and fall recovery from the administrator with orientati

Based on interview and documentation review, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder (EMS). 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 R2 had an accident, emergency, or injury on August 20, 2025, that resulted in facility personnel contacting EMS on behalf of R2. 2. A review of facility documentation revealed a “REPORT OF UNUSUAL OCCURRENCE” dated August 20, 2025. The report stated facility personnel “CALLED PARAMEDIC.” 3. In an interview, when the Compliance Officer requested a copy of the documentation given to EMS in compliance with this statute, E1 reported EMS input the information into a tablet. When the Compliance Officer asked if E1 had a copy of the documentation given to EMS, E1 stated, “No.” When the Compliance Officer asked if facility personnel gave EMS a document in compliance with this statute, E1 stated, “No.”

Based on documentation 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), for three of three sampled residents. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A review of facility documentation revealed standardized forms for R2 and R5. However, the forms revealed the following: - R2’s form did not include the address of R2’s current pharmacy; - R5’s form did not include the name, address, and telephone number of R5’s current pharmacy; - R2’s and R5’s forms did not include point-of-contact information for the assisted living home, including the email address; and - R2’s form did not include basic information about R2's physical and mental conditions and basic medical history. 2. In an interview, E1 acknowledged the facility did not maintain a standardized form that included all information prescribed in this statute.

Based on documentation review, record review, observation, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for two of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.” The webpage stated: “The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting…Initial TB training should be provided before the HCW starts working.” 2. A review of E1’s personnel record revealed E1 was hired as a caregiver in 2023. However, the review revealed E1 did not receive training and education related to recognizing the signs and symptoms of TB until March 5, 2025. 3. A review of facility documentation revealed a series of personnel schedules which indicated E1 worked on a regular basis between January 2025 and March 2025. 4. The Compliance Officer observed E3 interacting with residents. 5. A review of E3’s personnel record revealed E3 was hired as a caregiver in 2024. However, the review revealed no documentation demonstrating E3 received initial training and education related to recognizing the signs and symptoms of TB. 6. A review of facility documentation revealed a series of personnel schedules which indicated E3 worked on a regular basis between December 2024 and August 2025. 7. In the exit interview, the Compliance Officer reviewed the findings with E1 and E1 offered no comment.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of five total current residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Documentation in Resident Records.” The P&P stated: “2. Documentation will be completed by the caregiver or personnel completing the task, providing the service or assis[ting] the resident…3. Care or services to residents are to be documented as they are provided as much as possible.” 2. A review of R1's medical record conducted at approximately 1:30 PM revealed a service plan dated July 6, 2025. The service plan indicated R1 was to receive assistance with complete baths/showers twice per week and partial baths “On days complete bath is not given.” The review revealed documentation of assisted living services provided to R1 (ADLs) dated August 2025 which indicated R1 last received both a complete bath/shower as well as a partial bath on August 25, 2025. 3. In an interview, E1 reported R1 last received a complete bath/shower on August 24, 2025, and not on August 25, 2025, as documented on the ADLs. E1 stated R1 received a partial bath “this morning.” E1 acknowledged a caregiver or an assistant caregiver failed to document the partial bath on August 26, 2025. This is a repeat citation from the complaint and compliance inspections conducted on September 12, 2023, and September 15, 2022.

Based on documentation review, observation, and interview, the governing authority failed to notify the Department immediately when there was a change in the manager. Findings include: 1. A review of Department documentation revealed a letter from E2 dated June 15, 2025, stating E2 was the new manager effective June 11, 2025. 2. A review of facility documentation revealed a policy and procedure (P&P) titled “Manager/Caregiver/ Job Descriptions, duties, etc.” The P&P stated: "Regarding the manager: 12. Must notify the Department according to § A.R.S. 36-425(I) when there is a change in the manager and provide the name of the new manager.” 3. The Compliance Officer observed E2's manager certificate posted in the facility. 4. In an interview, E1 reported E2 took over as the manager in October 2024. E1 reported E2 notified the Department when E2 took over. When the Compliance Officer informed E1 the Department had received no such notice until June 2025, E1 reported E1 would have to check in with E2 regarding the notification. 5. A secondary review of Department documentation conducted on September 4, 2025, confirmed the Department received no notification of E2's appointment as manager until June 15, 2025. This is a repeat citation from the complaint and compliance inspection conducted on September 12, 2023.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for two of three sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(2) and (4) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card [and] 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.” 2. A review of E2's personnel record revealed E2 was hired as the manager before March 31, 2025. The review revealed a printout from the Adult Protective Services (APS) registry website dated November 1, 2024. However, the individual verifying E2 was not on the APS registry entered E2’s first name as E2’s last name and vice versa. The review revealed facility personnel did not verify E2 was not on the APS registry. 3. A review of the APS registry website revealed E2 was not on the registry. 4. In an interview, E1 acknowledged facility personnel entered E2’s name incorrectly and did not verify E2 was not on the APS registry, stating, “I’ll get it fixed.” 5. A review of facility documentation revealed a policy and procedure (P&P) titled “Obtaining verifications for employees.” The P&P stated: “Manager will verify every employee and volunteer fingerprints clearance card and document the results using the facility form. All the verifications will be done before the employee/volunteer start[s] working at the facility.” 6. A review of E3's personnel record revealed E3 was hired as a caregiver in 2024. The review revealed a fingerprint clearance card (FCC). The review further revealed a printout from the Department of Public Safety (DPS) website which indicated facility personnel did not verify E3’s FCC until June 11, 2025. 7. A review of facility documentation revealed a series of personnel schedules which indicated E3 worked on a regular basis between December 2024 and June 2025.

Based on observation and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. Findings include: 1. When the Compliance Officer arrived at the facility at approximately 9:45 AM, the Compliance Officer observed E1 and E3 working at the facility and no other personnel present. The Compliance Officer observed several residents at the facility. 2. In an interview, E1 reported the facility had five residents. 3. At approximately 10:50 AM, when the Compliance Officer was in the driveway with E1 checking the side of the house, the Compliance Officer observed E3 walk to the street to throw away something then return to the house. 4. In an interview, when the Compliance Officer brought up the issue of no caregivers being in the home at the time of the aforementioned observation, E1 reported E3 should not have been outside. 5. The Compliance Officer observed a floor-to-ceiling wall in the master bathroom approximately two feet in length dividing the shower and the toilet. The Compliance Officer observed the end of the wall closest to the access points of both the shower and toilet was missing the drywall and baseboard at the bottom, exposing the wood frame to the water from the shower and the potentiality of mold growth. The Compliance Officer further observed a small shelf attached to the shower wall. The Compliance Officer observed the small shelf appeared to be made of porcelain or a similar material and was broken on the outward edge, exposing several sharp edges. 6. In an interview, E1 confirmed the bathroom was used by at least one resident. 7. The Compliance Officer observed tile covering the back outdoor patio. However, the Compliance Officer observed several raised areas in the foundation which broke and dislodged the surrounding tiles, creating tripping hazards. The Compliance Officer observed some of these tripping hazards were directly next to and underneath a table and set of chairs while others were near the middle of where an individual would walk. 8. In an interview, E1 acknowledged the broken and dislodged tiles created tripping hazards. E1 reported E1 would have to talk to the home owner to get the tile fixed.

Based on documentation review, observation, and interview, 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 the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Manager/Caregiver/ Job Descriptions, duties, etc.” The P&P stated: "Regarding the manager: 14. Create a work schedule for all employees and volunteers, approve any changes and include the hours every employee works.” 2. When the Compliance Officer arrived at the facility at approximately 9:45 AM, the Compliance Officer observed E1 and E3 working at the facility and no other personnel present. 3. A review of facility documentation conducted at approximately 10:00 AM revealed a personnel schedule dated August 2025. The schedule revealed E3 worked between 7:00 AM and 7:00 PM on August 21, 2025, and E3 and E4 were scheduled to work between 7:00 AM and 7:00 PM on the date of the inspection. The schedule revealed documentation demonstrating E1 did not work at any time on August 21 or 26, 2025. 4. In an interview, E1 reported E3 left the facility for a few hours on August 21, 2025, and E1 covered that portion of E3’s shift. E1 stated, “[E4] didn’t work today.” E1 reported E1 was covering E4’s shift. 5. A review of facility documentation revealed a series of personnel schedules dated between August 2024 and August 2025. The schedules revealed documentation demonstrating the following: - No personnel worked on August 31, 2024; - September 2024 started on a Monday, when in reality it started on a Sunday, effectively shifting all dates and caregiver shifts in September 2024 by one day; - October 2024 started on a Wednesday, when in reality it started on a Tuesday, effectively shifting all dates and caregiver shifts in October 2024 by one day; - No personnel worked between 7:00 PM and 7:00 PM on December 29-31, 2024; - No personnel worked between 7:00 PM and 7:00 PM on March 31, 2025; - No personnel worked between 7:00 PM and 7:00 PM on April 27-30, 2025; - No personnel worked between 7:00 PM and 7:00 PM on May 19-23 and 26-30, 2025; - No personnel worked between 7:00 PM and 7:00 PM on June 29-30, 2025; and - No personnel worked between 7:00 PM and 7:00 PM on August 1, 2025. 6. E1 reported facility personnel did not keep track of hours worked anywhere other than the personnel schedule reviewed by the Compliance Officer. E1 confirmed the personnel schedule did not accurately contain documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. This is a repeat citation from the complaint and compliance inspections completed on September 12, 2023.

Based on documentation review, record review, interview, and observation, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for two of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) states: "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution…and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 2. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC).” 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 4. A review of E1’s personnel record revealed E1 was hired as a caregiver in 2023. The review revealed a negative TST dated as read on February 17, 2023, within one year before E1 began providing services at the facility. The review revealed two negative TSTs dated as read on January 16, 2024, and February 1, 2024, respectively, both after E1 began providing services at the facility. The review revealed E1 did not have two negative TSTs within one year before E1 began providing services at the facility. The review further revealed documentation assessing risks of prior exposure to infectious tuberculosis and determining if E1 had signs or symptoms of tuberculosis dated January 14, 2025, after E1 beg

Based on documentation review, 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, and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-ii) states: "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis [and] ii. Determining if the individual has signs or symptoms of tuberculosis.” 2. A review of R2's medical record revealed R2 was admitted to the facility more than seven days before the date of the inspection. However, the review revealed no documentation assessing risks of prior exposure to infectious tuberculosis and determining if R2 had signs or symptoms of TB. 3. In the exit interview, the Compliance Officer reviewed the findings with E1 and E1 offered no comment. This is a repeat citation from the complaint and compliance inspection conducted on September 12, 2023.

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established and documented that included the amount, type, and frequency of assisted living services being provided to the resident, for five of five total current residents and one previous resident. Findings include: 1. A review of R1's medical record revealed a current service plan. The service plan indicated R1 was to receive assistance with complete baths/showers twice per week, partial baths “On days complete bath is not given,” dressing, room maintenance, laundry, and toileting. However, the service plan did not include the frequency of dressing, room maintenance, laundry, and toileting. The review revealed documentation of assisted living services provided to R1 (ADLs) dated August 2025 which indicated R1 received assistance with complete baths/showers and partial baths on a daily basis, in contradiction with R1’s service plan. 2. A review of R2's medical record revealed a current service plan. The service plan indicated R2 was to receive assistance with dressing, room maintenance, and laundry, and did not require assistance with complete baths/showers, partial baths, and combing hair. However, the service plan did not include the frequency of dressing, room maintenance, and laundry. The review revealed ADLs dated August 2025 which indicated R2 received assistance with complete baths/showers, partial baths, and combing hair on a daily basis, in contradiction with R2’s service plan. 3. In an interview, when the Compliance Officer asked what services the facility provided R2, E1 reported the facility provided laundry services and food. E1 reported R2 often bathed and dressed R2’s self. E1 further reported sometimes facility personnel assisted R2 with bathing and dressing and sometimes facility personnel did not assist R2 with these services. When the Compliance Officer asked why facility personnel documented services on the ADLs if facility personnel did not provide said services, E1 offered no comment. 4. A review of R3's medical record revealed a current service plan. The service plan indicated R3 was to receive assistance with complete baths/showers twice per week, partial baths “On days complete bath is not given,” dressing, room maintenance, laundry, and incontinence care. However, the service plan did not include the frequency of dressing, room maintenance, laundry, and incontinence care. The review revealed ADLs dated August 2025 which indicated R3 received assistance with complete baths/showers and partial baths on a daily basis, in contradiction with R3’s service plan. 5. A review of R4's medical record revealed a current service plan. The service plan indicated R4 was to receive assistance with bed baths twice per week, partial baths “On days complete bath is not given,” dressing, room maintenance, laundry, and transferring to a bed or chair and did not require assistance with complete baths/showers. However, the service plan

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for one of two sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. A review of R2’s medical record revealed a service plan dated July 6, 2025. The service plan indicated R2 was to receive assistance dressing on a daily basis and did not require assistance with complete baths/showers, partial baths, and combing hair. The review revealed documentation of assisted living services provided to R2 dated August 2025 which indicated R2 received assistance with complete baths/showers, partial baths, dressing, and combing hair on a daily basis, in partial contradiction with R2’s service plan. 2. In an interview, when the Compliance Officer asked what services the facility provided R2, E1 reported the facility provided laundry services and food. E1 reported R2 often bathed and dressed R2’s self. E1 further reported sometimes facility personnel assisted R2 with bathing and dressing and sometimes facility personnel did not assist R2 with these services. When the Compliance Officer asked why facility personnel documented services on the ADLs if facility personnel did not provide said services, E1 offered no comment.

Based on record review, interview, and documentation review, the manager failed to ensure a resident’s medical record contained documentation of assisted living services provided to the resident, for five of five total current residents and one previous resident. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a current service plan. The service plan indicated R1 was to receive assistance with complete baths/showers twice per week. The review revealed documentation of assisted living services provided to R1 (ADLs) dated August 2025 which indicated R1 received complete baths/showers on a daily basis, including on August 25, 2025, in contradiction with R1’s service plan. 2. In an interview, E1 reported R1 last received a complete bath/shower on August 24, 2025. E1 confirmed R1 did not receive a complete bath/shower on August 25, 2025. 3. A review of R2’s medical record revealed R2 was a resident in April 2025. However, the review revealed no ADLs dated April 2025. The review revealed a current service plan. The service plan indicated R2 was to receive assistance dressing and did not require assistance with complete baths/showers, partial baths, and combing hair. The review revealed ADLs dated August 2025 which indicated R2 received assistance with complete baths/showers, partial baths, dressing, and combing hair on a daily basis, in partial contradiction with R2’s service plan. 4. In an interview, E1 reported E1 could not find R2’s ADLs for April 2025, stating, “I’ve been looking.” When the Compliance Officer asked what services the facility provided R2, E1 reported the facility provided laundry services and food. E1 reported R2 often bathed and dressed R2’s self. E1 further reported sometimes facility personnel assisted R2 with bathing and dressing and sometimes facility personnel did not assist R2 with these services. When the Compliance Officer asked why facility personnel documented services on the ADLs if facility personnel did not provide said services, E1 offered no comment. 5. A review of R3’s, R4’s, R5’s, and R6’s medical records conducted at approximately 1:30 PM revealed documentation of assisting living services provided to the four residents (ADLs) dated August 2025. However, other than lunch and dinner, the ADLs revealed documentation demonstrating the four residents had already received all available services on the date of the inspection, including services in the future, such as “DIAPER CHANGED [in the] AFTERNOON [and] NIGHT,” “FLUIDS BEING OFFERED [in the] AFTERNOON,” “PM SNACKS,” and “REPOSITIONING [every] (2-3 HRS) [in] BED.” 6. In an interview, when the Compliance Officer asked if the documented services had already been provided, E1 stated, “I don’t think so.” E1 reported E3 must have mistaken the date when signing off on the ADLs. E1 reported E3 must have meant to sign off for August 25, 2025, instead of August 26

Based on record review and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for two of two sampled residents. Findings include: 1. A review of R1’s medical record revealed a medication administration record (MAR) dated August 2025. The MAR revealed R1 received mesalamine 1.2 G on August 1-25, 2025; quetiapine 25 mg on August 1-26, 2025; and trazodone 100 mg on August 1-25, 2025, without medication orders. 2. In an interview, E1 reported R1 received a new medication order for the three aforementioned medications. 3. A review of R1’s medical record revealed no signed medication orders for mesalamine 1.2 G, quetiapine 25 mg, and trazodone 100 mg. 4. In an interview, E1 acknowledged the medication orders for mesalamine 1.2 G, quetiapine 25 mg, and trazodone 100 mg were not signed. 5. A review of R2’s medical record revealed a MAR dated August 2025. The MAR revealed R2 received famotidine 20mg on August 3-19, 2025, and naproxen 500mg on August 1-20, 2025, without medication orders. 6. In the exit interview, the Compliance Officer reviewed the findings with E1 and E1 offered no further comment. This is a repeat citation from the complaint and compliance inspection conducted on September 12, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the date and time of administration or assistance; the name, strength, dosage, and route of administration; and the name and signature of the individual administering the medication, for one of two sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Confidentiality of Resident Records.” The P&P stated, “Altering or falsifying any resident’s record by a personnel member is ground[s] for immediate termination.” The review further revealed a P&P titled "MEDICATION SERVICES" which stated, “Medication administration is not documented until the resident is seen taking them.” 2. A review of R2's medical record revealed a “PROGRESS/COMMUNICATION NOTE” which revealed R2’s date of occupancy. The note stated, “[R2] move-in today [without] medication." The review revealed a medication administration record (MAR) containing documentation demonstrating R2 received medication administration for a total of ten days before R2’s date of occupancy. 3. In an interview, E1 confirmed R2’s date of occupancy. E1 reported documentation on the MAR must have been a mistake or incorrect. 4. A review of R2’s medical record revealed a MAR dated July 2025. The MAR revealed white corrective fluid covering the name, strength, dosage, and route of a medication as well as the initials denoting its administration. Upon shining a light at the page, the MAR revealed the still unknown medication was administered on July 1-31, 2025. 5. In an interview, E1 reported not knowing what medication was listed under the white corrective fluid.

Based on documentation review, record review, and interview, the manager failed to ensure a resident’s medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) § 36-406(1)(d), for one of two sampled residents. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Vaccine availability.” The P&P stated, “The manager will make sure to inform the residents and residents [sic] families that Flu Vaccines are available every year.” 2. A review of R2’s medical record revealed documentation of notification of R2 of the availability of vaccination for influenza, signed and dated by R2’s Power of Attorney on July 16, 2024. However, the notification did not include the availability of vaccination for pneumonia The review further revealed no documentation of notification of R2 of the availability of vaccination for influenza and pneumonia within one year after July 16, 2024. 3. In the exit interview, the Compliance Officer reviewed the findings with E1 and E1 offered no comment. This is a repeat citation from the complaint and compliance inspections completed on September 15, 2022.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a current service plan which indicated R1 received medication administration. The review revealed a medication order for “MESALAMINE .375 GM ORAL CAPSULE 1 DAILY (3 PILLS)” dated March 27, 2025. The review further revealed a medication administration record (MAR) dated August 2025. The MAR revealed R1 received “Mesalamine 1.2g tab 1 tab by mouth at bedtime” on August 1-25, 2025, instead of “MESALAMINE .375 GM ORAL CAPSULE 1 DAILY (3 PILLS)” as stated on the medication order. The MAR further revealed R1 received quetiapine 25 mg on August 1-26, 2025, and trazodone 100 mg on August 1-25, 2025, without medication orders. 2. The Compliance Officer observed R1’s mesalamine 1.2 G. 3. In an interview, E1 reported R1 received a new medication order for the three aforementioned medications. 4. A review of R1’s medical record revealed no signed medication orders for mesalamine 1.2 G, quetiapine 25 mg, and trazodone 100 mg. 5. In an interview, E1 acknowledged the medication orders for mesalamine 1.2 G, quetiapine 25 mg, and trazodone 100 mg were not signed. 6. A review of R2’s medical record revealed a current service plan which indicated R2 received medication administration. The review revealed a medication order for the following medications: - “[B]enztropine mesylate 0.5 mg…TAKE 1 TABLET BY MOUTH TWICE DAILY” with a start date of February 18, 2025; - “[C]lozapine 100 mg…take 2 tablet[s] by oral route 2 times every day” with a start date of February 18, 2025; - “[F]amotidine 20 mg…take 1 tablet by oral route 2 times every day” with a start date of January 30, 2025; and - “[M]irtazapine 15 mg…take 1 tablet by oral route every day before bedtime” with a start date of February 18, 2025. The review further revealed a MAR dated August 2025. The MAR revealed the following: - R2 did not receive benztropine mesylate, clozapine, and mirtazapine on August 1-26, 2025, as ordered; - R2 received “Famotidine 20mg tab 1 tab by mouth at bedtime” on August 3-19, 2025, instead of two times every day as ordered; and - R2 received naproxen 500mg on August 1-20, 2025, without a medication order. 7. In the exit interview, the Compliance Officer reviewed the findings with E1 and E1 offered no further comment. This is a repeat citation from the complaint and compliance inspection conducted on September 12, 2023.

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 facility documentation revealed a policy and procedure (P&P) titled “MEDICATION SERVICES.” The P&P stated, “All medication including over the counter will be secured in locked cabinets and only trained caregivers will have access at any time.” 2. The Compliance Officer observed a door in the hall near the front entry with a sign which read “EMPLOYEES ONLY UNAUTHORIZED ENTRY NOT ALLOWED.” However, the Compliance Officer observed the door was unlocked. Inside, the Compliance Officer observed an office area and living quarters. The Compliance Officer observed a bottle of liquid acetaminophen and a bottle of Tylenol. 3. In an interview, E1 reported the medication belonged to E3. Regarding the office door, E1 stated, “We always close this all the time.” When the Compliance Officer explained the rule stated medications needed to be stored in a locked area and not simply behind a closed door, E1 reported E1 would have E3 hide the medication. When the Compliance Officer again explained the rule stated medications needed to be stored in a locked area and not simply hidden from residents, E1 reported E1 would have E3 keep the medication safe from residents. When the Compliance Officer explained the rule for the third time, E1 simply stated, “Mhmm” as if in agreement. E1 told E3 the door needed to remain locked when personnel were not in the office. This is a repeat citation from the complaint and compliance inspections completed on September 15, 2022.

Based on observation and interview, the manager failed to ensure food was free from spoilage, filth, or other contamination and was safe for human consumption. Findings include: 1. The Compliance Officer observed a refrigerator in the kitchen. On top of the refrigerator, the Compliance Officer observed three dried and rotten bananas. Inside the refrigerator, the Compliance Officer observed food debris and dead bugs. The Compliance Officer further observed several open containers with food inside and what appeared to be a rotting cucumber or small green squash in an open bag. 2. In an interview, E1 reported not knowing the refrigerator was dirty and contained dead bugs, open food containers, and rotting food. When the Compliance Officer informed E1 the refrigerator needed to be kept clean and food needed to be free from spoilage, filth, or other contamination, E1 stated, “Absolutely.” This is a repeat citation from the complaint and compliance inspections completed on September 15, 2022.

Based on observation and interview, the manager failed to ensure food was protected from potential contamination. The deficient practice posed a risk to the health and safety of the resident if there was a potential for food borne illnesses. Findings include: 1. The Compliance Officer observed an open bag of rice in a cabinet in the kitchen. The Compliance Officer observed loose grains of rice and live bugs on the floor of the cabinet. 2. In an interview, E1 acknowledged the rice was not protected from potential contamination. E1 reported E1 and E3 would close the bag of rice and clean the cabinet. 3. The Compliance Officer observed a refrigerator in the kitchen. On top of the refrigerator, the Compliance Officer observed three dried and rotten bananas. Inside the refrigerator, the Compliance Officer observed food debris and dead bugs. The Compliance Officer further observed several open containers with food inside and what appeared to be a rotting cucumber or small green squash in an open bag. 4. In an interview, E1 reported not knowing the refrigerator was dirty and contained dead bugs, open food containers, and rotting food. When the Compliance Officer informed E1 food needed to be protected from potential contamination, E1 stated, “Absolutely.”

Based on interview and documentation review, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a potential risk of re-injury and the Department was provided false or misleading information. Findings include: 1. In an interview, E1 reported R2 had an accident, emergency, or injury that resulted in R2 needing medical services on August 20, 2025. 2. A review of facility documentation revealed a “REPORT OF UNUSUAL OCCURRENCE” dated August 20, 2025. The report revealed R2 had an accident, emergency, or injury that resulted in R2 needing medical services. However, the report did not include any action taken to prevent the accident, emergency, or injury from occurring in the future. The review further revealed facility personnel notified R2’s primary care provider, R2’s “Responsible Person,” R2’s emergency contact, and emergency medical services personnel on August 8, 2025, nearly two weeks before the date of the incident. 3. In an interview, E1 reported E1 must have written August 8, 2025, instead of August 20, 2025, in error. 4. In the exit interview, the Compliance Officer reviewed the findings regarding the incident report missing the action taken to prevent the accident, emergency, or injury from occurring in the future with E1 and E1 offered no comment. This is a repeat citation from the complaint and compliance inspection conducted on September 12, 2023.

Based on observation and interview, the manager failed to ensure the premises were clean. Findings include: 1. Immediately upon entering the facility, the Compliance Officers observed a strong odor of urine. 2. In an interview, E1 reported R2’s bedroom was around the corner near the entryway. E1 reported R2 had the habit of throwing R2’s soiled briefs under R2’s bed. E1 reported E1 was going to change out the flooring in R2’s room now that R2 was no longer a resident. 3. In the kitchen, the Compliance Officer observed dirty countertops, walls, and cabinet doors and drawers. Inside several of the cabinets, the Compliance Officer observed a significant amount of food debris. The Compliance Officer observed the oven, stove, range hood, and warming rack were also dirty. The Compliance further observed the refrigerator in the kitchen was also dirty and contained food debris and dead bugs. 4. In an interview, E1 reported not knowing the refrigerator and freezer were dirty and contained dead bugs. 5. On the back patio, the Compliance Officer observed a chest freezer as well as a refrigerator and freezer combo. Upon opening both units, the Compliance Officer observed the chest freezer and refrigerator and freezer combo were dirty. 6. In a hallway, the Compliance Officer observed an air conditioning return vent on the ceiling with a significant amount of dust attached to it as if it had not been cleaned in several months. 7. In the living room, the Compliance Officer observed a white chair with dust, debris, and stains.

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to residents with access to the poisonous or toxic materials. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “EMERGENCY, SAFETY AND ENVIRONMENTAL STANDARDS.” The P&P stated, “Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparatio[n] and food storage areas.” 2. The Compliance Officer observed a cabinet under the sink in the kitchen with a latch attached and a lock hanging from the latch. However, the lock was open and the Compliance Officer was able to open the cabinet. The Compliance Officer observed no personnel in the area. Inside the cabinet, the Compliance Officer observed a variety of poisonous or toxic materials, including dishwasher detergent, disinfection multi-surface cleaner, kitchen degreaser, odor eliminator, and oven cleaner. 3. In an interview, E1 reported facility personnel kept the cabinet locked and had been cleaning. However, E1 acknowledged the cabinet was not locked when the Compliance Officer observed it. 4. The Compliance Officer observed a metal shed on the side yard with a busted latch and the key placed in the lock. The Compliance Officer observed the shed was not able to lock because of the busted latch. Inside the shed the Compliance Officer observed a variety of poisonous or toxic materials, including paint, pesticides, primer, and sealer. Opposite the shed, the Compliance Officer observed a bottle of air freshener placed atop a dresser. 5. In an interview, E1 reported the contents of the shed belonged to the previous owner of the LLC. E1 reported E1 received permission from the previous owner to throw away the contents of the shed. E1 reported E1 cut off the lock to the shed so E1 could get in and throw everything away. When the Compliance Officer asked when E1 purchased the LLC, E1 reported purchasing it in 2023. 6. The Compliance Officer observed a door in the hall near the front entry with a sign which read “EMPLOYEES ONLY UNAUTHORIZED ENTRY NOT ALLOWED.” However, the Compliance Officer observed the door was unlocked. Inside, the Compliance Officer observed an office area. The Compliance Officer observed three spray cans and one spray bottle of air freshener on a stand next to the printer. 7. In an interview regarding the office door, E1 stated, “We always close this all the time.” When the Compliance Officer explained closing the door did not ensure compliance with this rule, E1 reported the door remained closed when personnel were not in the office. When the Compliance Officer again explained closing the door did not ensure compliance with this rule, E1 told E3 the door needed to remain locked when personnel were not in the office. 8. The Compliance O

Based on interview and documentation review, the licensee failed to notify the department within thirty days after any change regarding a controlling person, and the licensee failed to provide the information and affirmation required pursuant to subsection A, paragraph 1, subdivision (d) of A.R.S. \'a7 36-422. Findings include: A.R.S. \'a7 36-422(H) An applicant or licensee must notify the department within thirty days after any change regarding a controlling person and provide the information and affirmation required pursuant to subsection A, paragraph 1, subdivision (d) of this section. 1. In an interview, O1 reported O1 and O2 owned AL11982. 2. A review of the Arizona Corporation Commission website revealed O1 was a member of Living Waters Assisted Living LLC and O2 was the statutory agent. O1 was appointed a member on April 1, 2023. O2 was appointed statutory agent on April 1, 2023. A review of the "Articles of Amendment" dated April 1, 2023, revealed O3 was removed from the LLC and O1 and O2 were added to the LLC. 3. A review of Department documentation revealed the previous owners, or O1 and O2 failed to notify the Department of the April 1, 2023 changes to the LLC. 4. In an interview, O1 reported being unaware of the requirements.

Based on documentation review, observation, and interview, the governing authority failed to notify the Department according to Arizona Revised Statutes (A.R.S.) \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings include: 1. A review of Department documentation revealed O3 was the manager for AL11982 as of April 2023. 2. The Compliance Officer observed E1's manager's license posted on the premises of AL11982. 3. In an interview, O1 reported E1 became the new manager in May 2023. 4. A review of Department documentation revealed evidence to indicate the governing authority notified the Department when there was a change from O3 to E1, and provided E1's qualifications, was not available. 5. In an interview, O1 acknowledged the facility did not notify the Department of a change in the facility's manager.

Based on 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 if there was no record to ensure shifts and tasks were covered. Findings include: 1. The Compliance Officer requested to review current documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. 2. In an interview, E2 reported E1 had taken the staffing schedule for September 2023 and the documentation was not available for review.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of four residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of R2's (admitted in 2023) medical record revealed a chest x-ray dated in May 2023. The chest x-ray stated "Reason for Exam: Edema." Additionally, a hand-written note on the document stated "No TB" signed by a medical practitioner. However, evidence R2 had a history of a positive skin test or other TB screening test recommended by the Centers for Disease Control and Prevention (CDC) was not available for review; and the chest x-ray was not an infectious TB screening test. 2. A review of R3's (admitted in 2023) medical record revealed evidence of freedom from infectious TB was not available for review. 3. In an interview, O1 and E2 acknowledged R2 and R3 did not provide current documentation of freedom from infectious TB in compliance with R9-10-113.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount and frequency of assisted living services being provided to the resident, for one of four residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a service plan for directed care services (dated in July 2023). The service plan stated "Bathing... Sponge bath... Peri care... Hygiene/Grooming... Elimination... Incontinent... bowel... bladder... uses disposable undergarments..." However, the service plan did not include the amount and frequency of the assisted living services being provided to R2. 2. A review of R2's medical record revealed an activities of daily living (ADL) sheet for September 2023. The ADL sheet stated "Oral Care... AM...Eve... Shaving (PRN)... Dressing... AM... Eve... Nail Care (PRN)... Full bath/Bed bath on Monday and Thursday..." The aforementioned services were documented as provided on September 1, 2023 - September 12, 2023. 3. In an interview, O1 and E2 acknowledged the amount and frequency of assisted living services being provided to R2 was not included on R2's service plan.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for three of four 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 R1's medical record revealed a current written service plan for personal care services dated in June 2023. The service plan revealed R1 was incontinent of bowel and bladder. Additionally, the service plan stated, "Summary of level of assistance needed... toileting...moderate..." However, documentation was not available to indicating the service was provided September 1 - 12, 2023. 2. In an interview, E2 reported R1 used disposable undergarments. E2 reported caregivers occasionally assist R1 with the undergarments. 3. A review of R2's medical record revealed a current written service plan for directed care services dated in July 2023. The service plan revealed R2 was incontinent of bowel and bladder and used disposable undergarments. Additionally, the service plan stated, "Summary of level of assistance needed... toileting... maximum..." However, documentation was not available indicating the service was provided September 1 - 12, 2023. 4. In an interview, E2 reported R2 is bed-ridden. E2 reported caregivers assisted R2 with incontinence needs. 5. A review of R3's medical record revealed a current written service plan for personal care services dated in August 2023. The service plan revealed R3 was incontinent of bowel and bladder. Additionally, the service plan stated, "Summary of level of assistance needed... toileting...maximum..." However, documentation was not available indicating the service was provided September 1 - 12, 2023. 6. In an interview, O1 and E2 acknowledged R1's, R2's, and R3's medical records did not include documentation of the above listed services and reported the services were provided as indicated in the service plan. This is a repeat deficiency from the compliance inspection conducted on September 15, 2022.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for one of four residents sampled who received medication administration. Findings include: 1. A review of R1's medical record revealed a signed medication order for Oxybutynin Chloride tab 5 mg, one tab, twice a day at 8:00 AM and 8:00 PM. 2. A review of R1's medical record revealed a medication administration record (MAR) for September 2023. The MAR stated, "Oxybutynin 5 mg tablet, take on tablet by mouth once a day." The MAR revealed the aforementioned medication was administered from September 1 - 12, 2023 at 8:00 AM. 3. The Compliance Officer observed Oxybutynin 5 mg tablet prefilled in the "AM" slot of R1's medication organizer. 4. In an interview, O1 and E2 reported the medication order had recently changed. However, O1 and E2 acknowledged R1's medical record did not contain a medication order from a medical practitioner for Oxybutynin Chloride tab 5 mg, once a day.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of four residents sampled who received medication administration. Findings include: 1. A review of R1's medical record revealed a signed medication order for Oxybutynin Chloride tab 5 mg, one tab, twice a day at 8:00 AM and 8:00 PM. 2. A review of R1's medical record revealed a medication administration record (MAR) for September 2023. The MAR stated, "Oxybutynin 5 mg tablet, take on tablet by mouth once a day." The MAR revealed the aforementioned medication was administered from September 1 - 12, 2023 at 8:00 AM. 3. The Compliance Officer observed Oxybutynin 5 mg tablet prefilled in the "AM" slot of R1's medication organizer. 4. In an interview, O1 and E2 reported the medication order had recently changed. O1 and E2 acknowledged R1's medication was not administered in compliance with a medication order, and were unable to provide the new medication order for review.

Based on record review and interview, the manager failed to ensure when a resident had an emergency resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one residents reviewed who had an emergency resulting in the resident needing medical services. Findings include: 1. A review of R1's medical record revealed an incident report dated April 8, 2023. The report stated, "[R1] was in bed and attempted to get up in the middle of the night [sic] slid off [R1's] bed and onto the floor. Injury Sustained: At time of fall, no injury. Edit: 24 hours pain started. Action Taken: Helped [R1] into bed after assessing fall. Stated [R1] was okay. Monitor for 24-72 hours. 24-48 hours after fall, experiencing pain. Called primary." However, the document did not include any action taken to prevent the accident, emergency, or injury from occurring in the future. 2. In an interview, R1 reported to recall injuring R1's hip in 2023 at the facility. 3. In an interview, E2 reported R1 had pain in R1's hip shortly after the incident. E2 reported management called R1's primary doctor to send a mobile x-ray. E2 reported shortly after, R1's family arrived at the facility. R1 reported to the family an issue with R1's heart. An ambulance was called to transport R1 to the hospital. 4. A review of R1's medical record revealed documentation of the aforementioned incident was not available to include the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one residents reviewed who had an emergency resulting in the resident needing medical services. 5. In an interview, E2 reported the x-ray revealed R1 had a hairline fracture and it would heal on its own. 6. In an interview, O1 and E2 acknowledged R1's medical record did not include documentation of the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent both incidents from occurring in the future.