Medina House CORP

Based on documentation review and interview, the assisted living home failed to maintain a copy of the document provided to the emergency responder as prescribed in A.R.S. § 36-420.04.A.1-9, for any resident who required the assistance of emergency responders. The deficient practice posed a risk as the designated standards were not followed and the department was unable to ensure compliance with the applicable statute. Findings include: 1. A review of facility documentation revealed an incident report for R4 dated October 13, 2025, in which 911 had been called to respond. Further review of facility documentation revealed prepared emergency packets for each of the residents; however, the "Assisted Living Resident Transfer Checklist" forms for all of the residents only contained the master copy, in which the "Date Completed" section, the "Reason(s) Emergency Response Requested" section, and the "Notification to Authorized Representative" section were all blank. No copies of any completed forms that were provided to EMS for any of the residents at the time of the incident/transport were available for review. 2. In an interview, E6 and E7 acknowledged the facility did not make copies of the "Assisted Living Resident Transfer Checklist" forms that were provided to EMS responders for any of the residents because E6 and E7 did not know it was required to do so. 3. Technical assistance was provided on this statute at the compliance and complaint inspection conducted on December 11, 2024.

Based on documentation review, record review, and interview, the assisted living home failed to initiate cardiopulmonary resuscitation (CPR) in accordance with its certification training for CPR before the arrival of emergency medical services, to a resident who was nonresponsive or had a cessation of normal respiration, in accordance with that resident's advance directives, for one of one applicable resident. The deficient practice resulted in the death of the resident. Findings include: 1. A review of Department documentation revealed that Mesa Fire and Medical Department (MFMD) responded to the facility at approximately 2145 hours to find R2 laying in a hospital bed not breathing and with no pulse. E3 reported to MFMD that R2 was first discovered unresponsive at 2100 hours, at which point E3 reportedly called the manager. E3 did not call 911. Someone from the facility called hospice but it was unknown who. Once hospice arrived, hospice called 911. E3 told MFMD that E3 did not perform chest compressions at any point, which meant that, according to MFMD, R2 had been deceased for upwards of 45 minutes with no chest compressions being done. A hospice nurse on scene advised MFMD that R2 was full code status and not DNR. MFMD attempted resuscitation but R2 was pronounced deceased at 2214 hours. 2. A review of R2's medical record revealed a "Medina House Group Resident Face Sheet." In the section for Code Status, it stated, "FULL." Further review revealed an "Assisted Living Resident Transfer Checklist," which did not have the box checked for an Advance Directive or DNR because R2 did not have one. 3. A review of E3's personnel record record revealed current CPR/FA certification. 4. In an interview, E5 and E6 confirmed that E3 did not perform CPR on R2. E5 and E6 stated that the facility was unsure of R2's code status because hospice said they were "working on a DNR" for R2 when R2 was first admitted. E5 and E6 acknowledged that the assisted living home failed to initiate CPR in accordance with its certification training for CPR before the arrival of emergency medical services.

Based on documentation review and interview, the manager failed to provide written notification to the Department of a resident’s death, if the resident’s death was required to be reported according to A.R.S. § 11-593, within one working day after the resident’s death, for one of one applicable resident. Findings include: 1. A.R.S. § 11-593 classifies reportable deaths to include "unexpected or unexplained deaths." 2. A review of Department documentation revealed R2 had passed away due to an unexpected death. The Department was notified of R2's death by a staff member from the Mesa Fire and Medical Department due to the unexpected and unusual circumstances surrounding R2's death. At no point in time did the Department receive notification from the facility. 3. In an interview, E5 and E6 reported E5 and E6 did not know it was required to notify the Department. E5 and E6 acknowledged that the manager failed to provide written notification to the Department of R2’s death within one working day after the death.

Based on documentation review and interview, the manager failed to ensure that a documented report was submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of facility documentation revealed a binder that included recent incident reports. There were two incidents from October 13, 2025 involving R4. At 9:15 AM, R4 fell. The details of the report were very minimal. At 9:40 AM, R4 was having shortness of breath. 911 was called and R4 was transported to the hospital. The section titled "Followup / Corrective Action" was left blank. The Medina House Quality Management Meeting Report for October 2025 indicated there were "0" Resident Incident Reports, "0" Falls or Found on Floor, and "0" times 911 was Activated. The "Significant Trends or Other Findings Noted" section was left blank and the "Action Plan" section was also left blank. Further review revealed another incident report from November 11, 2025, also involving R4. The report indicated that "R4 slide down from the recliner." The Medina House Quality Management Meeting Report for November 2025 indicated there were "0" resident incident reports and "0" falls or found on floor. The "Significant Trends or Other Findings Noted" section was left blank and the "Action Plan" section was also left blank. 2. A review of the facility's policies and procedures revealed a policy titled "Quality Management Program." The policy stated, "2. A documented report...that includes: a. An identification of each concern...b. Any change made or action taken as a result of the identification of a concern..." The policy continued to state, "Step #2 - Perform a "Risk Assessment" plus all incident/accident reports. Step #3 - Review "Risk Assessment" for any opportunities to reduce concerns or to reduce risk to residents. Step #4 - Develop and implement a "Corrective Action" on each target concern." 3. In an interview, E5 and E6 acknowledged the manager failed to ensure that the documented monthly report submitted to the governing authority included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care.

Based on documentation review and interview, the manager failed to ensure that documentation of the caregivers and assistant caregivers schedule and days worked, including the hours worked by each, had been completed and was accurate. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a posted work schedule for December 2025. According to the schedule, E4 was working on the night of December 27, 2025. 2. A review of Department documentation indicated that E3 was the staff member working on the night of December 27, 2025. 3. In an interview, E3, E5, and E6 confirmed that E3 was working the night of December 27, 2025, because E4 was sick. 4. In an interview, when asked if any other staff were working the night of December 27, 2025, E5 and E6 stated E3 was the only staff member working. When asked why there was a male staff member referred to in the Department's documentation of the incident being investigated, E5 and E6 said E2 lived in the home and must have come out to the living area at some point. When asked why E7's name was listed as the "Person Representing The Facility That Released The Human Remains" at 12:49 AM on December 28, 2025, E5 and E6 could not provide an answer at first because E5 and E6 did not know why. E5 and E6 then stated that E7 must have spent the night at the facility that night because E7 does so on occasion. 5. In an interview, E6 and E7 acknowledged the schedule did not accurately reflect the caregiver scheduled to work on the night of December 27, 2025.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility before or at the time of an individual’s acceptance by the assisted living facility, for one of three residents reviewed. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's medical record revealed a blank Residency Agreement with other mostly blank admissions forms. 2. In an interview, E5 and E6 reported R1 had recently moved in and E5 and E6 had not yet completed all of the move-in paperwork. E5 and E6 acknowledged the manager failed to ensure there was a documented residency agreement with the assisted living facility before or at the time of R1’s acceptance.

Based on observation, documentation review, and interview, the manager failed to ensure that the means of exiting the facility (both front and back doors) alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Upon arrival to the facility, the Compliance Officer observed the front door to have an alert device; however, the device was turned off. During the environmental inspection, the Compliance Officer observed the back door to have an alert device; however, the device was turned off. In addition, the lock on the back sliding glass door did not work, leaving the back door unsecured and not alarmed. 2. A review of the facility's policies and procedures revealed a policy titled "Wandering Residents." The policy stated, "4. Caregivers will maintain security of locks on the front door, yards and hazardous areas at all times. 5. If alarms are being used on doors and/or windows, the caregivers will check them daily for operation and security. a. Alarms that are triggered will be investigated immediately by the caregiver on duty." 3. In an interview, E5 and E6 acknowledged the alerts on both the front and back door had been turned off, and therefore, the means of exiting the facility (both front and back doors) did not alert employees of the egress of a resident from the facility.

Based on documentation review, observation, and interview, the manager failed to ensure that a food menu included any food substitution no later than the morning of the day of meal service. Findings include: 1. A review of facility documentation at 9:46 AM revealed a menu. The menu indicated that lunch for December 31, 2025, would be "American Meatloaf, Baked Potato w/ Sour Cream, and Buttered Green Beans." There was no other writing or substitution listed on the menu. 2. The Compliance Officer observed the caregiver prepare and serve lunch to the residents. The meal consisted of chicken wings, fried rice, and mixed vegetables. At this time, the menu was still observed to be the same as it was at 9:46 AM. 3. In an interview later in the afternoon, E5 and E6 stated the meatloaf hadn't thawed out so the caregiver had to prepare something different, and E5 and E6 stated the change had been indicated on the menu. 4. The Compliance Officer again reviewed the menu that had been posted on the side of the refrigerator, and observed that an arrow had been drawn to "switch" two of the days. It appeared a line was drawn to "Sauteed Chicken with Mixed Vegetables, Fried Rice." 5. In an interview, E5 and E6 acknowledged the facility's food menu for December 31, 2025, did not include documentation of the food substitution that was made for the lunchtime meal until later in the afternoon on the day the meal was served. 6. This is a repeat citation from the compliance and complaint inspection conducted on December 11, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure that meals provided by the assisted living facility were served according to posted menus. Findings include: 1. A review of facility documentation at 9:46 AM revealed a menu. The menu indicated that lunch for December 31, 2025, would be "American Meatloaf, Baked Potato w/ Sour Cream, and Buttered Green Beans." There was no other writing or substitution listed on the menu. 2. The Compliance Officer observed the caregiver prepare and serve lunch to the residents. The meal consisted of chicken wings, fried rice, and mixed vegetables. At this time, the menu was still observed to be the same as it was at 9:46 AM. 3. In an interview later in the afternoon, E5 and E6 stated the meatloaf hadn't thawed out so the caregiver had to prepare something different, and E5 and E6 stated the change had been indicated on the menu. 4. The Compliance Officer again reviewed the menu that had been posted on the side of the refrigerator, and observed that an arrow had been drawn to "switch" two of the days to indicate that the lunch meal for December 31, 2025, was "Sauteed Chicken with Mixed Vegetables, Fried Rice." 5. In an interview, E5 and E6 acknowledged the meal provided for lunch on December 31, 2025, by the assisted living facility, was not served according to the posted menu.

Based on record review, documentation review, observation, and interview, the manager failed to ensure that a resident received orientation to the exits from the assisted living home and the route to be used when evacuating the assisted living home within 24 hours after the resident’s acceptance by the assisted living home, and the resident’s orientation was documented. Findings include: 1. A review of R1's medical record revealed a blank "Residency Emergency Orientation" form. 2. A review of the facility's policies and procedures revealed a policy titled "Evacuation Plan." The policy stated, "To ensure the personal safety of all residents and employees, everyone needs to understand the process of evacuating the facility therefore; the following requirements are to be clearly understood and accomplishable...A manager shall ensure that 1. A resident receives orientation to the exits...within 24 hours after the resident's acceptance..., and 2. The resident's orientation is documented...Residents will be oriented to the evacuation plan within twenty-four hours of their admission...Each resident or representative will be oriented to the following by explanation and/or demonstration: a. Entry/exit doors; b. How to open and close windows; c. Location and use of fire extinguishers; ..." 3. During the environmental inspection, the Compliance Officer observed R1's window to be blocked by a dresser and R1's personal belongings, and the fire extinguisher in the hallway was marked as "non-compliant." 4. In an interview, E5 and E6 reported R1 had recently moved in and E5 and E6 had not yet completed all of the move-in paperwork. E5 and E6 acknowledged the manager failed to ensure R1 received orientation to the exits from the assisted living home and the route to be used when evacuating the home within 24 hours after R1’s acceptance, and that the orientation was documented.

Based on observation, documentation review, and interview, the manager failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months, and had a tag attached to the fire extinguisher that specified the date of the last servicing and the identification of the person who serviced the fire extinguisher. Findings include: 1. During the environmental tour, the Compliance Officer observed a fire extinguisher affixed to the wall in the hallway. The tag on the fire extinguisher had been marked as "NON-COMPLIANT" in October 2025 by Metro Fire+Security. 2. A review of facility documentation revealed a Mesa Fire and Medical Department (MFMD) Fire Inspection Report dated November 13, 2025. There were five violations noted in the report. Violation Code 906.2 stated, "Portable fire extinguishers shall be selected, installed and maintained in accordance with this section and NFPA 10...The fire extinguishers are tagged non-compliant. Have your licensed third party contractor rectify the problem and tag them compliant." 3. In an interview, E5 and E6 acknowledged the violation noted from the Fire Inspection Report, and stated the facility had ordered new fire extinguishers and that they were in the closet, but the facility hadn't taken them out of the box and hung them up yet. E5 and E6 acknowledged the current fire extinguisher affixed to the hallway wall was non-compliant and in violation according to MFMD.

Based on observation and interview, the manager failed to ensure that the premises of the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to residents. Findings include: 1. During the environmental inspection, the Compliance Officer observed R1's only bedroom window to be blocked by a dresser, along with large bags and miscellaneous items piled up several feet high on either side of the dresser and in front of the dresser. In addition, there were other large black garbage bags filled with the R1's property, blankets, personal belongings, and large boxes of medical supplies impeding the walkway around R1's bed. 2. Upon further inspection, the Compliance Officer observed R4's only bedroom window to be blocked by a dresser and a nightstand. 3. Upon further inspection, the Compliance Officer observed R6's only bedroom window to be blocked by R6's headboard. R6's bed was not on wheels, therefore, R6's bed and headboard would have to be moved to access the bedroom window. 4. Upon further inspection, the Compliance Officer observed the lock on the back sliding glass door to be broken. In addition, from the outside, the handle of the sliding glass door was not secured to the door and was missing the screw that was used to attach the handle to the door. The alerts to notify caregivers of a resident's egress from the home were also turned off. 5. In an interview, E5 and E6 acknowledged that R1's, R4's, and R6's direct egress from their bedroom windows was impeded by furniture; that the clutter in R1's room was a potential safety hazard; that the lock on the back sliding glass door was broken or not functioning properly; and that the alerts to notify caregivers of a resident's egress from the home were also turned off.

Based on observation and interview, the manager failed to ensure that a resident’s sleeping area had a window that could be used for direct egress to outside the building, for three of eight resident rooms observed. The deficient practice posed a risk to the physical health and safety of a resident in the event of an emergency. Findings include: 1. During the environmental inspection, the Compliance Officer observed R1's only bedroom window to be blocked by a dresser, along with large bags and miscellaneous items piled up several feet high on either side of the dresser and in front of the dresser. 2. Upon further inspection, the Compliance Officer observed R4's only bedroom window to be blocked by a dresser and a nightstand. 3. Upon further inspection, the Compliance Officer observed R6's only bedroom window to be blocked by R6's headboard. R6's bed was not on wheels, therefore, R6's bed and headboard would have to be moved to access the bedroom window. 4. In an interview, E5 and E6 acknowledged that R1's, R4's, and R6's windows that could be used for direct egress to outside the facility were impeded by furniture.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that accurately included the amount, type, and frequency of assisted living services being provided to the resident, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated December 3, 2024. R1's service plan stated R1 required assistance with incontinence care and dressing. However, R1's service plan did not state the amount of services R1 was expected to receive. 2. A review of R2's medical record revealed a service plan dated December 5, 2024. R2's service plan stated R2 required assistance with incontinence care and dressing. However, R2's service plan did not state the amount of services R2 was expected to receive. 3. In an interview, E1 acknowledged R1's and R2's service plans did not reflect the amount of incontinence care and dressing services R1 and R2 would be expected to receive.

Based on documentation review, observation and interview, the manager failed to ensure a food substitution was documented on the posted menu. This posed a health and safety risk if residents are not provided meals that meet their nutritional needs. Findings include: 1. A review of the facility's posted food menu for December 11, 2024 reflected the following meal would be served: - Lunch: American meatloaf, baked potato with sour cream, coleslaw juice and water. 2. The compliance officer observed six residents eating spaghetti with toasted rolls for lunch. There were no vegetables or fruit observed with the residents' meal. 3. In an interview, E1 acknowledged the residents were not provided lunch according to the posted menu and the substitution was not documented.

Based on documentation review and interview, the governing authority failed to designate, in writing, a manager who has either a certificate as an assisted living facility manager (ALM) issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. A review of https://elicense.az.gov/ARDC_LicenseSearch revealed E1's ALM license had expired effective June 30, 2023. 2. A review of Department documentation revealed an email from a representative from the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). The email revealed E1's license expired on June 30, 2023 and a renewal application had not been received by the NCIA Board. 3. In a telephonic interview, E2 reported E4 was hired as the manager on August 14, 2023. 4. In an interview, E3 acknowledged the facility did not have a manager from July 1, 2023 to August 14, 2023 as E1's manager license had expired.

Based on documentation review, record review, and interview, the governing authority failed to notify the Department according to 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. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. A review of https://elicense.az.gov/ARDC_LicenseSearch revealed E1's ALM license had expired effective June 30, 2023. 2. A review of Department documentation revealed an email from a representative from the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). The email revealed E1's license expired on June 30, 2023 and a renewal application had not been received by the NCIA Board. 3. A review of E4's personnel record revealed a license, issued by the NCIA Board, issued on December 28, 2007. 2. In a telephonic interview, E2 reported E4 was hired as the manager on August 14, 2023. 3. In an interview, E3 acknowledged the governing authority did not notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training and first aid training, for one of two personnel member sampled. The deficient practice posed a risk if E4 unable to meet a resident's needs during an accident, emergency, or injury; and if E4 unable to provide first aid to a noninjured resident who had fallen and was unable to reasonably recover independently. Findings include: 1. A review of documentation provided by E3, for E4, revealed documentation of first aid and cardiopulmonary resuscitation (CPR) training. However, the training card had an expiration date of March 5, 2023. 2. In an interview, E3 acknowledged E4's training had expired and documentation of E4's current CPR and first aid training was not available for review.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the requirements in R9-10-806(C)(1)(a)(b)(c)(i)(ii)(iii)(ix), for one of two employees employees sampled. The deficient practice posed a risk if E4 was unable to meet a resident's needs, and the required information could not be verified for E4. Findings include: 1. A review of documentation provided by E3, for E4, revealed the following documentation for E4: -Manager's ALM license; and -Evidence of freedom from infectious tuberculosis. However, documentation of the requirements in R9-10-806(C)(1)(a)(b)(c)(i)(ii)(iii) was not available for review. 2. In an interview, E1 acknowledged E4's personnel record to include the requirements in R9-10-806(C)(1)(a)(b)(c)(i)(ii)(iii) was not available for review.

Based on record review and interview, the manager accepted an individual requiring continuous nursing services, for one of one discharged resident sampled. The deficient practice posed a risk as an assisted living facility is not authorized to provide continuous nursing services. Findings include: 1. A review of R1's (accepted in 2023 and discharged in 2023) medical record revealed a document titled "ADMISSION ORDERS or CONSENT to CONTINUE RESIDENCY." The document stated "...Please check the appropriate boxes...Resident requires Continuous Nursing Services:...Yes...No..." The box next to "Yes" was marked to indicate R1 required continuous nursing services. 2. In an interview, E3 reported the Veterans Affair (VA) was to assist R1; however the VA never got involved. E3 acknowledged the document indicated R1 required continuous nursing services.