Mosaic Garden Memory Care at Scottsdale

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. A review of facility documentation revealed a policy and procedure (P&P) titled, "Abuse, Neglect, and Exploitation.” The P&P stated: “[W]hen abuse is suspected, staff and volunteers are required to immediately provide notification to persons/agencies as described in this policy…2. All staff and volunteers at Mosaic Management Inc. are ‘mandated reporters.’...5. Abuse, neglect, and exploitation is reported to…Adult Protective Services (APS).” 4. A review of facility documentation revealed two documents titled “Incident Report” detailing an incident which occurred between R2 and R3 on February 19, 2026, at 1:30 PM. The reports revealed the incident was romantic/sexual in nature. The report for R3 included a section titled "ABUSE REPORTING" which stated: "If abuse can not be ruled out at time of incident, then it must be reported immediately. Ruled out abuse and neglect? No." Both reports further revealed facility personnel reported the suspected abuse on February 20, 2026, at 10:20 AM, more than 20 hours after the incident. 5. In an interview, E1 reported E1 originally did not believe E1 needed to report the incidents to APS as E1 did not believe the incident constituted abuse. E1 reported E1 wanted to talk to the family members of R2 and R3 before reporting to APS. 6. In the exit interview, the Compliance Officer reviewed the findings with E1, and E1 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on February 17, 2026, and a repeat citation from the complaint inspection conducted on November 5, 2025; the complaint inspection completed on December 6, 2024; and the complaint and compliance inspection conducted on September 10-11, 2024.

Based on record review, interview, and observation, the manager failed to ensure a medication was administered in compliance with a medication order, for three of three sampled residents. The deficient practice posed a risk if the 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 “RisperDal Oral Tablet 1 MG…Take 1 tablet (1 MG) by mouth one time daily at bedtime” and “traZODone HCI Oral Tablet 100 MG…Give 1 tablet (100MG) by mouth once daily at bedtime.” The review further revealed a medication administration record (MAR) dated February 2026. The MAR revealed R1 started taking the Risperdal on March 27, 2024, and the trazodone on December 23, 2023. The MAR further indicated the following: - Facility personnel administered R1’s Risperdal on February 1, 5, 7-8, 10-15, and 17-22, 2026; - Facility personnel did not administer R1’s Risperdal on February 2-4, 6, 9, and 16, 2026, as the “Medication [was] unavailable;” - Facility personnel administered R1’s trazodone on February 5, 8, 10, 14, and 19-22, 2026; and - Facility personnel did not administer R1’s trazodone on February 1-4, 6-7, 9, 11-13, and 15-18, 2026, as the “Medication [was] unavailable.” 2. In a series of interviews, E4 reported the facility did not have R1’s Risperdal and trazodone for a period of approximately two weeks in the beginning of February. E4 reported facility personnel did not administer the medications, including on many days facility personnel documented the medications as administered. E4 and E6 reported E4 and E6 documented the medication as administered in the beginning of February by mistake. 3. The Compliance Officers observed delivery receipts for R1’s Risperdal and trazodone dated February 19, 2026, confirming E4’s and E6’s reports. 4. A review of R2’s medical record revealed a current service plan which indicated R2 received medication administration. The review revealed the following medication orders: - “Acetaminophen 325mg 2 tabs po at 12 PM and 8 PM X 1 week” dated February 17, 2026; - “Hydrocodone 5/325mg 1 tab po at 8AM and 4PM X 1 week” dated February 17, 2026; - “Lisinopril 5 mg Oral Daily” dated February 3, 2026; and - “Tylenol 500 mg 2 tabs po BID at 8AM and 8PM,” with a start date of February 18, 2026. The review further revealed a MAR dated February 2026 which indicated the following: - Facility personnel did not administer R2’s acetaminophen; - Facility personnel did not administer R2’s hydrocodone; - Facility personnel did not administer R2’s lisinopril on February 9-10, 2026, as the “Medication [was] unavailable;” and - Facility personnel did not administer R2’s Tylenol at 8:00 PM on February 21, 2026, or at 8:00 AM on February 22, 2026, as the “Medication [was] unavailable.” 5. In an interview, E3 reported facility personnel did not

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. A review of facility documentation revealed a policy and procedure (P&P) titled, "Abuse, Neglect, and Exploitation.” The P&P stated: “[W]hen abuse is suspected, staff and volunteers are required to immediately provide notification to persons/agencies as described in this policy…2. All staff and volunteers at Mosaic Management Inc. are ‘mandated reporters.’...5. Abuse, neglect, and exploitation is reported to…Adult Protective Services (APS).” 4. In an interview, E1 reported two incidents between R1 and R2 which occurred on January 5 and 9, 2026. 5. A review of facility documentation revealed three documents titled “Incident Report” detailing the incidents which occurred on January 5 and 9, 2026. The reports revealed the incidents were romantic/sexual in nature. 6. In an interview, E1 reported E1 originally did not believe E1 needed to report the incidents to APS as R1 and R2 reported the contact between the two was consensual and did not include penetration. E1 reported E1 was instructed by upper management on February 9, 2026, to report the incidents. E1 reported E1 called APS on February 11, 2026, to report the incidents and APS came to the facility on February 13, 2026, to investigate. 7. A review of E1’s cell phone call logs revealed an outgoing call to APS on February 11, 2026, lasting 22 minutes. 8. In the exit interview, the Compliance Officer reviewed the findings and E1 and E1 offered no further comment. This is an uncorrected citation from the complaint inspection conducted on November 5, 2025, and a repeat citation from the complaint inspection completed on December 6, 2024, and the complaint and compliance inspection conducted on September 10-11, 2024.

Based on documentation review and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk as a personnel member injured a resident. Findings include: 1. A review of facility documentation revealed an incident report detailing an incident between E3 and R1 at 8:45 AM on October 27, 2025. The report stated: “I was walking by [R1’s] room and overheard [a] verbal altercation…As I walked into the room, I heard [E3] yelling at [R1]. I walked into the bathroom and witnessed [E3] slap [R1] in the face. [R1] cried out in pain and [E3] said don’t spit on me after hitting [R1], I told [E3 that E3] cannot hit [R1], and [E3] said [E3] didn’t when I told [E3] I witnessed it [E3] then apologized.” The indecent report stated: “Was there any serious loss of personal dignity? Yes. Comments: [R]esident being hit.” 2. In an interview, E2 confirmed the account of the incident report and reported E3 was terminated.

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. A review of facility documentation revealed an incident report detailing an incident between E3 and R1 at 8:45 AM on October 27, 2025. The report stated: “I was walking by [R1’s] room and overheard [a] verbal altercation…As I walked into the room, I heard [E3] yelling at [R1]. I walked into the bathroom and witnessed [E3] slap [R1] in the face. [R1] cried out in pain and [E3] said don’t spit on me after hitting [R1], I told [E3 that E3] cannot hit [R1], and [E3] said [E3] didn’t when I told [E3] I witnessed it [E3] then apologized.” The indecent report stated: “Was APS or state specific reporting agency notified? Yes…APS or state specific reporting agency notification date: 10/27/2025 11:00AM.” The report further revealed a printout of the report made to Adult Protective Services (APS). 4. In an interview, E2 reported E1 did not report the abuse until 11:00 AM because E1 was awaiting instructions from corporate. This is a repeat citation from the complaint inspection completed on December 6, 2024, and the complaint and compliance inspection conducted on September 10-11, 2024.

Based on documentation review and interview,, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a personnel member injured a resident. Findings include: 1. A review of facility documentation revealed an incident report detailing an incident between E3 and R1 at 8:45 AM on October 27, 2025. The report stated: “I was walking by [R1’s] room and overheard [a] verbal altercation…As I walked into the room, I heard [E3] yelling at [R1]. I walked into the bathroom and witnessed [E3] slap [R1] in the face. [R1] cried out in pain and [E3] said don’t spit on me after hitting [R1], I told [E3 that E3] cannot hit [R1], and [E3] said [E3] didn’t when I told [E3] I witnessed it [E3] then apologized.” The indecent report stated: “Was there any serious loss of personal dignity? Yes. Comments: [R]esident being hit.” 2. In an interview, E2 confirmed the account of the incident report and reported E3 was terminated.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included terms of occupancy, including the date of occupancy or expected date of occupancy, for two of two sampled residents. Findings include: 1. A review of R1's and R2’s medical records revealed residency agreements. However, the residency agreements did not include R1's and R2’s dates of occupancy or expected dates of occupancy. 2. In an interview, E1 acknowledged R1’s and R2’s residency agreements did not include this information.

Based on documentation review and interview, the manager of an assisted living center who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of facility documentation revealed an incident report which indicated R1 had an accident, emergency, or injury on December 21, 2024, that resulted in facility personnel contacting an emergency responder on R1's behalf. The review further revealed an incident report which indicated R3 had an accident, emergency, or injury on December 9, 2024, that resulted in facility personnel contacting an emergency responder on R3's behalf. 2. In an interview, the Compliance Officer requested documentation in compliance with this statute for the two aforementioned incidents. E1 stated, "just the face sheets" attached to the incident reports were the documents provided to the emergency responders. 3. A review of facility documentation revealed face sheets for R1 and R3. However, R1's face sheet provided to the emergency responder did not include the following: - The reason or reasons the emergency responder was requested on behalf of R1; - The name, address and telephone number of R1's current pharmacy; - Basic information about R1's medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes; - The point-of-contact information for the assisted living center, including the email address; and - A copy of R1's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center to plan for R1's discharge. 4. R3's face sheet provided to the emergency responder did not include the following: - The reason or reasons the emergency responder was requested on behalf of R3; - The address number of R3's current pharmacy; - Basic information about R3's medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes; - The point-of-contact information for the assisted living center, including the email address; and - A copy of R3's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center to plan for R3's discharge. 5. In an interview, E1 acknowledged the written documents provided to emergency responders on December 9 and 21, 2024, did not include all required information. Technical assistance was provided on this statute during the complaint and compliance inspection conducted on September 11, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirement in R9-10-814(F)(2), for two of three sampled residents. Findings include: 1. R9-10-814(F)(2) states, "In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes offering sufficient fluids to maintain hydration." 2. A review of R1's and R3's medical records revealed current service plans which revealed R1 and R3 were receiving directed care services. However, the service plans did not include offering sufficient fluids to maintain hydration. 3. In an interview, E1 acknowledged R1's and R3's service plans did not include offering sufficient fluids to maintain hydration.

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. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 2. A review of facility documentation revealed an incident report which indicated R1 had an accident, emergency, or injury on December 21, 2024, that resulted in R1 needing medical services. However, the incident report revealed facility personnel did not notify R1's primary care provider until December 23, 2024. The review further revealed an incident report which indicated R3 had an accident, emergency, or injury at 11:00 AM on December 9, 2024, that resulted in R3 needing medical services. However, the incident report revealed facility personnel did not notify R3's primary care provider until 1:25 PM on December 9, 2024. 3. In an interview, E1 acknowledged a caregiver or an assistant caregiver did not immediately notify R1's and R3's primary care providers as required by rule. Technical assistance was provided on this rule during the complaint inspection conducted on September 30, 2024.

Based on documentation review, interview, and observation, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) \'a7 46-454 and document the names of witnesses to the suspected abuse and the actions taken by the manager to prevent the suspected abuse from occurring in the future. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. \'a7 46-454(A) states: "A health professional... or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. A review of facility documentation revealed an incident report dated October 16, 2024. The incident report revealed the manager had a reasonable basis to believe abuse occurred on the premises. The report included a section titled "ABUSE REPORTING" which stated: "If abuse can not be ruled out at time of incident, then it must be reported immediately. Ruled out abuse and neglect? No." The report revealed facility personnel reported the suspected abuse on October 17, 2024, at 8:04 AM, more than 20 hours after the incident. 4. In an interview, E1 reported E1 first learned of the incident via text message on October 16, 2024, at 5:24 PM. E1 reported E1 asked facility personnel via text message on October 17, 2024, at 7:26 AM to report the suspected abuse to Adult Protective Services. 5. The Compliance Officer observed the text messages in question confirmed E1's report. This is an uncorrected citation from the compliance and complaint inspection conducted on September 11, 2024.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. The deficient practice posed a risk if measures were not in place for staff to always know the whereabouts of a resident. Findings include: 1. In documentation review, the facility's policies and procedures revealed no documentation covering methods by which the facility was aware of the general or specific whereabouts of a resident, as required. 2. In an interview, E2 acknowledged not having a policy that covered methods by which the facility was aware of the general or specific whereabouts of a resident. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on September 11, 2024.

Based on documentation review, interview, and record review, the manager failed to ensure an assisted living facility had a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety of a resident. The deficient practice posed a risk as employees were unable to ensure the health and safety of a resident. Findings include: 1. A review of facility documentation revealed an incident report dated January 22, 2024. The incident report stated: "[R1] was found on floor during room check by [personnel]. Resident was on floor, face down, head towards top of bed, feet pointing towards bathroom. [R1] has a laceration to [R1's] right side head." The report stated, an"Investigation of carestaff activities" was to be conducted to "lead to concludion [ sic ] of how fall occurred." The report stated revealed R1 was last seen by facility personnel at 8:00 PM the night before and stated, "Hourly checks were not completed by carestaff on duty. Carestaff responsible [E4] was terminated...[E4] claimed [R1's] apartment door was propped open and [E4] could see [R1] in bed. Watching the camera the door was not open enough to see [R1] in bed. [R1] was not checked on until 2:35am." 2. In an interview, E1 reported E4's employment was terminated for leaving R1 in R1's bedroom, not putting R1 to bed, and not checking on R1 every two hours as required. 3. A review of E4's personnel record revealed a "Corrective Action Form" dated January 24, 2024. The document indicated E4's employment had been terminated. The document stated: "On 1/22/24 you reported a fall for [R1]. In your written statement you stated that you put [R1] in [R1's] bed and checked on [R1] during your shift. After reviewing the video we were unable to substantiate your statement. [R1] was placed in [R1's] apartment at 7:52pm and you left [R1's] apartment at 7:55pm. [R1] was in the same clothing and [R1's] bed was made indicating that [R1] had not been put in bed...Based on the severity of these issues and potential harm to the residents we are terminating your employment immediately." 4. In an interview, E1 confirmed E4's employment was terminated due to E4 not meeting the needs and ensuring the health and safety of R1.

Based on record review, documentation 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 three sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated January 3, 2024. The service plan stated: "Resident needs carestaff assistance with dressing and undressing...Incontinence pads, Briefs, Bowel incontinent, Bladder incontinent, Night checks. Carestaff to assist resident with toileting every two hours, including changing brief and cleaning." 2. A review of facility documentation revealed an incident report dated January 22, 2024. The incident report stated: "[R1] was found on floor during room check by [personnel]. The report stated, an"Investigation of carestaff activities" was to be conducted to "lead to concludion [sic] of how fall occurred." The report stated revealed R1 was last seen by facility personnel at 8:00 PM the night before and stated, "Hourly checks were not completed by carestaff on duty. Carestaff responsible [E4] was terminated...[E4] claimed [R1's] apartment door was propped open and [E4] could see [R1] in bed. Watching the camera the door was not open enough to see [R1] in bed. [R1] was not checked on until 2:35am." 3. A review of E4's personnel record revealed a "Corrective Action Form" dated January 24, 2024. The document indicated E4's employment had been terminated. The document stated: "On 1/22/24 you reported a fall for [R1]. In your written statement you stated that you put [R1] in [R1's] bed and checked on [R1] during your shift. After reviewing the video we were unable to substantiate your statement. [R1] was placed in [R1's] apartment at 7:52pm and you left [R1's] apartment at 7:55pm. [R1] was in the same clothing and [R1's] bed was made indicating that [R1] had not been put in bed." 4. In an interview, E1 confirmed E4's employment was terminated for leaving R1 in R1's bedroom, not putting R1 to bed, and not checking on R1 every two hours as required.

Based on documentation review, interview, and record review, 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 three sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed an incident report which revealed R1 was sent to the hospital at approximately 3:00 AM on January 22, 2024. 2. In an interview, E1 reported R1 returned to the facility from the hospital after noon on January 22, 2024. 3. A review of R1's medical record revealed documentation of assisted living services provided to R1 (ADLs) on January 22, 2024. The ADLs revealed documentation demonstrating E7 provided R1 assistance with dressing, grooming, and toileting the morning of January 22, 2024. However, R1 was in the hospital at this time. The review further revealed no other ADLs for R1 between admission and termination of residency other than several days in February and a few shower reports. 4. A review of facility documentation revealed E7 was not scheduled to work on January 22, 2024. 5. In an interview, E1 reported E7 was the Resident Care Coordinator at the time, was not working as a caregiver, and did not provide any services to R1 on January 22, 2024. When the Compliance Officer asked why E7 signed off on R1's ADLs, E1 stated, "Just to check it off [E7's] list." Regarding the missing ADLs, E1 reported the facility switched to a different ADL documenting system in March and the ADLs provided were all the ADLs the facility had for R1.