Mosaic Gardens Memory Care at Chandler

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; document the immediate action to stop the suspected abuse and document 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. § 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 (A.A.C.) R9-10-101(111) states, "'Immediate' means without delay." 3. A review of the department documentation revealed, "...On 01/03/2026 at approximately 1122 hours...responded to a rape..." 4. A review of facility documentation revealed an incident report regarding R1 and E3 dated January 3, 2026. The report stated, “family states that R1 was raped…” However, Adult Protective Services (APS) was only notified by E2 on January 7, 2026, by phone, and no documented immediate action was taken to stop the suspected abuse. In addition, the incident report did not include documentation for any action taken to prevent the incident from occurring in the future. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat citation from the inspection conducted on March 7, 2024; a repeat citation from the inspection conducted on December 10-11, 2024; and an uncorrected citation from the inspection conducted on December 2, 2025.

Based on documentation review, interview, and record review, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently and required information could not be verified. Findings include: 1. A review of facility documentation revealed no policy and procedure (P&P) covering training regarding fall prevention and fall recovery, including the time frame for continued competency training. However, the review revealed a P&P titled “Staffing and Training Requirements.” The P&P stated: “5. Training Requirements: a. All care staff, including medication staff will be training in accordance with state regulations. b. All training including orientation, initial training and annual training will be documented in the employee’s file. c. Refer to the Business Office for training requirements and documentation.” The review further revealed a list of 54 current employees of the facility, which included the position, and/or hire date of 51 of the 54 employees. 2. In an interview, the Compliance Officers requested E1’s, E5’s, E6’s, E7’s, E8’s, E9’s, E10’s, and E11’s personnel records. E2 reported all personnel records were locked in the business office and E1 was the only individual with the key. E2 reported E1 was not at the facility and was unable to come to the facility during the inspection. The Compliance Officers informed E2 the Compliance Officers needed the personnel records to ensure compliance with applicable rules. E2 reported E2 would try to get the personnel records. 3. In a telephonic interview, E2 told E1 that E2 was unable to get into the business office to obtain the personnel records. After a brief pause, E2 stated, “[E1] said, ‘It is what it is.’” 4. A review revealed no personnel records for E1, E5, E6, E7, E8, E9, E10, E11, and all 46 other employees. This is a repeat citation from the complaint inspections conducted on April 15, 2025, and April 1, 2025.

Based on record review, documentation review, and interview, the manager of an assisted living center who contacted an emergency responder on behalf of a resident failed to maintain a written document with all required information to be given to the emergency responder for eight of eight residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic 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, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of facility documentation revealed standardized forms for R1, R2, R3, R4, R5, R6, R7, and R8. However, the standardized form to be provided to an emergency responder did not include the following; -The name, address, and telephone number of the resident's current pharmacy. -A copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital

Based on documentation review, record review, and interview, the manager failed to ensure that an assisted living center maintained a copy of the document provided to the emergency responders and documentation of the actions required for a period of two years after the date of the emergency. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A.R.S. § 36-420.04.A.1-9 states, “Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: (...).” 2. A review of R6’s medical record revealed that the assisted living center contacted emergency responders on August 19, 2025, and the incident report stated that “... 911 was called due to the resident’s abnormal behavior...”; however, no documentation showed that an emergency responder was provided with the required documentation in A.R.S. § 36-420.04.A.1-9. 3. In an interview, E3 reported the facility did not keep a copy provided to the emergency responder on August 19, 2025, for R6. 4. In an exit interview, the findings were reviewed with E2 and E3, and no additional information was provided. Technical assistance was provided on this rule during the complaint, compliance, and on-site plan of correction follow-up inspection conducted on November 13-14, 2024.

Based on documentation review, interview, and record review, 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 eight of eight sampled employees, and annually assessing the health care institution’s risk of exposure to infectious TB. The deficient practice posed a potential TB exposure risk to residents and required information could not be verified. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Tuberculosis: Care Staff.” The P&P stated, “Mosaic Management Inc. will provide annual education to staff and volunteers regarding the signs and symptoms of TB.” The review revealed a P&P titled “Staffing and Training Requirements.” The P&P stated: “5. Training Requirements: a. All care staff, including medication staff will be training in accordance with state regulations. b. All training including orientation, initial training and annual training will be documented in the employee’s file. c. Refer to the Business Office for training requirements and documentation.” The review further revealed a list of 54 current employees of the facility, which included the position, and/or hire date of 51 of the 54 employees. The list revealed E1 was the manager and E5, E6, E7, E8, E9, E10, E11 and 25 others were caregivers. 2. In an interview, the Compliance Officers requested E1’s, E5’s, E6’s, E7’s, E8’s, E9’s, E10’s, and E11’s personnel records. E2 reported all personnel records were locked in the business office and E1 was the only individual with the key. E2 reported E1 was not at the facility and was unable to come to the facility during the inspection. The Compliance Officers informed E2 the Compliance Officers needed the personnel records to ensure compliance with applicable rules. E2 reported E2 would try to get the personnel records. 3. In a telephonic interview, E2 told E1 that E2 was unable to get into the business office to obtain the personnel records. After a brief pause, E2 stated, “[E1] said, ‘It is what it is.’” 4. A review revealed no personnel records for E1, E5, E6, E7, E8, E9, E10, E11 and all 46 other employees (including 25 other caregivers). 5. A review of facility documentation revealed no documentation demonstrating facility personnel assessed the health care institution’s risk of exposure to infectious TB. Technical assistance was provided on this rule during the on-site abbreviated initial follow-up inspection conducted on July 12, 2023.

Based on observation, record review, documentation review and interview, for one of two residents sampled, who received opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident's health and safety if the facility did not appropriately assess and monitor opioid administration for a resident. Findings include: 1. During the environmental inspection, R3's medications were observed at the facility, and included "traMADol HCL 50MG TABLET, 1 TAB BY MOUTH EVERY NIGHT AT BEDTIME for pain.” 2. A record review of R3's medical record revealed a service plan for directed care services and medication administration services. A review of R1's medication order revealed "traMADol HCL 50MG TABLET, 1 TAB BY MOUTH EVERY NIGHT AT BEDTIME for pain.” A review of R3's medication administration record (MAR) included documentation that R3 received the traMADol HCL 50MG medication daily from October 2025 to present. The medical record did not include documentation of an identification of the need for the opioid before the opioid was administered, nor did it include monitoring of the effect of the opioid administered. 3. A review of R3's medical record did not include documentation of an active malignancy or an end-of-life condition. 4. A review of facility policies revealed a policy titled "MP 28 - Pain Managment and Opioid Medications." The policy stated, "8. Opioid Medication "f. Opioid Administration and Assistance with self-administration must include: i. Identification and documentation of the resident’s pain level prior to medication using the pain scale. 1. The Pain Rating forms may be used. ii. Monitoring resident’s response to medication. iii. Documenting the effectiveness of medication forty-five (45) minutes after administration in resident’s record. g. Document on the MAR the resident’s need, monitoring, and response to the medication. This documentation shall include: i. The name of the staff member responsible for administering/assisting the resident with the opioid medication, ii. The resident’s level of pain prior to administering the medication, iii. How the resident’s level of pain was assessed, iv. How the resident’s response was monitored including the time and person(s) responsible for monitoring, and v. The resulting effect of the medication on the resident." 4. In an exit interview, the findings were reviewed with E2 and E3, and no additional information was provided.

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 cardiopulmonary resuscitation (CPR) training for applicable employees and volunteers, including all items required by this rule. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Staffing and Training Requirements.” The P&P stated: “6. Each Community must have at least one (1) staff member trained in CPR and First Aid [on duty] and on the premises at all times. a. All care staff will be trained in CPR and First Aid. b. Documentation is retained in the employee’s file.” However, the P&P did not include the following: - The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee’s or volunteer’s ability to perform cardiopulmonary resuscitation; - The qualifications for an individual to provide cardiopulmonary resuscitation training; - The time-frame for renewal of cardiopulmonary resuscitation training; and - The documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training. 2. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no additional information. Technical assistance was provided on this rule during the complaint, compliance, and on-site plan of correction follow-up inspection conducted on November 13-14, 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 to cover 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 as policies and procedures reinforce and clarify standards expected of employees and facility personnel were unaware of the whereabouts of a resident. Findings include: 1. A review of facility documentation revealed no policy and procedure (P&P) in compliance with this rule. 2. In an interview, E2 reported E2 had provided the entire P&P manual. 3. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no additional information. This is an uncorrected citation from the complaint inspections conducted on April 1, 2025, and January 28, 2025.

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.) § 46-454 and document the time of the suspected abuse and the names of witnesses to the suspected abuse. The deficient practice posed a risk to the physical health and safety of a resident and the Department was provided false or misleading information. 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 two incident reports. The reports revealed an altercation between R1 and R7 occurred at 9:31 PM on November 10, 2025, and the incident reports revealed the manager had a reasonable basis to believe abuse occurred on the premises. Both reports included a section titled “ABUSE REPORTING.” The “ABUSE REPORTING” section for R1’s report revealed facility personnel reported the suspected abuse to Adult Protective Services (APS) at 3:54 PM on November 2, 2025, more than one week before the altercation. The “ABUSE REPORTING” section for R7’s report revealed facility personnel reported the suspected abuse to APS at 11:16 AM on November 11, 2025, more than 12 hours after the altercation. The reports further did not include names of witnesses to the suspected abuse. 4. In an interview, E2 and E3 reported the incident occurred at approximately 7:30 PM and not 9:31 PM as stated in the two incident reports, making the time between the altercation and the report to APS greater. When the Compliance Officers informed E2 any suspected abuse, neglect, or exploitation must be reported immediately, E2 stated, “Even at night?” E2 acknowledged facility personnel did not report the suspected abuse immediately and the report did not include the names of the witnesses. This is a repeat citation from the complaint inspection conducted on December 10-11, 2024; an uncorrected citation from the complaint and compliance inspection conducted on November 13-14, 2024; and a repeat citation from the complaint inspection conducted on March 7, 2024.

Based on documentation review, interview, and record review, 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 there was incomplete documentation identifying the staff present each day to ensure the health and safety of residents and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a series of personnel schedules dated between November 10, 2024, and December 21, 2024, as well as between July 13, 2025, and the date of the inspection. However, the review revealed no personnel schedule between December 22, 2024, and July 12, 2025. 2. In an interview regarding the missing personnel schedules, E2 stated, “I can’t find them.” However, E2 reported the personnel schedules E2 did provide were accurate. 3. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed documentation of assisted living services (ADLs) provided to the eight residents and medication administration records (MARs). The ADLs and MARs revealed the following: - E9 provided assisted living services in the AM on December 1, 2025, and in the PM on November 1, 2025; - E12 administered medication at 7:00 AM and 12:00 PM on October 4, 2025; - E13 administered medication at 7:00 AM and 12:00 PM on November 1, 2025; and - E14 provided assisted living services in the AM on November 9, 2025. 4. A review of facility documentation revealed the aforementioned personnel schedules. The schedules revealed documentation demonstrating the following in contradiction with the ADLs and MARs: - E9 did not work in the AM on December 1, 2025, or in the PM on November 1, 2025; - E12 did not work at 7:00 AM or 12:00 PM on October 4, 2025; - E12 did not work at 7:00 AM or 12:00 PM on November 1, 2025; and - E14 did not work in the AM on November 9, 2025. 5. In an interview, E2 reported facility personnel forgot to update the personnel schedules when there was a change. E2 acknowledged the personnel schedules were not accurate. Technical assistance was provided on this rule during the complaint, compliance, and on-site plan of correction follow-up inspection conducted on November 13-14, 2024.

Based on documentation review, interview, and record review, the manager failed to ensure a personnel record for each employee included the items required by this rule, for eight of eight sampled employees. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Staffing and Training Requirements.” The P&P stated: “5. Training Requirements: a. All care staff, including medication staff will be training in accordance with state regulations. b. All training including orientation, initial training and annual training will be documented in the employee’s file. c. Refer to the Business Office for training requirements and documentation.” The review further revealed a list of 54 current employees of the facility, which included the position, and/or hire date of 51 of the 54 employees. 2. In an interview, the Compliance Officers requested E1’s, E5’s, E6’s, E7’s, E8’s, E9’s, E10’s, and E11’s personnel records. E2 reported all personnel records were locked in the business office and E1 was the only individual with the key. E2 reported E1 was not at the facility and was unable to come to the facility during the inspection. The Compliance Officers informed E2 the Compliance Officers needed the personnel records to ensure compliance with applicable rules. E2 reported E2 would try to get the personnel records. 3. In a telephonic interview, E2 told E1 that E2 was unable to get into the business office to obtain the personnel records. After a brief pause, E2 stated, “[E1] said, ‘It is what it is.’” 4. A review revealed no personnel records for E1, E5, E6, E7, E8, E9, E10, E11, and all 46 other employees.

Based on documentation review, record review, and interview, the manager failed to ensure a documented residency agreement was available for eight of eight residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. The Compliance Officers provided a list of resident names and requested the medical records for R1, R2, R3, R4, R5, R6, R7, and R8 at 9:30 a.m. from E2, who was the assigned designee of E1. 2. A review of the medical records for R1, R2, R3, R4, R5, R6, R7, and R8 revealed that no residency agreements were present, and based on their acceptance dates, this documentation was required but not provided; therefore, the Compliance Officers was unable to determine whether the facility was in compliance with the rule at the time of the inspection. 3. In separate interviews, E2 and E3 reported that E1 reported during a telephonic interview that the residents’ residency agreements were kept in the business office and could not be accessed, and E2 and E3 acknowledged that the medical records for R1, R2, R3, R4, R5, R6, R7, and R8 did not contain documented residency agreements. 4. In an exit interview, the findings were reviewed with E2 and E3, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a service plan to include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for eight of eight residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. A review of R1's medical record revealed a service plan dated September 24, 2025, for personal care services. However, the service plan did not include a description of R1's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. A review of R2's medical record revealed a service plan dated November 05, 2025, for directed care services. However, the service plan did not include a description of R2's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 3. A review of R3's medical record revealed a service plan dated October 28, 2025, for directed care services. However, the service plan did not include a description of R3's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 4. A review of R4's medical record revealed a service plan dated February 19, 2025, August 19, 2025, and November 4, 2025, for directed care services. However, the service plan did not include a description of R4's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 5. A review of R5's medical record revealed a service plan dated November 03, 2025, for directed care services. However, the service plan did not include a description of R5's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 6. A review of R6's medical record revealed a service plan dated September 24, 2025, for directed care services. However, the service plan did not include a description of R6's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 7. A review of R7's medical record revealed a service plan dated March 03, 2025, for directed care services. However, the service plan did not include a description of R7's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 8. A review of R8's medical record revealed a service plan dated October 20, 2025, for directed care services. However, the service plan did not include a description of R8's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 9. In an interview, E2 and E3 acknowledged that R1's, R2's, R3's, R4's, R5's, R6's, R7's, and R8's service plans did not include a description of the residents’ medical or health problems, including physical, behavioral, cognitive, or

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident, for eight of eight residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1’s medical record revealed a current service plan for directed care services. The service plan revealed R1 received medication administration, coordination of communications with the resident’s representative, and reminders/ encouragements to participate in activities, exercise activities. However, the service plan did not include the frequency of these services. 2. A review of R2’s medical record revealed a current service plan for directed care services. The service plan revealed R2 received medication administration, coordination of communications with the resident’s representative, and reminders/ assistance to participate in activities. However, the service plan did not include the frequency of these services. 3. A review of R3’s medical record revealed a current service plan for directed care services. The service plan revealed R3 received medication administration, and coordination of communications with the resident’s representative. However, the service plan did not include the frequency of these services. 4. A review of R4’s medical record revealed a current service plan for directed care services. The service plan revealed R4 received medication administration, and coordination of communications with the resident’s representative. However, the service plan did not include the frequency of these services. 5. A review of R5’s medical record revealed a current service plan for directed care services. The service plan revealed R5 received medication administration, assistance with transferring and mobility, coordination of communications with the resident’s representative, and reminders/ encouragements to participate in activities, exercise activities. However, the service plan did not include the frequency of these services. 6. A review of R6’s medical record revealed a current service plan for directed care services. The service plan revealed R6 received medication administration, and coordination of communications with the resident’s representative. However, the service plan did not include the frequency of these services. 7. A review of R7’s medical record revealed a current service plan for directed care services. The service plan revealed R7 received medication administration, and coordination of communications with the resident’s representative. However, the service plan did not include the frequency of these services. 8. A review of R8’s medical record revealed a current service plan for directed care services. The service plan revealed R8 received medication administration, and coordination of communications with the resident’s repres

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when updated, was signed and dated by the resident or resident's representative, for one of eight sampled residents. The deficient practice posed a health and safety risk if the required individual did not acknowledge the services that were to be provided. Findings include: 1. A review of R4's medical record revealed two service plans for directed care level dated August 19, 2025, and November 4, 2025. However, the service plans were not signed and dated by R4 or R4’s representative. 2. In an interview, E2 and E3 acknowledged R4's service plans were not signed and dated by R4 or R4's representative. This is a repeat citation from the inspection conducted on April 1, 2025, and March 7, 2024; an uncorrected citation from the inspection conducted on November 13-14, 2024.

Based on 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 eight of eight sampled 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 R1’s medical record revealed a current service plan for directed care services. The service plan indicated R1 received assistance with reminders to activities, mealtimes, coordination of communication with family, and offering fluids to maintain hydration. The review further revealed documentation of assisted living services (ADLs) provided to R1 between October 2025 and December 2025. However, the ADLs revealed no documentation of the aforementioned services. 2. A review of R2’s medical record revealed a current service plan for directed care services. The service plan indicated R2 received assistance with activities, mealtimes, coordination of communication with family, and offering fluids to maintain hydration. The review further revealed documentation of ADLs provided to R2 between October 2025 and December 2025. However, the ADLs revealed no documentation of the aforementioned services. 3. A review of R3’s medical record revealed a current service plan for directed care services. The service plan indicated R3 received assistance with transferring and mobility, activities, mealtimes, coordination of communication with family, and offering fluids to maintain hydration. The review further revealed documentation of ADLs provided to R3 between October 2025 and December 2025. However, the ADLs revealed no documentation of the aforementioned services. 4. A review of R4’s medical record revealed a current service plan for directed care services. The service plan indicated R4 received assistance with transferring and mobility, activities, mealtimes, coordination of communication with family, and offering fluids to maintain hydration. The review further revealed documentation of ADLs provided to R4 between October 2025 and December 2025. However, the ADLs revealed no documentation of the aforementioned services. 5. A review of R5’s medical record revealed a current service plan for directed care services. The service plan indicated R5 received assistance with transferring and mobility, activities, mealtimes, coordination of communication with family, and offering fluids to maintain hydration. The review further revealed documentation of ADLs provided to R5 between October 2025 and December 2025. However, the ADLs revealed no documentation of the aforementioned services. 6. A review of R6’s medical record revealed a current service plan for directed care services. The service plan indicated R6 received assistance with activities, mealtimes, coordination of communication with family, and offering fluids to maintain hydration. The review further revealed documentation of ADLs provided to R6 between

Based on documentation review, record review and interview, the manager failed to ensure that a resident or resident's representative received a complete written copy of the requirements in subsection (B) and the resident rights in subsection (C) at the time of admission, for one of three sampled residents. The deficient practice posed a risk if a resident was not properly informed of their rights. Findings include: 1. The Compliance Officers provided a list of resident names and requested the medical records for R1, R2, R3, R4, R5, R6, R7, and R8 at 9:30 a.m. from E2, who was the assigned designee of E1. 2. A review of the medical records for R1, R2, R3, R4, R5, R6, R7, and R8 revealed no documentation indicating that the residents or their representatives received a written copy of the requirements in subsection (B) and the resident rights in subsection (C). The Compliance Officers were unable to determine whether the facility was in compliance with the rule. 3. In separate interviews, E2 and E3 acknowledged that the medical records for R1, R2, R3, R4, R5, R6, R7, and R8 did not contain documentation showing that the residents or their representatives received the subsection (B) requirements and subsection (C) resident rights at the time of admission. 4. In an exit interview, the findings were reviewed with E2 and E3, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Resident Record." The P&P stated, “Each resident record will remain confidential and is accessible to Caregivers and Medication Technicians. The review further revealed a P&P titled “Confidentiality.” The P&P stated, “Resident records, information, preadmission documentation, etc. are kept inaccessible to visitors and any individuals not involved in the admission and direct care of the resident.” 2. The Compliance Officers observed two medication carts in common areas. On the medication carts, the Compliance Officers observed shift notes which contained documentation of assisted living services provided to residents. 3. In an interview, E2 reported the shift notes contained the shower schedules for residents. E2 acknowledged the medical records were not protected from loss, damage, or unauthorized use. This is an uncorrected citation from the complaint inspection conducted on January 28, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for three of four residents sampled who required this documentation on a yearly basis. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states: "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record revealed R1 was offered the flu and pneumonia vaccines in 2023. However, documentation of additional offers was not available for review. 3. A review of R3's medical record revealed R3 was offered the flu and pneumonia vaccines in 2023. However, documentation of additional offers was not available for review. 4. A review of R4's medical record revealed R4 was offered the flu and pneumonia vaccines in 2023. However, documentation of additional offers was not available for review. 5. In an interview, E2 and E3 acknowledged that R1's, R3's, and R4's medical records did not include documentation showing that pneumonia vaccinations were received or refused. 6. In an exit interview, the findings were reviewed with E2 and E3, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for eight of eight residents sampled. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. The Compliance Officers provided a list of resident names and requested the medical records for R1, R2, R3, R4, R5, R6, R7, and R8 at 9:30 a.m. from E2, who was the assigned designee of E1. 2. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed no documentation showing that the residents were oriented to the exits of the assisted living facility. 3. In separate interviews, E2 reported that E1 reported during a telephonic interview that this documentation were kept in the business office and could not be accessed, and E2 and E3 acknowledged that documentation showing R1, R2, R3, R4, R5, R6, R7, and R8 were oriented to the facility exits was not available for review at the time of the inspection. 4. In an exit interview, the findings were reviewed with E2 and E3, and no additional information was provided.

Based on interview and record review, for two of two residents sampled, who was confined to a bed or chair and unable to ambulate even with assistance, the manager failed to ensure the facility did not retain a resident unless the facility obtained a signed and dated determination from a primary care provider (PCP) or medical practitioner (MP), every six months, that stated resident’s needs could be met by the assisted living facility within the assisted living facility’s scope of services. The deficient practice posed a safety risk to a resident if the facility retained a resident without the required authorization. Findings include: 1. During the environmental inspection, the Compliance Officers observed that R2 and R3 were confined to a bed or chair. 2. In an interview, E2 reported that R2 and R3 were unable to ambulate, even with assistance. 3. A review of R2's medical record revealed a service plan for directed care services, and stated "Resident is unable to bare weight; Bedridden." 4. A review of R2's medical record revealed no documentation of a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for R2, who was confined to a bed or chair. 5. A review of R3's medical record revealed a service plan for directed care services, and stated " [R3] requires 2-person assistance to transfer in/out of bed. Requires staff to push [R3] wheelchair to/from meals and activities. [R3] can move [R3] in wheelchair a short distance using [R3] feet." 6. A review of R3's medical record revealed no documentation of a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for R3, who was confined to a bed or chair. 7. In an exit interview, the findings were reviewed with E2 and E3, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure documentation of each evacuation drill included the items required by this rule. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of facility documentation revealed a series of evacuation drills dated December 27, 2024, and June 27, 2025. However, the documentation did not include the time of the evacuation drill, an identification of residents needing assistance for evacuation, and any problems encountered in conducting the evacuation drill. 2. In the exit interview, the Compliance Officers reviewed the findings and E2 and E3, and E2 and E3 offered no additional information. Technical assistance was provided on this rule during the complaint, compliance, and on-site plan of correction follow-up inspection conducted on November 13-14, 2024.

Based on documentation review and interview, 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 the items required by this rule. The deficient practice posed a potential risk of re-injury and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed two incident reports. The reports revealed that an altercation between R1 and R7 occurred at 9:31 PM on November 10, 2025, which culminated in both residents requiring medical services. The reports further did not include the names of individuals who observed the accident, emergency, or injuries. 2. In an interview, E2 and E3 reported that the incident occurred at approximately 7:30 PM and not 9:31 PM as stated in the two incident reports. E2 acknowledged that the reports did not include the names of individuals who observed the accident, emergency, or injuries. Technical assistance was provided on this rule during the complaint, compliance, and on-site plan of correction follow-up inspection conducted on November 13-14, 2024.

Based on observation and interview, the manager failed to ensure the premises were clean. The deficient practice posed a risk to the health and safety of the residents. Findings include: 1. The Compliance Officers observed the toilet in unit 122 was dirty. The Compliance Officers observed the inside of the toilet bowl and entrance to the trapway to contain what appeared to be stuck-on feces. 2. In an interview, E2 stated, “Oh my God. That one is dirty.” 3. Upon moving the bed in unit 227 away from the wall, the Compliance Officers observed debris along the wall where the resident’s bed had been. 4. In the small kitchen/dinning area on one side of the facility, one of the Compliance Officers observed a small refrigerator. Upon opening the refrigerator, the Compliance Officer observed stains, partially dried-up liquid of some sort, and food debris. 5. In an interview, E2 acknowledged the refrigerator was dirty. 6. In a corner behind a piano, one of the Compliance Officers observed a partially eaten sandwich. Technical assistance was provided on this rule during the complaint, compliance, and on-site plan of correction follow-up inspection conducted on November 13-14, 2024.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection. Findings include: 1. The Compliance Officers observed garbage in uncovered garbage containers in the entry foyer; in the small office near the entry foyer; near both of the resident dining areas; in the kitchen; and and in units 106, 121, and 227. The Compliance Officers further observed garbage in a covered garbage container not lined with a plastic bag in the bedroom of unit 121. 2. In a series of interviews, E2 stated the garbage containers in unit 121 were “supposed to” have liners and lids. E2 further acknowledged the other aforementioned containers were not covered. Technical assistance was provided on this rule during the on-site abbreviated initial follow-up inspection conducted on July 12, 2023.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled, and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officers observed multiple ambulatory residents. 3. During the environmental inspection with E2, the Compliance Officers observed an unlocked janitor’s closet in the memory care unit that contained the following poisonous and toxic materials; -"Butler Chemicals, Inc. – Bathroom Plus, labeled as Shower, Tub, Tile, and Fiberglass Cleaner, in a large gallon jug." -"Butler Chemicals, Inc. – Fresh Aire, labeled as Concentrated Odor Counteractant, in a large gallon jug." -"Butler Chemicals, Inc. – Sunshine, labeled as Neutral All Purpose Cleaner, in a large gallon jug." -"Butler Chemicals, Inc. – Sani-Klean, labeled as Neutral Disinfectant and Deodorant, in a large gallon jug." -"Butler Chemicals, Inc. – Clear View, labeled as Glass & Surface Cleaner, in a large gallon jug." -"Butler Chemicals, Inc. – Oxy Fresh, labeled as Multi-Surface Cleaner, Degreaser & Stain Remover, hydrogen peroxide fortified, in a 32 fl oz (1 qt) bottle." 4. In an interview, when the Compliance Officers asked why the closet was unlocked, E4 stated, "I'm not sure." 5. In an exit interview, the findings were reviewed with E2, E3, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "Fall Prevention and Recovery Policy and Training" which stated, "All Staff will be trained on the Fall Prevention and Recovery upon hire and then again annually during their employment." 2. A review of E7's and E8’s personnel records revealed E7 and E8 were hired as caregivers. The review revealed E7 and E8 received training regarding fall prevention and fall recovery on February 7, 2024, and April 9, 2025, and not annually as required per P&P. 3. In an interview, E2 confirmed E7 and E8 did not receive training regarding fall prevention and fall recovery between February 7, 2024, and April 9, 2025, stating, “That’s the only one I have.” When the Compliance Officer asked if E1 had any fall training documentation for E7 and E8 yet to be filed, E1 stated, “There’s nothing on my desk.” This is an uncorrected deficiency from the complaint inspection conducted on April 1, 2025, and no acceptable plan of correction has been received by the Department.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of six sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed no policy and procedure (P&P) covering how the manager would verify and document a caregiver or assistant caregiver's skills and knowledge. 2. The review further revealed a series of personnel schedules which indicated E5 worked several shifts as a caregiver before June 20, 2024. 3. A review of E5's personnel record revealed E5 was hired as a caregiver. The review revealed a "CAREGIVER SKILLS CHECKLIST" which indicated E5's skills and knowledge were not verified and documented until June 20, 2024, after E5 began providing services. 4. In an interview regarding the P&P, E2 stated, “I don’t think we have that yet.” When the Compliance Officer asked if E5 was in training during all shifts before June 20, 2024, E2 stated, “No.” E2 reported E5 was working as a caregiver before June 20, 2024. This is an uncorrected deficiency from the complaint and compliance inspection conducted on November 14, 2024, and no acceptable plan of correction has been received by the Department.

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention and Recovery Policy and Training" which stated, "All Staff will be trained on the Fall Prevention and Recovery upon hire and then again annually during their employment." 2. A review of E5's personnel record revealed E5 was hired as a caregiver. The review revealed E5 received training regarding fall prevention and fall recovery on February 7, 2024. However, the review revealed no annual training thereafter. 3. In an interview, E1 stated, “[E5’s] due.” E1 reported E5 was not current and missed the last training session.

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 to cover 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 as policies and procedures reinforce and clarify standards expected of employees and facility personnel were unaware of the whereabouts of a resident. Findings include: 1. A review of facility documentation revealed no policy and procedure (P&P) in compliance with this rule. 2. In an interview, E1 reported personnel had not yet finished updating the facility’s P&Ps, stating, “There’s not an update yet.” E1 reported the P&Ps were the same as those the Compliance Officer reviewed on January 28, 2025. E1 acknowledged the facility did not have a P&P in compliance with this rule. This is an uncorrected deficiency from the complaint inspection conducted on January 28, 2025.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when updated, was signed and dated by the resident or resident's representative, for one of three sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated March 12, 2025. However, the service plan was not signed and dated by R1 or R1’s representative. 2. In an interview, E1 confirmed R1’s service plan was not signed by R1 or R1’s representative, stating, “[R1’s] missing signatures there.” This is an uncorrected deficiency from the complaint and compliance inspection conducted on November 14, 2024, and a repeat citation from the complaint inspection conducted on March 7, 2024.

Based on 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 three sampled 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 R1's medical record revealed a service plan dated December 28, 2024, which indicated facility personnel were to provide assistance with dressing, grooming, and toileting at the “Scheduled Time(s) [of] AM, PM, GRAVEYARD, [and] PRN].” The review further revealed documentation of assisted living services provided to R1 (ADLs) dated March 2025. However, the ADLs revealed no documentation of assistance with dressing, grooming, or toileting in the AM on March 2-3, 7, and 15, 2025. 2. In an interview, E1 stated, “Services were provided.” However, E1 reported the tablets used to document services provided to a resident often had issues and the services were not documented for that reason. This is an uncorrected deficiency from the complaint inspection conducted on January 28, 2025.