Mosaic Gardens Memory Care at Surprise

Based on documentation review and interview, the health care institution failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of ten personnel sampled. Findings include: 1. A review of E4's personnel record revealed a hire date of Febuary 16, 2025. E4's personnel file included documentation of initial fall prevention and fall recovery training. However, E4's personnel file did not include documentation of continued competency training on fall prevention and fall recovery. 2. In an interview, the findings were reviewed with E1. E1 acknowledged the facility required annual fall prevention and fall recovery training. E1 acknowledged E4 had not completed the fall prevention and fall recovery continued competency training for this year. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 26, 2023.

Based on documentation review and interview, the assisted living center failed to provide a written document that covered A.R.S § 36-420.04.A.1-9. when the assisted living center contacted an emergency responder on behalf of the resident, for one of six residents sampled. Findings include: 1 . A review of R1's medical record revealed an incident where R1 was sent to the hospital by the facility on April 25, 2025. However, documentation of a written document presented to emergency medical services (EMS) that included all items covered under A.R.S § 36-420.04.A.1-9 at the time of incident was not available for review at the time of inspection. 2 . A review of R2's medical record revealed an incident where R2 was sent to the hospital by the facility on October 1, 2025. However, documentation of a written document presented to EMS that included all items covered under A.R.S § 36-420.04.A.1-9 at the time of the incident was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1, and no additional information was provided. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 17, 2024.

Based on record review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for three of ten sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A record review of E8, E9, and E10's personnel records revealed no documentation of freedom from infectious tuberculosis. 2. In an interview, E1 acknowledged that the aforementioned records did not contain documentation of freedom from tuberculosis as required. 3. In an exit interview with #1, the findings were reviewed, and no additional paperwork was provided. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 17, 2024, and the complaint investigation conducted on October 17, 2024.

Based on record review and interview, the manager failed to ensure that a resident had a current service plan for one of six residents sampled. The deficient practice posed a risk. Findings include: 1. A review of R1's medical record revealed a service plan dated Febuary 2026. However, notes documented that R1 was placed on hospice care in January 2026, and these services were not identified on the service plan. 2. In an interview, E1 indicated that Hospice provided a CNA twice a week and a nurse once a week. 3. In an exit interview with E1, the finding was reviewed, and no additional information was provided. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on April 24, 2025.

Based on record review, interview, and documentation review, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk or harm for one of six residents sampled. The deficient practice posed a risk to health and safety. Findings include: 1. A review of R1's medication record revealed an incident report dated January 18, 2026. The incident report stated "...I was coming onto shift prior to the incident. Resident was found sitting on the floor in [R1's] closet...Resident was last seen in the evening...Right shoulder and hip had some redness/discoloring...Resident was crying, but couldn't tell us why [R1] was crying...I've self-reported to APS for potential neglect..." 2. In an interview, E1 reported that the staff during the night shift did not check for the whereabouts of R1 and assumed that R1 was offsite with family. E1 reported that the morning staff located R1. An incident report was completed and R1 was transferred to the hospital for observation. 3. A documentation review revealed the facility's policy and procedure titled "PO06 - Missing Person Elopement" that stated "...4. Routine rounds will be made by staff to account for resident whereabouts. a. refer to Community Rounds Policy..." 4. A documentation review revealed the facility's policy and procedure titled "PPO04 - Community Rounds" that stated "Resident whereabouts will be monitored to minimize the potential for elopement from the Memory care Community while allowing for resident independence and dignity. 1. Memory Care Staff will ensure resident safety with awareness of where (location) their assigned residents are throughout the day. 2. A systematic approach for resident monitoring will be provided with routine staff rounds. 4. Shift overlap time will include additional accounting of residents. 6. The resident will be physically visited to account for their whereabouts." 5 . In an exit interview, findings were reviewed with E1 and no additional information was provided.

Based on record review, interview, and documentation review, the manager failed to ensure policies and procedures were inplemented 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 to health and safety. Findings include: 1. A review of R1's medication record revealed an incident report dated January 18, 2026. The incident report stated "...I was coming onto shift prior to the incident. Resident was found sitting on the floor in [R1's] closet...Resident was last seen in the evening...Right shoulder and hip had some redness/discoloring...Resident was crying, but couldn't tell us why [R1] was crying...I've self-reported to APS for potential neglect..." 2. In an interview, E1 reported that the staff during the night shift did not check for the whereabouts of R1 and assumed that R1 was offsite with family. E1 reported that the morning staff located R1. An incident report was completed and R1 was transferred to the hospital for observation. 3. A documentation review revealed the facility's policy and procedure titled "PO06 - Missing Person Elopement" that stated "...4. Routine rounds will be made by staff to account for resident whereabouts. a. refer to Community Rounds Policy..." 4. A documentation review revealed the facility's policy and procedure titled "PPO04 - Community Rounds" that stated "Resident whereabouts will be monitored to minimize the potential for elopement from the Memory care Community while allowing for resident independence and dignity. 1. Memory Care Staff will ensure resident safety with awareness of where (location) their assigned residents are throughout the day. 2. A systematic approach for resident monitoring will be provided with routine staff rounds. 4. Shift overlap time will include additional accounting of residents. 6. The resident will be physically visited to account for their whereabouts." 5 . In an exit interview, findings were reviewed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that when a service plan was initially developed, and updated, it was signed and dated by the resident or resident's representative (POA) for two of six residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan dated April 17, 2025. The service plan was not signed by the resident or resident's representative as required. 2.A review of R2's medical record revealed a service plan dated March 19, 2025. The service plan was not signed by the resident or resident's representative as required. 3. In an interview, E1 acknowledged the aforementioned service plans were not signed by the resident or resident's representative as require.

Based on record review and interview, the manager failed to ensure a written service plan was developed within three days of acceptance for one of one resident who was receiving respite care services, which posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1. Review of R6's record and interview with E1 revealed R6 was accepted to the facility for respite care. The initial written service plan was not completed within three days of acceptance. Based on R6's date of acceptance this was required. 2. During an interview, E1 acknowledged R6's service plan was not completed within three days of acceptance.

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of valid cardiopulmonary resuscitation (CPR) training before providing assisted living services. The deficient practice posed a health and safety risk if the employee did not know how to properly perform CPR. Findings include: 1. Review of E3's (hired November 2024) personnel record revealed a CPR card that was obtained from www.NationalCPRFoundation.com, which was an online course. E3's CPR online certificate was issued on June 14, 2024. There was no other current documentation of CPR training available for review that would document that E3 had attended an approved CPR training course that included hands-on demonstration of the employee's ability to perform CPR. 2. The compliance officer contacted a representative from NationalCPRFoundation who stated "Our courses are online only." 3. During an interview, E1 acknowledged that E3 did not have current documentation of CPR training that included hands-on demonstration of the employee's ability to perform CPR.