New Beginning Homes LLC

Based on record review and interview the administrator failed to ensure that an employee record was maintained for each employee which contained training in preventing, recognizing, and reporting abuse or neglect, required according to R9-10-2203(C)(1)(d)(i). Findings include: 1 . A review of Employee records revealed one of three employees with an outdated certificate for training related to recognizing signs and symptoms of Abuse and Neglect. The certificate on file for E1 was from 2023. 2 .In an exit interview, E1 acknowledged that the administrator failed to ensure that all employees had current training for recognizing signs and symptoms of Abuse and Neglect.

Based on record review and interview, the administrator failed to ensure that at the time of admission, a resident or the resident's representative received a written copy of the resident rights. Findings include: 1 . A review of R1's and R2's records revealed no copy of the resident rights for the Compliance Officer to review, in the member's files. 2 . In an exit interview, the findings were reviewed were O1 and no further information was provided.

Based on record review and interview, the administrator failed to ensure that a resident's comprehensive assessment was reviewed at least once every three months after the date of the current comprehensive assessment and if there was a significant change in the resident's condition. Findings include: 1 . A review of R2's records revealed an outdated Person Centered Service Plan, dated July 28, 2025. 2 . In an exit interview, the findings were reviewed with O1 and no further information was provided.

Based on documentation review and interview, the governing authority failed to designate, in writing, an administrator for the nursing supported group home. Findings include: During the on-site inspection, the Compliance Officer requested to review the written designation of the facility's administrator. However, this documentation was not available for review. In an interview, E1 acknowledged written designation of the facility's administrator had not been provided for review.

Based on observation, documentation review, the administrator failed to designate, in writing, an individual who is present on the premises of the nursing-supported group home and accountable for the nursing-supported group home when the administrator is not present on the nursing-supported group home's premises. Findings include: 1 . Upon arriving at the facility, the Compliance Officer observed the administrator was not present on the nursing-supported group home's premises. 2. A review of facility documentation revealed documentation of the administrator's designees was not available for review. 3. In an interview, E1 acknowledged documentation of the administrator's designees was not available for review.

Based on documentation review and interview, the administrator failed to ensure documentation of the most recent monitoring of the nursing-supported group home by the Arizona Department of Economic Security (DES) was on the premises. Findings include: During the on-site inspection, the Compliance Officer requested to review the most recent DES monitoring report. However, a DES monitoring report was not available to review. In an interview, E1 acknowledged a DES monitoring report was not provided for review.

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include all required documentation, for four of four sampled personnel members. The deficient practice posed a risk if employees were unable to meet a resident’s needs. Arizona Revised Statutes (ARS) § 36-406 states: ARS § 36.411 states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually rev

Based on record review and interview, the administrator failed to ensure a resident's medical record contained all required documentation for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed the following documents were not provided for review: a. Documentation of the initial assessment required in R9-10-2207(3) to determine acuity; b. The medical history and physical examination required in R9-10-2215(A)(2); c. Documentation of the resident's comprehensive assessment required in R9-10-2214.A; d. Individual program plans, including nursing care plans or medical care plans, if applicable required in R9-10-2214.B; e. Documentation of physical health services provided to the resident; and f. Documentation of freedom from infectious tuberculosis required in R9-10-2207(10). 2. In an interview, E1 acknowledged the medical records provided for R1 and R2 did not include all required documentation.

Based on documentation review, record review, and interview, the administrator failed to ensure a copy of the Clinical Laboratory Improvement Act (CLIA) certificate of waiver was provided for review upon the Department's request. Findings include: During the on-site inspection, the Compliance Officer requested to review the facility's CLIA certificate of waiver. However, a CLIA waiver was not available for review. A review of R2's medical record revealed R2 required daily blood glucose monitoring. In an interview, E1 acknowledged the facility performs waived testing and acknowledged a CLIA certificate of waiver had not been provided for review.

Based on record review, and interview, the administrator failed to ensure policies and procedures for medication services were implemented to include procedures to ensure that a pharmacist reviews a resident's medications at least once every three months and provided documentation to the resident's designated medical practitioner and the director of nursing indicating potential medication problems such as incompatible or duplicative medications. Findings include: 1. A review of R1's and R2's medical record revealed the required pharmacist reviews, dated at least once every three months, were not available for review. 2. In an interview, E1 acknowledged the facility had not implemented a policy to ensure a pharmacist reviewed each resident's medications at least once every three months and had provided documentation to the resident's designated medical practitioner and the director of nursing indicating potential medication problems such as incompatible or duplicative medications.

Based on documentation review and interview, the Administrator failed to ensure policies and procedures for medication administration were reviewed and approved by a pharmacist. Findings include: 1. A review of the facility's policies and procedures revealed policies covering medication administration, storage, disposal, and documentation. However, the policies were not reviewed and signed by a pharmacist. 2. In an interview, E1 acknowledged the provided medication administration policies and procedures did not include documentation of review and approval by a pharmacist.

Based on observation and interview, the administrator failed to ensure a posted food menu included any food substitution no later than the morning of the day of meal service with a food substitution and was maintained for at least 60 calendar days after the last day included in the food menu. Findings include: During an environmental inspection of the facility, the Compliance Officer observed a food menu posted on the refrigerator in the kitchen was dated "September," showed the18th, the day of the inspection, as a Friday instead of a Tuesday, and did not include documentation of any food substitutions, listing dinner for the day of the inspection as, "Mac and cheese with mixed veggies." In an interview, E1 reported the menu was for March 2025 but they had not updated the month. Online research revealed the last time September had a Friday the 18th was in 2020, and the most recent Friday the 18th prior to the inspection was in October 2024. During an environmental inspection of the facility, at approximately 3:00 PM, the Compliance Officer observed chicken defrosting on the kitchen counter. The Compliance Officer requested to review the prior 60 days of menus including all substitutions, however, these records were not available for review. In an interview, E1 acknowledged the posted menu was not current, did not include food substitutions no later than the morning of the day with a food substitution, and menus including substitutions for the previous 60 days had not been provided for review.

Based on documentation review and interview the Administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility documentation revealed documentation of a disaster drill for employees conducted once on each shift every three months was not available for review. 2. In an interview, E1 acknowledged documentation of disaster drills was not available for review.

Based on documentation review and interview, the administrator failed to obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal. Findings include: During the on-site compliance and complaint inspection, the Compliance Officer requested to review a current fire inspection. However, the most recent fire inspection report available was dated January 24, 2023. In an interview, E1 acknowledged documentation of a current fire inspection had not been provided for review.