New Beginning Homes LLC

Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse, neglect, or exploitation according to A.R.S. § 46-454. The deficient practice posed a risk of a potential resident rights violation if the resident was subjected to abuse. Findings include: 1. A.R.S. § 46-454(A) stated "...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 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 ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.111 stated "Immediate" means without delay. 3. A review of the facility’s documentation revealed a document titled “Shower Schedule,” which reflected that R1's scheduled shower days were every Wednesday, Friday, and Sunday. 4. In an interview, E1 reported R1 attends a day treatment program (DTA) Monday through Friday from 7 am to 3 pm every week. 5. A review of R1’s medical record revealed documents titled “Chart Notes”, various dates reflected the following: Friday, May 23, 2025, at 4:58 pm [R1] went to DTA today and came back in stable condition. [R1] showered and bed sheets changed; Saturday, May 24, 2025, at 8:28 pm [R1] in bed watching television. [R1] slept off and on throughout the shift. Staff conducted rounds and changed [R1] as needed, [R1] trashed has been emptied. No issues to report; Sunday, May 25, 2025, at 10:39 pm “[R1] in bed sleeping. Staff conducted rounds and changed [R1] briefs as needed. At 1530 staff got [R1] ready shower. Staff turned on the water. Got all showering materials and undressed [R1] for shower. Staff checked temperature and positioned [R1] for shower head first. Staff began washing [R1] 's hair then detached the shower head to wet the [R1] 's body. [R1] began to kick and whimper while staff was wetting [R1]. Staff placed the shower head back on the shower hook. Then proceeded to wash member body starting with her neck. When staff got down to her chest, [R1] began to kick, whimper and cry. Staff looked and seen that [R1]’s skin had came off on the wash cloth. Staff then yelled out for nurse on duty. Nurse on duty came and accessed [R1] . Nurse then contacted DON and at that time it was determined member needed additional medical treatment. Nurse on duty gave [R1] PRN medication for pain. Staff then transported [R1] to Mercy Gilbert Hospital. [R1] was then transported from Mercy Gilbert Hospital to Valleywise Hospital Burn Unit at 2030. [R1] was currently admitted at Valleywise Hospital. Supervisor was notified of incident as well; Monday, May 26, 2025, at 6:56 am “[R1] admitted to Valleywise Burn Unit”. 6. A review of R1’s medical record revealed a document titled “Incident Report” dated Sunday, May 25, 2025, which reflected “Caregiver was showering [R1] and called [E2]

Based on record review and interview, the administrator failed to ensure that an illness or injury in subsection (H)(1)(c), document any action taken to prevent the illness or injury from occurring in the future, for one of two sampled residents. Findings include: 1. A review of R1’s medical record revealed a document titled “Incident Report” dated May 25, 2025, which reflected “Caregiver was showering [R1] and called [E2] in due to [R1] crying. [E2] went in to access [R1] and noticed approximately a 4-inch area with detached skin blisters, also around the GTUBE sight appears to be blisters, above the GTUBE insertion sight approximately 3 to 4 inches long by 2 inches wide, missing skin and showering blisters also. E2 called charge nurse, and it was determined to send [R1] out to Mercy Gilbert at approximately 1545, staff left with [R1]. R1’s representative was notified at 1536. R1 was given PRN Tylenol for pain. [R1] GTUBE intact and patent before R1’s shower [E2] flushed R1’s GTUBE and took off split 2x2, and no skin issues were noted." The incident reported failed to document any action taken to prevent the illness or injury from occurring in the future. 2. In an interview, E1 acknowledged that there was no documentation available for review at the time of the survey to reflect any action taken to prevent the injury from occurring in the future.

Based on observation and interview, the administrator failed to ensure hot water temperatures were maintained between 95° F and 120° F in areas of the assisted living facility used by residents. The deficient practice posed a potential burn risk to residents and resulted in an occurrence of actual harm. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a shared resident bathroom. Using a Department-issued thermometer, the Compliance Officer measured the hot water temperature and observed it to be 139.4° F in the sink of the shared resident bathroom, the compliance officer observed the water temperature to be 138.3° F in R3’s bathroom sink, and the compliance officer observed the water temperature to be 125.4° F in R4’s bathroom sink. 2. A review of R1’s medical record revealed documents titled “Chart Notes”, which reflected the following: Sunday, May 25, 2025, at 10:39 pm “[R1] in bed sleeping. Staff conducted rounds and changed [R1] briefs as needed. At 1530 staff got [R1] ready shower. Staff turned on the water. Got all showering materials and undressed [R1] for shower. Staff checked temperature and positioned [R1] for shower head first. Staff began washing [R1] 's hair then detached the shower head to wet the [R1] 's body. [R1] began to kick and whimper while staff was wetting [R1]. Staff placed the shower head back on the shower hook. Then proceeded to wash member body starting with her neck. When staff got down to her chest, [R1] began to kick, whimper and cry. Staff looked and seen that [R1]’s skin had came off on the wash cloth. Staff then yelled out for nurse on duty. Nurse on duty came and accessed [R1] . Nurse then contacted DON and at that time it was determined member needed additional medical treatment. Nurse on duty gave [R1] PRN medication for pain. Staff then transported [R1] to Mercy Gilbert Hospital. [R1] was then transported from Mercy Gilbert Hospital to Valleywise Hospital Burn Unit at 2030. [R1] was currently admitted at Valleywise Hospital. Supervisor was notified of incident as well." 3. In an interview, E1 acknowledged that the hot water temperature was not maintained between 95° F and 120° F.