New Beginnings Chandler LLC

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by an assisted living facility, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse. Findings include: 1. Record review revealed R2's pre-admission determination, which included whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner. However, this was not completed within 90 days before R2 was admitted to the facility. 2. In an exit interview, findings were discussed with E2 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents sampled. 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 May 20, 2025) that indicated R1 would receive the following services: Oral care, twice a day (bid); and Incontinence checks every 2 - 3 hours. 2. A review of R1's activities of daily living (ADL) documentation for September 2025 did not include documentation of the aforementioned services, September 1, 2025 - present. 3. A review of R2's medical record revealed a service plan (dated March 4, 2025) that indicated R2 would receive the following services: Oral care, bid; and Incontinence checks every 2 - 3 hours. 4. A review of R2's ADL documentation, for September 2025, did not include documentation of the aforementioned services, September 1, 2025 - present. 5. In an interview, E2 reported R1 and R2 received the aforementioned services in September 2025. 6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that a resident or resident's representative consented to photographs of the resident before the resident was photographed, for one of two residents sampled. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed cameras used in the facility to monitor residents' whereabouts. 2. A review of R2's medical record did not contain a photographic consent form signed by the resident or the resident's representative. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident’s weight or from a medical practitioner indicating that weighing the resident was contraindicated, for one of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a service plan update dated May 20, 2025. However, R1’s service plan did not include R1’s weight or documentation from R1’s medical practitioner stating that weighing R1 was contraindicated. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order and false or misleading information was provided to the Department. Findings include: 1. A review of R1's medical record revealed a signed medication order, dated August 11, 2025, for Potassium Chloride 20 meq, 1 tablet by mouth (po) twice a day (bid). 2. A review of R1's medication administration record (MAR) for September 2025, revealed that R1 was administered Potassium Chloride 20 meq at 8:00 AM and 8:00 PM on the day of the inspection (September 4, 2025). However, the MAR was provided to the Compliance Officers for review at approximately 1:30 PM. 3. In an interview, E2 reported that E2 had not yet administered PM medications to R1. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation and interview, the manager of an assisted living home failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months, and had a tag attached to the fire extinguisher that specified the date of the last servicing and the identification of the person who serviced the fire extinguisher. The deficient practice posed a risk if safety measures were not in place to protect residents in a fire. Findings include: 1. During an environmental inspection, Compliance Officers observed a fire extinguisher with a receipt of purchase dated November 30, 2023. The fire extinguisher did not have a tag attached identifying the last service date. 2. In an exit interview, findings were discussed with E2 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that pets or animals allowed in the assisted living facility were licensed consistent with local ordinances; and for a dog or cat, vaccinated against rabies. The deficient practice posed a risk if the dog allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1. During the environmental inspection, the Compliance Officers observed O1 did not have documentation of a Maricopa County license or rabies vaccination. 2. During an interview, E1 and E2 reported that O1 could not be vaccinated due to health reasons and provided a letter from O1's veterinarian. 3. During an exit interview, findings were discussed with E2 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure policies and procedures were implemented 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. Findings include: 1. A review of R1's and R2's service plans revealed, the residents received directed care services. 2. A review of the facility's policies and procedures revealed a policy titled "Policy on Whereabouts of the Residents". The policy stated, "Caregiver will lay eyes on residents every 2-3 hours day and night". 3. A documentation review revealed the facility lacked documentation of the caregiver's observation of the residents. 4. In an interview, E2 reported that [E2] goes to bed around midnight and wakes up 5:00AM-6:00AM and no other resident checks were done during those times. E2 acknowledged that resident checks were not done or documented every 2-3 hours as the policy stated or at nighttime hours to ensure the residents health and safety.

Based on record review, observation, documentation review, and an interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of R1's and R2's service plans revealed R1 and R2 received directed care services. 2. During an environmental inspection of the facility, the Compliance Officers observed the door in R1's room and the hallway door leading to the outdoor area were locked; however, the doors did not possess a working alarm or control. 3. A review of the facility's policies and procedures revealed in a policy titled "Policy on Whereabouts of the Residents" that stated, "Caregiver will make sure alarms are working so that the caregiver can hear when residents are outside". 4. In an interview, E2 acknowledged the facility provided direct care services and did not have a device that controlled or alerted employees of the egress from the facility.