Norbert Rogers

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that includes the information prescribed in A.R.S. § 36-420.04.A.1-9 for three out of three residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R1, R2, and R3’s medical records revealed there was no standardized form to be used if an emergency responder was contacted. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver's or assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures for one of the three employees sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E3's personnel record revealed there was a skills and knowledge document present in their record, however, the document was left blank. 2. A review of E3's personnel record revealed a hire date of August 15, 2025. 3. A review of the facility's staff schedule revealed E3 was listed to work every day for the entire month of September 2025 and had recently worked a shift on the date of September 4, 2025. 4. A review of the facility's policies and procedures revealed a section titled, "Verifying Caregiver's Skills and Knowledge" with the following verbiage, "All staff need to be trained and their skills and knowledge verified prior to staff providing assistance with new equipment or procedures. The manager will interview and assess the staff and test on caregiver skills." 5. 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 a caregiver or an assistant caregiver received orientation that was specific to the duties to be performed by the caregiver or assisted caregiver before they provided assisted living services to a resident for one of the three employees sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E3's personnel record revealed there was no documented orientation prior to E3 providing services to the residents. 2. A review of E3's personnel record revealed a hire date of August 15, 2025. 3. A review of the facility's staff schedule revealed E3 was listed to work every day for the entire month of September 2025 and had recently worked a shift on the date of September 4, 2025. 4. In an exit interview, the findings were reviewed with E2 and no additional information was provided. 5. This is a repeat deficiency from the inspection conducted on April 4, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident's date of occupancy, as stated in R9-10-113 for one of three residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R1's medical record revealed there was no screening and risk assessment documentation for infectious tuberculosis. Based on R1's date of occupancy, this documentation was required. 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 before or at the time of acceptance of an individual, the individual submitted documentation that was 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 of registered nurse. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R3's medical record revealed there was no documentation dated within 90 days of their acceptance date, which included whether R3 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner or registered nurse. Based on R3's acceptance date, this documentation was required. 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 a resident had a service plan that was established, documented, and implemented, that was completed no later than 14 calendar days after the resident’s date of acceptance. for one out of three residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R3's medical record revealed there was no service plan available. Based on R3's date of acceptance, this documentation was required. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on docuemntation review, observation, and interview, the manager failed to ensure that 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 that monitored or alerted employees of the egress of a resident from the facility or used a mechanism that met the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01. 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 the facility license revealed the facility was licensed at the directed care level. 2. During an environmental inspection of the facility with E2, the Compliance Officers observed the front door of the facility had a key still left in the lock which would allow residents to exit the facility. 3. During an environmental inspection of the facility with E2, the Compliance Officers observed the front door of the facility had an alarm, however, the alarm did not make a sound whenever the door was opened. The Compliance Officers also observed that the front door was not being monitored. 4. During an environmental inspection of the facility with E2, the Compliance Officers observed that throughout the duration of the inspection until the exit interview, the key was left in the door, the alert was not functioning, and the staff did not check on the door to the facility. 5. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that equipment used at the assisted living facility was maintained in working order. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed a bathroom with a broken sink with an "out of order" sign attached to the faucet. The sink was located in the bedroom of R4. 2. The Compliance Officers also observed the broken sink was the only sink in the only bathroom available in the bedroom of R4. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on record review and interview, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently, for one of one resident reviewed. The deficient practice posed a risk as the facility left a resident on the floor instead of providing first aid to a non-injured resident by assisting them off the floor after a fall. Findings include: 1. A review of R3's medical record revealed a document titled "Incident Report Form" dated September 16, 2023 which reflected "Heard [R3] calling for help, went in room and noted resident laying fallen down on the floor with urine all over R3. As per R3, R3 got up to go to the commode but wasn't able to hold and urinate on the floor and R3 slip down on the floor and hit right cheek on wheelchair causing skin care; called 911 to get [R3] up back to bed, treatment to right cheek done." 2. In an interview, acknowledged the facility failed to provide appropriate first aid to a non-injured resident.

Based on observation, documentation review, and interview, the manager failed to designate, in writing, a caregiver who is present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present. The deficient practice posed a risk as no individual on-site was designated to act on behalf of the governing authority in the management of the assisted living facility. Findings include: 1. The Compliance Officer arrived at the facility observed E2 and E3 were the only staff in the facility with five residents present. E1 arrived to the facility approximetly 30 minutes later. 2. The Compliance Officer observed a document titled "Manager's designee" posted in the office area. The "Manager's designee" form did not indicate E2 was accountable for the facility when the manager was not present. 3. In an interview, E1 acknowledged the "Manager's designee" form did not include E2.

Based on documentation review, record review, and interview, the manager failed to ensure a written notification was provided to the Department within two working days after a resident inflicted self-injury which required immediate intervention by an emergency services provider. Findings include: 1. A review of the Department's documentation revealed no written notification indicating a resident inflicted self-injury which required immediate intervention by an emergency services provider. 2. A review of R1's medical record revealed a document titled "Incident Report Form" dated August 25, 2024, which reflected R1 slit R1's wrist and 911 was called by the facility staff. 3. A review of the facility's documentation revealed there was no written notification indicating R1 inflicted self-injury which required immediate intervention by an emergency services provider. 4. In an interview, E1 acknowledged there was no written notification to the Department regarding R1's inflicted self-injury which required immediate intervention by an emergency services provider.

Based on record review and interview, the manager failed to ensure a personnel record was available for one of seven sampled employees. Findings include: 1. A request to review of personnel record of E7 revealed E7 did not have a personnel record to be reviewed. 2. A review of the facility's work schedule dated December 2023, which reflected E7 worked various days. 3. In an interview, the compliance officer requested to review E7's personnel record. E1 reported E7 was a caregiver, however E7's personnel record was not available for review.

Based on record review and interview, the manager failed to ensure a medical record was maintained for one former resident according to A.R.S. Title 12, Chapter 13, Article 7.1. The deficient practice posed a risk as required information could not be verified for the sampled resident. Findings include: 1. The surveyor requested R4's medical record for review. However, R4's medical record was not avaliable for review. 2. In an interview, E1 reported R4's medical record was unavailable for review and R4 was a resident for less than 24 hours.