North Scottsdale Assisted Living

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for three of three personnel sampled. The deficient practice posed a potential 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 the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. The Compliance Officer observed E3 working the day of the inspection. 4. A review of the facility’s October 2025 work schedule revealed the following: E3 worked from October 1, 2025, to October 3, 2025; October 6, 2025, to October 10, 2025; October 13, 2025, to October 16, 2025; October 20, 2025, to October 23, 2025. 5. A review of E3’s personnel record revealed an approximate hire date of 2024. E3 had one TB skin test administered and read that was less than 12 months old. However, there was no second TB skin. 6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as the required information could not be verified for E3. Findings include: 1. Upon arrival, the Compliance Officers observed E3’s cooking and cleaning. 2. A review of E3’s personnel record revealed the following: No documentation of E3’s name, date of birth, and contact telephone number No documentation of E3’s starting date No documentation of E3’s qualifications No documentation of E3’s education and experience No documentation of E3’s completed orientation Documentation of the second TB skin test No documentation of E3’s compliance with the requirements in A.R.S 36-411(A) and ( C ) 3. A review of the facility’s October 2025 work schedule revealed the following: E3 worked from October 1, 2025, to October 3, 2025. E3 worked from October 6, 2025, to October 10, 2025. E3 worked from October 13, 2025, to October 16, 2025. E3 worked from October 20, 2025, to October 23, 2025. 4. In an interview, E2 reported that E3 was an assisted caregiver. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of three residents reviewed. The deficient practice posed a health and safety risk to the resident if a caregiver did not know whether a medication was administered. Findings include: 1. A review of R2's medical record revealed the following: a current written service plan dated June 20, 2025. This service plan indicated R2 received medication administration. Medication order dated July 29, 2025, for “Senna Lax 8.6 mg tablet 1-2 tablet by mouth.” 2. A review of R2's October 2025 Medical Administration Record (MAR) revealed “Senna Lax 8.6 mg tablet” was not listed. 3. The Compliance Officer observed R2’s medication organizer prefilled with “Senna Lax 8.6 mg tablet.” The Wednesday and Thursday morning slots were empty. 4. In an interview, E1 reported that R2 was administered “Senna Lax 8.6 mg” that morning. 5. A review of the facility’s policies and procedures revealed a policy titled “Medication Including Opioids, Narcotics and Schedule 2.” The policy stated, “The trained caregiver will initial in the MAR and include the date and time the medication was given to the Resident and the medications that were taken.” 6. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided. 7. This is a repeat deficiency from the inspection conducted on October 2, 2023.

Based on observation and interview, the manager failed to ensure that food requiring refrigeration was maintained at 41°F or below. The deficient practice posed a risk of potential foodborne illness. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed opened bottles of Hoisin Sauce, A.1. Original Sauce, Mama Sita’s Garlic Oyster Sauce, and Great Value Soy Sauce in a kitchen cabinet near the refrigerator. The labels on all bottles stated “Refrigerate after opening.” 2. In an interview, E1 reported that E1 did not realize the bottles needed to be refrigerated. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. A review of the facility's disaster drill documentation revealed documentation of a disaster drill conducted on April 8, 2025. However, documentation of additional drills was not available for review. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement an evacuation. Findings include: 1. A review of the facility's evacuation drill documentation revealed documentation of a drill conducted on April 22, 2025. However, documentation of additional drills was not available for review. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that a smoke detector was installed in the laundry room and the smoke detectors were tested once a month. The deficient practice posed a health and safety risk to the residents. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed no smoke detector in the laundry room and no fire alarm system. 2. A review of the facility's documentation revealed a “Maintenance Log.” The “Maintenance Log” indicated that the smoke detectors were last tested in August of 2025. 3. In an interview, E2 acknowledged that the smoke detectors have not been tested since August 2025. 4. 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 the premises at the assisted living facility were free from conditions or situations that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to a resident. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed three hospital tables and a Hoyer lift blocking the sliding glass door that led to the backyard. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, record review and interview, for one of four residents reviewed, the manager failed to ensure a resident's written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided. Findings include: "Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident. 1. R1 was not observed to be residing at the facility during the inspection. 2. In record review, R1's medical record (level of care not documented) included documentation R1 received a shower once a week, daily assistance with putting on and removing clothing, grooming, nail care, assistance with eating, full assistance with mobility and transfers. R1's record included documentation R1 received medications, in May, 2023, including but not limited to Prednisone, Methenamine Pregabalin, Alprazolam, Docusate, Fentanyl, Oxygen, Haloperidol, Oxycodone, and Gentamycin. 3. In record review, R1's service plan, dated April 19, 2023, did not include a description of R1's medical or health problems. 4. During an interview, the findings were reviewed with E1, who reported R1's service plan did not include documentation of a description of R1's medical or health problems.

Based on record review and interview, for two of four residents reviewed, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: A.R.S. \'a7 36-401.A.50. defines "Supervisory care services" to mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications. A.R.S. \'a7 36-401.A.41. defines "Personal care services" to mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. A.R.S. \'a7 36-401.A.16. defines "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. In record review, R1's medical record included a service plan, dated April 19, 2023; however, did not include documentation of the level of service the resident was expected to receive. 2. In record review, R2's medical record included a service plan, dated September 3, 2023; however, did not include documentation of the level of service the resident was expected to receive. 3. During an interview, E1 acknowledged the service plans for R1 and R2 did not include the level of service the residents were expected to receive.

Based on observation, and interview, the manager failed to ensure a caregiver encouraged residents to participate in activities planned according to subsection (E). The deficient practice posed a risk if residents were not offered opportunities and encouraged to participate in planned activities. Subsection (E) requires: E. A manager shall ensure that: 1. Daily social, recreational, or rehabilitative activities are planned according to residents' preferences, needs, and abilities; 2. A calendar of planned activities is: a. Prepared at least one week in advance of the date the activity is provided, b. Posted in a location that is easily seen by residents, c. Updated as necessary to reflect substitutions in the activities provided, and d. Maintained for at least 12 months after the last scheduled activity; 3. Equipment and supplies are available and accessible to accommodate a resident who chooses to participate in a planned activity; and 4. Multiple media sources, such as daily newspapers, current magazines, Internet sources, and a variety of reading materials, are available and accessible to a resident to maintain the resident's continued awareness of current news, social events, and other noteworthy information. Findings include: 1. The posted activity calendar titled, October, 2023, indicated the residents were provided with the following planned activities: Sunday - Church and Family Day and Ice Cream Social Monday - Group Exercise. Room Cleaning and Live Events Tuesday - Game Show, Bingo and Outside Walking Wednesday - Group Exercise, Reading Time and Movie & Chips Thursday - Board Games, Folding Laundry and Movie & Popcorn Friday - Group Exercise, Coffee on Patio and Personal Time Saturday - Music Time, Craft Making and Room Cleaning 2. In observation, the facility had seven residents residing at the facility. Six residents were observed sitting at the dining table for lunch, and one resident was observed being assisted with feeding in the common area. Following lunch, four residents were observed throughout the afternoon sitting in the common area with the television on. 3. During interviews, the following information was reported to the compliance officer: - R4 reported no activities were offered or provided at the facility; however, R4 liked to walk when assisted by staff. "They had a guitar player about a year ago, but I didn't like the music." - R5 reported no activities were offered or provided by the facility; however, if encouraged, R5 might participate in exercise. - O1 reported no activities were observed to be provided or offered, and R2 was not taken out of [R2's] bedroom for activities. 4. During an interview, E1 acknowledged activities were not provided according to the posted activity calendar. E1 reported activities had been offered and residents often did not want to participate.

Based on record review, observation, and interview, for one of three residents reviewed, the manager failed to ensure a caregiver documented the services provided in the resident's medical record. The deficient practice posed a risk if services provided for residents could not be verified. Findings include: 1. In record review, R2's medical record included a service plan (no level of care documented), dated September 3, 2023. The service plan documented R2 had Renal Failure, Prostatic Hyperplasia, Expressive Aphasia and Parkinson's signs/Parkinson's like symptoms, and had a "Foley place from pre-admission... Facility to empty dignity bag as needed..." 2. In record review, a document titled, "Activities of Daily Living Chart," did not include documentation of care and services provided for R2's Foley catheter. 3. In observation, R2 was observed to be in bed, and had a Foley catheter in place. 4. During an interview, E2 reported R2's Foley catheter was emptied by the caregivers, and the catheter area was cleaned approximately three times a day, including after a bowel movement. E1 and E2 acknowledged the care and services provided by the caregivers, for R2's Foley catheter, were not documented in the resident's medical record.

Based on record review, and interview, for two of three residents who had a health care power of attorney (POA), the manager failed to ensure a resident's medical record contained a copy of the (POA) documentation. The deficient practice posed a risk if the facility did not obtain and adhere to a resident's documentation of representation. Findings include: 1. In record review, R1's medical record indicated R1 had a POA, who signed R1's acceptance documentation. R2's medical record indicated R2 had a POA, who signed R2's acceptance documentation. The medical records for R1 and R2 did not include a copy of the residents' POA documents. Based on the residents' acceptance dates, this documentation was required to be in the residents' records. 2. During an interview, E1 reported R1 and R2 had a POA, and acknowledged the medical records for R1 and R2 did not include a copy of the residents' POA documentation.

Based on record review, observation, and interview, for one of three residents reviewed, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication that was administered. The deficient practice posed a health and safety risk. Findings include: 1. In observation, a medication container was observed in the kitchen refrigerator, and contained two packages of prefilled Morphine syringes (a Schedule II narcotic and opioid medicine) for R1. One medication package indicated 20 syringes were dispensed on June 3, 2023, with four syringes observed remaining. The second medication package indicated 15 syringes were dispensed on June 5, 2023, with 11 syringes observed remaining. 2. In record review, R1's medical record did not include documentation of a medication order for the Morphine medication, nor documentation the Morphine medication was administered to R1. 3. In documentation review, a facility policy titled, "Part II - Medication administration, ..., " documented... 3. Facility personnel will provide opioid medication based on doctor's orders for regular administration (on a regular basis... If opioid medication is administered on a PRN basis... caregiver will administer... the opioid based on physician PRN written order..." 4. During an interview, E2 reported the morphine medication was administered to R1. E1 reviewed R1's medical record, and acknowledged the documentation of a physician's order for the Morphine medication was not available for review.

Based on observation, record review, documentation review, and interview, for one of four residents reviewed, the manager failed to ensure medications were administered in compliance with a medication order. The deficient practice posed a health and safety risk if the facility did not have a documented medication order for a medication administered to a resident. Findings include: 1. In observation, a medication container was observed stored in the refrigerator, and contained two packages of prefilled Morphine syringes (a Schedule II narcotic and opioid medicine) for R1. One medication package indicated 20 syringes were dispensed on June 3, 2023, with four syringes observed remaining. The second medication package indicated 15 syringes were dispensed on June 5, 2023, with 11 syringes observed remaining. 2. In record review, R1's medical record did not include documentation of a medication order for the Morphine medication, nor documentation the Morphine medication was administered to R1. R1's record did not include documentation of an inventory of the Morphine medication. 3. In documentation review, a facility policy titled, "Part II - Medication administration, ..., " documented... 3. Facility personnel will provide opioid medication based on doctor's orders for regular administration (on a regular basis... If opioid medication is administered on a PRN basis... caregiver will administer... the opioid based on physician PRN written order..." 4. During an interview, E2 reported the morphine medication was administered to R1. E1 reviewed R1's medical record, and acknowledged the documentation of a physician's order for the Morphine medication was not available for review.

Based on observation, record review, and interview, for one of four residents reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a manager or caregiver did not know if a medication was administered. Findings include: 1. In observation, a medication container was observed stored in the refrigerator, and contained two packages of prefilled Morphine syringes (a Schedule II narcotic and opioid medicine) for R1. One medication package documented 20 syringes were dispensed on June 3, 2023, with four syringes observed remaining. The second medication package documented 15 syringes were dispensed on June 5, 2023, with 11 syringes observed remaining. 2. In record review, R1's medical record did not include documentation of the administration of the Morphine medication to R1 3. During an interview, E2 reported the morphine medication was administered to R1. E1 acknowledged R1's medical record did not include documentation of the administration of the morphine medication to R1.

Based on observation, record review, documentation review, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication. The deficient practice posed a health and safety risk if medications were not disposed of, as required. Findings include: 1. In observation, a medication container was observed stored in the refrigerator, and contained two packages of prefilled Morphine syringes (a Schedule II narcotic and opioid medicine) for R1. One medication package documented 20 syringes were dispensed on June 3, 2023, with four syringes observed remaining. The second medication package documented 15 syringes were dispensed on June 5, 2023, with 11 syringes observed remaining. The medication container also contained a package of Haldol syringes, quantity 20 dispensed on May 23, 2023, with 20 syringes observed remaining. R1 was not observed at the facility during the inspection. 2. In record review, R1's residency had been terminated. 3. In documentation review, a facility policy titled, "Medication Administration, ... Part IV - Disposal (discarding) of medication..." ..documented "... The facility manager ... will check on a monthly basis all medication in the facility to identify and locate any discontinued medication..., expired medication, including deceased resident's medication. 2. Such medication will be disposed of by the facility manager or manager designee the last day of the month, as follows... 3. The medication disposal will be recorded in the Medication Disposal Form. 4. Documentation and proof of return or destruction of medication will be maintained in the resident's records... 4. During an interview, E1 reported R1 no longer resided at the facility, and acknowledged R1's medications were not disposed of in accordance with the facility's policies and procedures.

Based on observation, documentation review, record review, and interview, for one resident reviewed who received controlled substances, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for. Findings include: 1. In observation, a medication container was observed stored in the refrigerator, and contained two packages of prefilled Morphine syringes (a Schedule II narcotic and opioid medicine) for R1. One medication package documented 20 syringes were dispensed on June 3, 2023, with four syringes observed remaining. The second medication package documented 15 syringes were dispensed on June 5, 2023, with 11 syringes observed remaining. 2. In record review, R1's medical record did not include documentation of an inventory of the Morphine medication. 3. In documentation review, a facility policy titled, "Opioid Medications," documented, ... 3. The opioid medication will be inventoried and placed in the medication storage..." The policy, "Part V - Storing, inventory and disposing controlled substances," documented, "... Daily narcotic administration will be recorded on each resident MAR or Narcotic Administration record. 3. As needed narcotic administration will be recorded in the Narcotic Administration Record separate for each resident to ensure proper inventorying...." 4. During an interview, E1 reviewed R1's medical record, and acknowledged R1's record did not include an inventory of the Morphine medication.

Based on observation, documentation review, and interview, the licensee implemented a modification of the facility, without an approval or amended license issued by the Department. The deficient practice posed a risk as the Department was unable to assess and approve the modification, as the facility did not submit an updated floor plan, and documentation of compliance with local building and zoning codes. Findings include: 1. During an environmental inspection with E1 and E2, the compliance officer observed the facility had converted a one car garage (attached to a two car garage) into two bedrooms; each containing furniture, a bed, and personal belongings. 2. In documentation review, Department documentation revealed a room occupancy report for AL10730, which indicated AL10730 had nine bedrooms. Department documentation revealed no documentation the licensee submitted documentation for approval for a modification to the physical plant to include two bedrooms attached to the garage. 3. During an interview, E2 reported [E2] resided in one bedroom. E1 and E2 reported E5's belongings were in the other bedroom. 4. In email correspondence, E1 reported the "storage closets in the garage were created early on," for use by staff for storing items. E1 reported the facility was informed by the City of Scottsdale that a permit wasn't required for the modification of the garage to "storage" closets.