Oak Haven Assisted Living

Based on observation, record review, and interview, for one of six caregivers or assistant caregivers sampled, the Governing Authority failed to ensure compliance with A.R.S. § 36-411. The deficient practice posed a risk if E3 was a danger to a vulnerable adult population. Findings include: 1. During the environmental tour, the Compliance Officer observed E3 was the only certified caregiver present at the facility. E3 was also observed providing various assisted living services to numerous residents at the facility. 2. A review of E3’s personnel record revealed E3 was hired as a caregiver on November 6, 2023. Further review revealed a photocopy of a fingerprint clearance card with an issue date of September 7, 2022, and an expiration date of September 7, 2028. On the copy was the manager’s signature and the date “11-6-24.” 3. In an interview, E1 advised E1 had last checked the status of E3’s fingerprint card on November 6, 2024, and the card was valid at that time. E1 indicated they had not verified the current status of E3's fingerprint clearance card since November 2024. 4. Research regarding the status of E3’s fingerprint card, conducted through the Arizona Department of Public Safety, https://psp.azdps.gov/services/cardStatusRequest, revealed the card was “Not Valid.” 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on document review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services for two of two employees sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of facility policy and procedures, last updated June 1, 2024, revealed a policy titled “Applicant and Employee Requirement Policy and Procedure.” The policy stated, “Upon being hired by the facility the applicant must: …Verification of qualifications, knowledge, and skills to perform the duties of the job hired for.” The policy also stated, “A Caregiver or Reliever [assistant caregiver] will complete a skills questionnaire to ensure that they have experience, knowledge and skills to complete the requirements of the job.” 2. A review of E2’s personnel record revealed E2 was hired as an assistant caregiver on January 12, 2024. Evidence of documentation indicating E2’s skills and knowledge were verified was unavailable for review. In addition, evidence of documentation indicating E2 completed a skills questionnaire was unavailable for review. 3. A review of E3’s personnel record revealed E3 was hired as a caregiver on November 6, 2023. Evidence of documentation indicating E3’s skills and knowledge were verified was unavailable for review. In addition, evidence of documentation indicating E3 completed a skills questionnaire was unavailable for review. 4. A review of facility staff documentation revealed E2 and E3 worked numerous shifts in January 2026. 5. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, document review, and interview, the manager failed to ensure an assistant caregiver provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at or on behalf of the facility, for one of two employees sampled who were expected to have more than eight hours per week of direct interaction with residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. During an on-site compliance and complaint investigation, the Compliance Officer observed E2 performing various duties, including interacting with residents, preparing the mid-day meal, cleaning, and preparing the dining room. 2. A review of E2’s personnel record revealed E2 was hired on January 12, 2024, as an assistant caregiver. E2’s personnel record included evidence of documentation of a baseline screening for signs and symptoms and risk assessment. However, evidence of a negative two-step skin test or a negative blood test was unavailable for review. 3. A review of facility staffing schedules revealed E2 worked numerous shifts during January 2026. 4. In an interview, E1 advised E2 worked as an assistant caregiver and performed various non-caregiver duties at the facility weekly, at least 8 hours per week. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, for one of three residents sampled, the manager failed to ensure a resident had a written service plan, which, when updated, was signed and dated by the resident or resident’s representative and a nurse or medical practitioner. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R2’s medical records revealed a service plan dated November 15, 2025, indicating R2 received personal care services, including medication administration. The service plan had a signature page, which included the signature of the resident’s representative, dated December 22, 2025. However, the resident’s signature was missing. Furthermore, the service plan contained a signature of a medical provider; however, the medical provider’s signature was dated January 14, 2026. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than two ambulatory residents. The Compliance Officer observed a door leading to a storage closet, which was not secured. The Compliance Officer was able to open the door with little effort, and observed a bottle of “Lysol Advanced Power Clinging Gel Toilet Bowl Cleaner." The containers had a label reading “KEEP OUT OF REACH OF CHILDREN,” and “DANGER: CORROSIVE.” 2. In an interview, E2 advised the toilet bowl cleaner should not have been stored in the unsecured closet and removed the cleaner. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat citation from a compliance inspection conducted on November 16, 2023.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a health and safety risk to the resident. Findings include: 1. R9-10-101.199 defines "Restraint" as any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. 2. A review of the facility's policy and procedures manual revealed "Limitations on Level of Service & Use of Restraints. Procedures: A. This facility Manager and or Owner shall ensure that this assistant Living facility does not accept or retain a resident who requires: Physical Restraints, Chemical Restraints, Behavioral Health Residential Services, Services that the Assisted Living Facility is not licensed to provide, and Services that the Assisted Living Facility is not able to provide". B. ... 2. Staff, Manager, and/or Owner shall ensure bed rails are NEVER used in the facility. Bed Canes can be used however, must be documented on the resident's service plan and must not restrict movement of the resident. The Staff, Manager, and/or Owner shall ensure that residents are free of any and all restraints in the assisted living facility. There are NO EXCEPTIONS. Family, friends, physicians and hospice agencies are to adhere to the NO restraints regulations". 3. During a tour of the facility the Compliance Officer observed, R4 in a hospital bed with full-length bed rails on both sides of the bed, and a trapeze Bar with a stand at the head of R4's bed. The Compliance Officer asked E1 why R4 has bedrails and a trapeze. E1 reported R4 is receiving physical therapy and they are to assist R4 with turning from side to side. The Compliance Officer asked E1 if R4 was able to move the bedrails up and down, E1 reported I believe so. The Compliance Officer asked E1 if R4 was able to get up and out of bed alone without any assistance, E1 reported no R4 is a one to two-person transfer. In an interview, R4 reported to the Compliance Officer being unable to lower the bed rails up and down. 4. A review of documentation dated August 22, 2023, revealed R4 was receiving personal care services, occupational therapy three times a week, needs assistance moving in and out of bed with a one or two-person assist, and moves in and out of a wheelchair with a two-person assist. Nowhere in this service plan did it state the use of restraints, a bed cane or trapeze. 5. In an interview, E1 reported being unaware R4 could not have the bedrails and acknowledged they were not to assist R4 in and out of bed alone.

Based on observation, record review, and interview the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a residents need or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies for four of four personal care residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a facility tour the Compliance Officer observed in R1's room there was no bell, intercom, or other means to alert employees to needs or emergencies. The Compliance Officer observed R1 sitting on the toilet and no caregiver was with R1. R1 did not have any means to alert employees to needs or emergencies. 2. In an interview the Compliance Officer asked E2 what devices the facility used for residents to alert employees to a resident's needs or emergencies. E2 reported using personal call buttons. 3. During a facility tour the Compliance Officer observed in R4's room a call button was wrapped around a side bed rail. 4. During a facility tour the Compliance Officer observed in R5's room there was no bell, intercom, or other means to alert employees to needs or emergencies. During a search of R5's room, E2 found the call button underneath R5's pillows. 5. During a facility tour the Compliance Officer observed in R6's room there was no bell, intercom, or other means to alert employees to needs or emergencies. 6. In an interview, E1 reported being unaware that residents were not wearing their call buttons to alert employees to needs or emergencies.

Based on record review, observation, and interview the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a residents need or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies for four of four directed care residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R2, R3, R7, and R8's medical records revealed all were receiving directed care services. 2. During a tour of the facility the Compliance Officer observed in R3's room a mechanical device (call button without a lanyard) sitting on top of R3's dresser away from R3's bed where R3 was sleeping. This device was not within reaching distance of R3's bed to alert a caregiver to their needs in case of an emergency. 3. During a tour of the facility the Compliance Officer observed in R2, R7, and R8's rooms no bell, intercom, or other mechanical means to alert employees to a resident's need or emergencies was available in a bedroom being used by a resident receiving directed care services. 4. In an interview, E1 reported being unaware that residents were not wearing their call buttons to alert employees to needs or emergencies

Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential elopement dangers to residents. Findings include: 1. A review of documentation revealed this facility is licensed for directed care residents. 2. A review of documentation revealed R2, R3, R7, and R8 are receiving directed care services from the facility. 3. The Compliance Officer observed the backyard was accessible to residents. The Compliance Officer observed a wall surrounding the backyard. The Compliance Officer observed a gate on the right side of the facility. The gate had a lock with a key lock and a thumbturn-style lock on the handle. It also had what looked like a white keypad alarm with a wire connecting the keypad unit to a switch on the gate that would alert when opened. There was a third black keypad lock above. The Compliance Officer was able to open the gate which led the Compliance Officer out in the parking lot and into the surrounding neighborhood. No alarm could be heard. 4. In an interview, the Compliance Officer asked E2, and E3 if they received an alarm to alert them to the Compliance Officer exiting the facility property through the side gate, E2, and E3 reported that they did hear an alarm and did not know it had an alarm on it. 5. In an interview, E1 was unaware the gate in the back yard which led into the street and surrounding area had been left unlocked.

Based on observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and were inaccessible to residents. Findings include: 1. The Compliance Officer observed inside an unlocked cabinet under the kitchen sink contained the following poisonous and toxic materials: - a gallon of "Clorox Bleach"; - a gallon of "Members Mark" liquid dish soap; and - a gallon of "Fabuloso" multi-purpose cleaner. 2. The Compliance Observed sitting on top of a counter in the kitchen was a container of "Members Mark" disinfecting wipes 3. In an interview, E1 reported being unaware the cabinet under the kitchen sink had been left unlocked. E2 reported to E1 that yes the cabinet had been left unlocked and poisonous and toxic materials were accessible to residents.