Oasis at El Corral Assisted Living Center

Based on record review and interview, for ten of ten sampled residents, the assisted living home failed to maintain a standardized form for each resident which included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. The deficient practice posed a risk if staff were unable to relay critical information to emergency responders in a timely manner. 1. During an on-site inspection, the Compliance officer reviewed ten sampled resident medical records. However, documentation of a standardized form for each resident that included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted, was not available for review. 2. In an interview, after the Compliance Officer requested specific forms for two residents, E2 reported these forms were not available for any resident. During the on-site inspection, E2 provided the Compliance Officer with a draft of a form based on the regulation, which had not been implemented, and asked for clarification of the regulation while looking online for an example of a HIPAA release to include with the form. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the assisted living center failed to maintain a copy of documentation provided to an emergency responder, for three of three sampled residents who had recently had an emergency. The deficient practice posed a risk as the Department was unable to ensure the facility's compliance. Findings include: 1. A review of R7's medical record revealed an incident report, dated December 4, 2025, at 1:50 PM, which stated, "During rounds resident was observed on the floor next to bed with blood in [R7's] forehead. Resident was disoriented. 911 called: Yes. Time they arrived: 2 PM. [R7] was transported to [A hospital] Investigative findings: [R7] suffered heart block on [R7's] way to hospital" 2. During the on-site inspection, the Compliance Officer requested to review the facility's copy of the documentation provided to the emergency responder for this incident; however, documentation was not available for review. 3. A review of R9's medical record revealed an incident report, dated November 26, 2025, at 11:15 AM, which stated, "Checked on [R9] and [R9] stated [R9] wasn't feeling well, I dumped [R9's] urine and it was brown so I asked [R9] some questions and [R9] stated [R9] fell so I checked the bathroom and saw the blood and check [R9] over reported my findings. Description of injury: Blood Toe. 911 called: Yes. Time they arrived 11:35. Resident transported to hospital, admitted with sepsis." 4. During the on-site inspection, the Compliance Officer requested to review the facility's copy of the documentation provided to the emergency responder for this incident; however, documentation was not available for review. 5. A review of R10's medical record revealed an incident report, dated November 18, 2025, at 9 AM, which stated, "Resident was in scooter at the med room, as [R10] was backing up [R1] got too close to the edge causing [R10's] scooter to go off the ledge, falling backwards. During fall, resident hit [R10's] head on the tree. 911 Called: Yes. Time they arrived: 9:15 AM." 6. During the on-site inspection, the Compliance Officer requested to review the facility's copy of the documentation provided to the emergency responder for this incident; however, documentation was not available for review. 7. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review, record review, and interview, for two of two sampled residents who received administration of an opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident's health and safety if the facility did not appropriately assess and monitor opioid administration for a resident. Findings include: 1. A review of the facility's policies and procedures, last approved by E1 on January 24, 2024, revealed an opioid policy, which stated, "Prior to administering the opioid the caregiver or manager will identify and record the resident's pain using either a 1-10 scale if the resident is supervisory or personal level or care (sic) or the 'Dementia Pain Identifiers' scale if the resident is directed level of care... One hour after administration, the caregiver or manager will identify and record the resident's pain using either a 1-10 scale if the resident is supervisory or personal level or care (sic) or the 'Dementia Pain Identifiers' scale if the resident is directed level of care... the manager or designee will review the opioid administration for completeness weekly and ensure it is appropriately completed. The manager or designee will review the opioid documentation for effectiveness weekly. If a resident's pain is not controlled with the prescribed medication or if the resident is having increased sleepiness from medication or other adverse effects the manager or designee will notify the medical practitioner of these things, the manager or designee will review the effectiveness of the opioids with the Medical Practitioner at each visit." 2. A review of R2's medical record revealed a service plan, dated April 22, 2025, for personal care services including medication administration. 3. A review of R2's medical record revealed an order for "Methadone HCL 10MG TAB, take one tablet by mouth twice a day for chronic pain." 4. A review of R2's medical record revealed a medication administration record (MAR) dated November 2025. The MAR documented R2 had been administered "Methadone HCL 10 MG Tablet, take 1 tablet by mouth twice daily for pain" on each day in November at 8 AM and 5 PM. 5. A review of R2's medical record revealed documentation of the pain assessment and monitoring of the effect for each dose of opioid medication administered to R2, and documentation of weekly reviews by the manager or designee were not available for review. 6. A review of R9's medical record revealed a service plan, dated November 19, 2025, for personal care services including medication administration. 7. A review of R9's medical record revealed an order, dated November 11, 2025, for "Oxycodone HCI 5 MG oral tablet, ta

Based on documentation review, record review, observation and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to health and safety. Findings include: 1. A review of ten sampled resident records revealed emergency transfer forms required by ARS 36-420.04 for all residents were not available, and copies of documentation given to emergency responders for three of ten reviewed emergencies were not available. This deficient practice placed residents at risk of harm because critical information may not be provided to emergency responders in a timely manner. 2. A review of two sampled residents who had received administration of opioid medications revealed an assessment of their need for the opioid and monitoring of residents after the administration of the opioid for the effect of the opioid, per R9-10-120(F), was not being documented. This deficient practice placed residents at risk of having an adverse reaction to opioids go unnoticed by facility staff. 3. A review of ten sampled resident records revealed one of ten residents, R9, did not have valid TB clearance per R9-10-807(A) and R9-10-113, as the clearance documentation indicated E1 had administered expired tuberculin serum to R9. This deficient practice placed residents at risk of exposure to TB and placed R9 at risk of injury due to the injection of an expired biological product. 4. A review of ten sampled resident records revealed two of ten residents did not have valid documentation from a medical practitioner or registered nurse stating they were appropriate for admission to the facility per R9-10-807(B)(1). This deficient practice placed residents at risk of harm if a resident was accepted whom the facility did not have the ability to provide care for. 5. A review of ten sampled resident records revealed one of ten residents, R3, was retained by the facility even though the primary condition for which R3 required assisted living services was a behavioral health issue, per R9-10-807(B)(2). This deficient practice placed residents at risk of harm as the facility was not licensed to provide behavioral health services. 6. A review of ten sampled resident records revealed two of ten residents did not have a valid residency agreement at the time of admission, per R9-10-807(D-E), and false or misleading information was provided to the department. This deficient practice placed residents at risk of harm if a resident was admitted who requires services not offered by the facility within their scope of services or did not have the ability to pay for services rendered. 7. A documentation review of facility termination notices revealed a termination notice for R10 which did not include the required information per R9-10-807(H-I). This deficient practice placed residents at risk of harm because without accurate and complete termination information, a resident’s ability to obtain new placement may be

Based on record review, documentation review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious Tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy as specified in R9-10-113, for two of ten sampled residents. The deficient practice posed a potential TB exposure risk to residents, and false or misleading information was provided to the Department. Findings include: 1. A review of R9's medical record revealed documentation of evidence of freedom from infectious Tuberculosis before or within seven calendar days after R9's date of occupancy was not available for review. 2. Approximately 1 hour after being advised R9's medical record did not include documentation of freedom from TB E1 provided a TB screening form and negative skin test for R9 which had been conducted by E1. The record indicated the injection date of the serum was on November 6, 2025 at 3:30 PM, and the induration read date was November 8, 2025 at 3:00 PM, less than 48 hours later. The record indicated the Tuberculin serum had expired on "10/25," before the serum was injected into R9. 3. A review of R4's medical record revealed a TB screening form and negative TB skin test conducted by E1 in April 2025. However, R4's TB screening indicated less than 48 hours had elapsed at the time the induration was documented by E1. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of ten residents sampled. 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 a form titled "Provider Approval for Admission into The Oasis Assisted Living." The form had boxes to indicate, yes or no, whether R3 required Continuous Medical Services, Continuous Nursing Services, Intermittent Nursing Services, or Restraints. The form had been signed and dated; however, all of the relevant boxes had been left blank. 2. A review of R4's medical record revealed a "Provider Approval for Admission into The Oasis Assisted Living" form, which had all of the boxes checked. However, the form was not dated, so it was not possible to determine if the form had been dated within 90 calendar days before R4's acceptance. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to discharge an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue, for one of ten residents sampled. 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 a service plan, dated June 25, 2025, for personal care services. The service plan stated, "Medical Diagnosis/Health Problems: HTN, bi-polar," and did not list any physical, cognitive or functional impairments. The service plan indicated R3's "community or other services utilized," included: "MHC behavioral health." The service plan indicated R3 was independent of all activities of daily living (ADLs) and the only personal care service being provided was medication administration. R3's service plan included the following service: "Bi-Polar, symptoms anxious, pacing at times. 1) Notify [behavioral health provider] who's prescribing psychiatric medications if [R3] refuses to take any of those medications or if [R3] becomes more hyper (active) or less active (depressed) as this may mean a change in their bi-polar phase." 2. A review of R3's medical record revealed documentation from a medical provider dated in January 2025. The documentation included a history of present illness which stated, "[R3]...hx of afib, chronic schizoaffective disorder bipolar type, who lives at a group home residential facility (since 2010's apx) who present for TOC visit. Plays piano and sings." 3. In an interview, E1 reported the services provided to R3 include cooking and laundry. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure, before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility, for two of ten residents reviewed. The deficient practice posed a risk if the resident was not informed of the terms of residency, and false or misleading information was provided to the Department. Findings include: 1. A review of R9's medical record revealed a residency agreement was not available for review. However, based on R9's approximate date of admission, a residency agreement was required. 2. A review of R9's medical record revealed a Medication Administration Record, which documented when R9 had started receiving medication services from the facility. 3. During the on-site inspection, after E1 was advised the residency agreement for R9 was not available in R9's medical record, a residency agreement was provided for R9. However, this residency agreement contained false or misleading information. The date of acceptance on the residency agreement was not accurate and stated R9 was admitted 12 days after R9 actually began receiving medication services from the facility. Additionally, the managers and resident's signatures were also dated on the incorrect, later date, and the resident's signature date appeared to have been written in the same pen and handwriting as the manager's signature and date, and was in different handwriting from the resident's signature. 4. A review of R10's medical record revealed a residency agreement was not available for review. However, based on R10's date of admission, a residency agreement was required. 5. A review of R10's medical record revealed a service plan and a notice of termination that both gave an admission date for R10, which matched the MAR showing when medication had been administered to R10. 6. During the on-site inspection, after E1 was advised the residency agreement for R10 was not available in R10's medical record, a residency agreement was provided for R10. However, this residency agreement contained false or misleading information. The date of acceptance on the residency agreement was not accurate and stated R10 was admitted 31 days after R10 actually began receiving medication services from the facility. Additionally, the residency agreement had not been signed by the resident, and the manager's signature and date were 9 months and 21 days before R10's actual date of admission. 7. In an exit interview with E1, the findings were reviewed. E1 did not provide any additional information and stated all of the issues on the documents E1 had provided were typos.

Based on record review and interview, the manager failed to ensure, before or within five working days after a resident's acceptance by an assisted living facility, the manager obtained, on the documented residency agreement, the signature of one of the required individuals, for two of ten residents reviewed. The deficient practice posed a risk if the resident was not informed of the terms of residency and false or misleading information was provided to the department. Findings include: 1. A review of R9's medical record revealed a residency agreement was not available for review. However, based on R9's approximate date of admission, a residency agreement was required. 2. A review of R9's medical record revealed a Medication Administration Record, which documented when R9 had started receiving medication services from the facility. 3. During the on-site inspection, after E1 was advised the residency agreement for R9 was not available in R9's medical record, a residency agreement was provided for R9. However, this residency agreement contained false or misleading information. The date of acceptance on the residency agreement was not accurate and stated R9 was admitted 12 days after R9 actually began receiving medication services from the facility. Additionally, the managers and resident's signatures were also dated on this incorrect date, more than five days after R9's actual date of acceptance. The resident's signature date appeared to have been written in the same pen and handwriting as the manager's signature and date, and was clearly written differently from the resident's signature. 4. A review of R10's medical record revealed a residency agreement was not available for review. However, based on R10's date of admission, a residency agreement was required. 5. A review of R10's medical record revealed a service plan and a notice of termination that both gave an admission date for R10, which matched the MAR showing when medication had been administered to R10. 6. During the on-site inspection, after E1 was advised the residency agreement for R10 was not available in R10's medical record, a residency agreement was provided for R10. However, this residency agreement contained false or misleading information. The date of acceptance on the residency agreement was not accurate and stated R10 was admitted 31 days after R10 actually began receiving medication services from the facility. Additionally, the residency agreement had not been signed by the resident or another required person within five days after R10's acceptance, and the manager's signature and date was 9 months and 21 days before R10's actual date of admission. 7. In an exit interview with E1, the findings were reviewed. E1 did not provide any additional information and stated the incorrect dates on the documents E1 had found were mistakes.

Based on documentation review, record review, and interview, the manager failed to ensure a written notice of termination of residency included the policy for refunding fees, charges, or deposits, or the deposition of a resident’s fees, charges, and deposits, for one of the reviewed termination notices. The deficient practice posed a risk if the resident was misled about their terms of residency. Findings include: 1. A review of the facility's policies and procedures, reviewed by E1 on January 24, 2024, revealed a refund policy was not established or documented. The policy manual stated, "Refund policy is described in the residency agreement." 2. A review of R10's alleged residency agreement revealed the following refund policy: "Fee refunds following termination. Refunds on rent monies are not given to the resident/family unless the Center chooses to terminate the agreement. Any funds that are owed to the resident, following appropriate termination of this agreement, shall be paid to the resident or their responsible party within 30 days of the resident moving out of the facility. Any damages caused by the resident to the Center or property will be deducted from monies owed to the resident by The Oasis Assisted Living Center. There are no refunds of base monthly fees if the resident is absent from the home for any reason." 3. A review of R10's medical record revealed a termination notice dated November 19, 2025. The termination notice provided an incorrect termination policy, and stated, "The Oasis does not refund any fees, charges or deposits as per policy." However, neither the policy from the policy and procedure manual or from the residency agreement were included in the notice. Based on the residency agreement, R10 would be entitled to a refund in this situation, because the Center was choosing to terminate residency. Additionally, the termination notice did not include the deposition of R10's fees, charges, and deposits, if any. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on August 19, 2025.

Based on record review and interview, when a manager provided a written notice of termination of residency, the manager failed to provide a copy of the resident's current service plan or documentation of the resident's freedom from infectious tuberculosis, for one of one reviewed termination notice. This deficient practice poses a risk, as a resident is less able to obtain new placement in a timely manner without this documentation. Findings include: 1. A review of R10's medical record revealed a termination notice dated November 19, 2025. However, the termination notice was a single page and did not include a copy of the R10's current service plan or documentation of the R10's freedom from infectious tuberculosis. The termination notice stated, "You will be provided with a current service plan, TB, and Dr. orders. 2. In an interview, O3 reported only the single page termination notice was provided to R10 at the time of the notice, and even after asking for the service plan and tuberculosis test, there was a significant delay in obtaining these documents from E1. O3 reported, on December 4, 2025, when R10 went to lunch with a family member, E1 ordered R10 to be prevented from re-entering the facility. O3 reported when R10 did return and was denied entry to the facility, E1 called the police and reported them for trespassing, however, the police sided with R10, who was let back into the facility. 3. In an interview, E1 reported R10 has never made a payment since moving in, and has refused to sign any documentation, such as the residency agreement and service plan. E1 reported the proper documentation was given to R10 with the termination notice. E1 reported R10's family member was belligerent when they wouldn't let R10 back in, but it had been two weeks since the notice, and R10 had told them, "I am leaving" when they left the facility that day, so they considered that statement to mean R10 had moved out and called the police when they pushed through the gate when they came back. E1 reported another facility has accepted R10, but if R10 doesn't go, they will file a court action to have R10 evicted. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a complete service plan no later than 14 calendar days after the resident's date of acceptance, for one of ten sampled residents. 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 R8's medical record revealed a service plan was not available for review. However, based on R8's date of acceptance, a service plan was required. 2. In an exit interview with E1, the finding was reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on August 19, 2025.

Based on record review and interview, the manager failed to ensure that a resident's service plan included the level of service the resident was expected to receive, for one of nine residents sampled who had a service plan available. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R10’s medical record revealed a service plan. However, the service plan did not include the level of service the resident was expected to receive. Based on R10's actual date of admission, a completed service plan was required. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure, for one of ten sampled residents, a resident had a service plan which accurately included the amount, type, and frequency of assisted living services and ancillary services being provided to the resident. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. A review of R10's medical record revealed a service plan, dated November 12, 2025. The service plan listed services which would be provided to R10, however, the service plan contained contradictory services. The service plan stated, "COPD/Lung Disease, short of breath at times, 1) avoid stress, fatigue, wind, aerosol sprays, excessive heat or cold 2) Encourage [R10] to not go outside when it's windy 3) Monitor daily for increased shortness of breath, wheezing or difficulty breathing - report any of these to doctor. 4) Has oxygen and uses it when [R10] needs it. [R10] is independent with [R10's] oxygen and uses it as [R10] chooses." However, the service plan also stated, "Oxygen Therapy. 1) Check oxygen flow once each shift to make sure it is flowing at the rate ordered. 3) Check at least once each shift to make sure oxygen tubing is positioned correctly on face and doesn't cut into skin. 3) Care staff follow Dr. orders regarding flow rate." 2. A review of R10's medical record revealed a list of initial orders titled "Initial Physician Plan of Care" (PPOC). The PPOC was signed by a medical practitioner and was dated October 29, 2025. The PPOC included the order, "This person requires oxygen 2.5 LPM, Yes, Continuous." 3. A review of R10's medical record revealed documentation of services provided to R10 on a daily basis (ADL). However, the ADL did not specifically document oxygen services being provided to R10. 4. In an interview, E1 reported R10 does not use oxygen regularly and staff are not ensuring R10 is using oxygen at all times. E1 reported the service plan was not accurate. 5. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's service plan included the psychosocial interactions or behaviors for which the resident required assistance; the psychotropic medications ordered for the resident; the planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and the goals for changes in the resident's psychosocial interactions or behaviors, for two of two residents reviewed who required behavioral care. The deficient practice posed a risk as a service plan directs the services to be provided to a resident. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. Findings include: 1. A review of R3's medical record revealed a service plan, dated June 25, 2025, for personal care services. The service plan stated, "Medical Diagnosis/Health Problems: HTN, bi-polar," and did not list any physical, cognitive or functional impairments. The service plan indicated R3's "community or other services utilized," included: "MHC behavioral health." The service plan indicated R3 was independent of all activities of daily living (ADLs) and the only personal care service being provided was medication administration. R3's service plan included the following service: "Bi-Polar, symptoms anxious, pacing at times. 1) Notify [behavioral health provider] who's prescribing psychiatric medications if [R3] refuses to take any of those medications or if [R3] becomes more hyper (active) or less active (depressed) as this may mean a change in their bi-polar phase. 2) monitor each shift for anxiety, pacing. 3) Interventions that work: get [R3] interested in activities [R3] likes, take [R3] for a walk outside." However, the service plan did not include a list of the psychotropic medications ordered for the resident or the goals for changes in the resident's psychosocial interactions or behaviors. 2. A review of R8's medical record revealed R8 did not have a service plan to review. Based on R8's date of admission, a service plan was required. 3. A review of R8's medical record revealed a list of admission diagnoses, which included "COPD, Alcoholic cirrhosis of liver w/o ascites, alcohol abuse, anxiety

Based on record review and interview, the manager failed to ensure, for two of two sampled residents who required behavioral care, service plans were reviewed by a medical practitioner or behavioral health provider. The deficient practice posed a risk as a service plan was not completed to articulate decisions and agreements of services to be provided. 1. A review of R3's medical record revealed a service plan, dated June 25, 2025, for personal care services. The service plan stated, "Medical Diagnosis/Health Problems: HTN, bi-polar," and did not list any physical, cognitive or functional impairments. The service plan indicated R3's "community or other services utilized," included: "MHC behavioral health." The service plan indicated R3 was independent of all activities of daily living (ADLs) and the only personal care service being provided was medication administration. R3's service plan included the following service: "Bi-Polar, symptoms anxious, pacing at times. 1) Notify [behavioral health provider] who's prescribing psychiatric medications if [R3] refuses to take any of those medications or if [R3] becomes more hyper (active) or less active (depressed) as this may mean a change in their bi-polar phase. 2) monitor each shift for anxiety, pacing. 3) Interventions that work: get [R3] interested in activities [R3] likes, take [R3] for a walk outside." However, the service plan was not reviewed by a medical practitioner or behavioral health professional. 2. A review of R8's medical record revealed R8 did not have a service plan to review. Based on R8's date of admission, a service plan was required. 3. A review of R8's medical record revealed a list of admission diagnoses, which included "COPD, Alcoholic cirrhosis of liver w/o ascites, alcohol abuse, anxiety disorder. 4. A review of R8's medical record revealed a prescription pad order dated September 1, 2023 (sic), which stated: "1) 2 hour check the pt. Pt has SI (suicidal ideation) but no plans. 2) D/C Quetiapine 100mg 1.5 tag PO daily at bedtime. 3) Quetiapine 200 MG, 2 tabs PO daily at bedtime." 5. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for two of seven personal care residents reviewed. The deficient practice posed a risk as service plans reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan, last updated April 28, 2025, for personal care services. However, a service plan updated within the previous six months was not available for review. 2. A review of R2's medical record revealed a service plan, last updated April 24, 2025, for personal care services. However, a service plan updated within the previous six months was not available for review. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, a manager failed to ensure a resident had a service plan, which when initially developed, was signed and dated by the resident or resident's representative, for one of nine residents with an available service plan. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R10's medical record revealed a service plan, dated November 12, 2025. The service plan was not completed and did not include a level of care, did not include a description of any physical, cognitive, or functional conditions or impairments, and included contradictory services. Additionally, the service plan had not been signed by the resident or the resident's representative, and had an undated note stated, "[R10] refused to sign care plan." 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that residents were treated with dignity, respect, and consideration. The deficient practice violated a resident's rights. Findings include: 1. A review of R7's medical record revealed a residency agreement which stated, "Residents who reside at The Oasis Assisted Living Center are expected to come to the dining room for meals and medication administration. Medications are delivered to resident rooms after 6 PM and before 6 AM. Residents who choose to have meals delivered to his/her apartment are charged a minimum fee of $15 for every meal delivered to his/her apartment. The goal of The Oasis Assisted Living Center is to promote a social atmosphere during meal time. The administration and staff of The Oasis Assisted Living Center encourages all residents to have their meals in the dining room." 2. A review of the facility roster revealed 21 of 30 current residents were recipients of the Arizona Long Term Care System (ALTCS). 3. Online research revealed the 2025 ALTCS Share of Cost calculation included a total personal needs allowance (PNA) of $145.05. Based on this PNA, at least 21 residents could not afford food delivery. 4. In an interview with E1, E1 denied residents who fail to come to the dining room at meal times or medication times are deprived of their food or medications. E1 explained medications that go out between 5-6 AM are delivered to the rooms, but for medications scheduled during daylight hours, and for meals, residents are required to come to the office or dining room. E1 stated that if a resident is unable to ambulate, or is sick, they deliver food and medications, but if a resident is ambulatory and able to come to get food and medications than they are required to do so. E1 stated if an ambulatory resident fails to come to a meal or for medications, staff are instructed to go to the resident's room and remind them to come to the dining room or office, not to deliver meal or medication. E1 said if a resident is able to come to get food or medications but refuses to do so, that could be marked as a refusal in their chart. E1 reported by the time the staff can go to the rooms of residents to deliver medications, it would already be after the one hour window allowed to administer medications, so they could not administer it at that time anyhow. 5. In an interview with O1, O1 stated E1 has told all staff that for the 8 AM, 12 PM, and 5 PM medication passes, staff are not allowed to deliver medication to rooms, even if the residents are sick or it is very cold or very hot outside. O1 stated E1 has told staff all residents have agreed to this on their residency agreement and they must comply. O1 reported E1 has instructed all staff that unless a resident is on hospice, they must come to the dining room to get food, staff cannot deliver food. O1 reported there is supposed to be a snack at 8 PM, but there is frequently nothing to serve for the sna

Based on record review and interview, the manager retained two of two sampled residents who required behavioral care without meeting the requirements, to include documentation to demonstrate a behavioral health professional or medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility. 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 a service plan, dated June 25, 2025, for personal care services. The service plan stated, "Medical Diagnosis/Health Problems: HTN, bi-polar," and did not list any physical, cognitive or functional impairments. The service plan indicated R3's "community or other services utilized," included: "MHC behavioral health." The service plan indicated R3 was independent of all activities of daily living (ADLs) and the only personal care service being provided was medication administration. R3's service plan included the following service: "Bi-Polar, symptoms anxious, pacing at times. 1) Notify [behavioral health provider] who's prescribing psychiatric medications if [R3] refuses to take any of those medications or if [R3] becomes more hyper (active) or less active (depressed) as this may mean a change in their bi-polar phase. 2) monitor each shift for anxiety, pacing. 3) Interventions that work: get [R3] interested in activities [R3] likes, take [R3] for a walk outside." 2. A review of R3's medical record revealed documentation to demonstrate a behavioral health professional or medical practitioner had examined the resident at least once every six months throughout the duration of R3's bipolar disorder; reviewed the facility's scope of services; and signed and dated a determination stating the R3's needs were being met at the facility, was not available for review. 3. A review of R8's medical record revealed R8 did not have a service plan to review. Based on R8's date of admission, a service plan was required. 4. A review of R8's medical record revealed a list of admission diagnoses, which included, "COPD, Alcoholic cirrhosis of liver w/o ascites, alcohol abuse, anxiety disorder." 5. A review of R8's medical record revealed a prescription pad order dated September 1, 2023 (sic), which stated: "1) 2 hour check the pt. Pt has SI (suicidal ideation) but no plans. 2) D/C Quetiapine 100mg 1.5 tag PO daily at bedtime. 3) Quetiapine 200 MG, 2 tabs PO daily at bedtime." 6. A review of R8's medical record revealed documentation to demonstrate a behavioral health professional or medical practitioner had examined the resident at least once every six months throughout the duration of R8's anxiety disorder; reviewed the facility's scope of services; and signed and dated a determination stating the R8's needs were being met at the fac

Based on record review and interview, the manager failed to ensure the service plan for one of one sampled resident receiving directed care services included documentation of the resident's weight or documentation from a medical practitioner stating that weighing the resident is contraindicated. Findings include: 1. A review of R7's medical record revealed a service plan, dated September 18, 2025, for directed care services. However, the service plan did not include documentation of R7's weight. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order, for three of ten sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication, and false or misleading information was provided to the department. Findings include: 1. A review of R3's medical record revealed a service plan, dated June 25, 2025, for personal care services, including medication administration. 2. A review of R3's medical record revealed the most recent full medication list was dated January 24, 2025. 3. A review of R3's medical record revealed all single orders available dated after January 24, 2025 were for psychiatric medications. 4. A review of R3's medical record revealed a medication administration record (MAR) dated November 2025. However, the MAR included documentation of the administration of Carvedilol, Ferrous Sulfate, Lisinopril, and Amlodipine which did not comply with the orders present in R3's medical record. 5. In an interview, E2 reported R3 recently switched doctors, but none of the new doctor's orders were available for review. 6. A review of R4's medical record revealed a service plan, dated October 22, 2025, for personal care services including medication administration. 7. A review of R4's medical record revealed a MAR dated November 2025. The MAR indicated R4 had not been administered, "Lidocaine 5% patch, apply 2 patches topically daily to affected site(s) for 12 hours then remove for twelve hours, had not been provided to R4 on November 23, 24, 25, 26, 27, and November 30, 2025, with the comment, "waiting on order." However, the patches had been falsely marked as having been administered on November 28 and November 29, 2025, despite not being available at the time. 8. In an interview, E2 reported the Lidocaine patch required a prior authorization which took a long time to go through and be approved. 9. A review of R6's medical record revealed a service plan, dated June 25, 2025, for personal care services including medication administration. 10. A review of R6's medical record revealed an order, dated November 11, 2025, for "Metoprolol Succ ER 25 MG Tab, take 1 tablet by mouth daily **hold for HR less than 60**." 11. A review of R6's medical record revealed a blood pressure log dated October 1, 2025 through October 27, 2025. This log included the following entries: on October 2, 2025, R6's heart rate was documented to have been 107; on October 7, 2025, R6's heart rate was documented to have been 58; on October 11, 2025, R6's heart rate was documented to have been 55; and on October 24, 2025, R6's heart rate was documented to have been 56. 12. A review of R6's medical record revealed a MAR dated October 2025. The MAR documented the following medication errors: On October 2, 2025, R6's Metoprolol was held with the note, "HR less than 60."; On October 7, 2025, R

Based on observation and interview, the manager failed to ensure a food menu was prepared a week in advance, included the foods to be served each day, was conspicuously posted at least one calendar day before the first meal on the food menu was served, included any food substitution no later than the morning of the day of meal service with a food substitution, and was maintained for at least 60 calendar days after the last day included in the food menu. Findings include: 1. The Compliance Officer observed a food menu was not posted conspicuously on the premises. 2. The Compliance Officer observed a one week menu, posted on a commercial refrigerator in the kitchen's food preparation area. However, the menu was dated October 20 through October 26, 2025. The menu did not include any snacks. 3. In an interview, E5 reported E5 prepared the food at the facility, but does not make the menus or order the food. E5 reported there have not been any menus since E5 has been working there and E5 just sees what food is available and makes the best food E5 can with what is available. 4. In an interview, E1 was asked if there was a posted menu and E1 pointed to the menu from October posted in the kitchen area. 5. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure meals and snacks provided by the assisted living facility were served according to posted menus. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. The Compliance Officer observed a food menu was not posted conspicuously on the premises. 2. The Compliance Officer observed a one week menu, posted on a commercial refrigerator in the kitchen's food preparation area. However, the menu was dated October 20, 2025 through October 26, 2025. The menu did not include any snacks. 3. In an interview, E5 reported E5 prepared the food at the facility, but does not make the menus or order the food. E5 reported there have not been any menus since E5 has been working there and E5 just sees what food is in stock and makes the best food E5 can with what is available and what residents want. 4. In an interview, E1 was asked if there was a posted menu and E1 pointed to the menu from October posted in the kitchen area. 5. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure meals and snacks for each day were planned using the applicable guidelines in http://www.health.gov/dietaryguidelines/2015. The deficient practice posed a risk if residents did not receive nutritious food options. Findings include: 1. The Compliance Officer observed a food menu was not posted conspicuously on the premises. 2. The Compliance Officer observed a one week menu, posted on a commercial refrigerator in the kitchen's food preparation area. However, the menu was dated October 20 through October 26, 2025. The menu did not include any snacks. The menu included the following planned meals: "Monday, 10/20/2025, Breakfast: Sausage, Egg, Cheese Quesadilla, Tots, Fruit. Lunch: Sloppy Joes, Fries, Pudding. Dinner: Lemon Chicken Pasta, Garlic Toast, Cake. Tuesday, 10/21/2025, Breakfast: Red Chilaquiles, Hash Browns, Fruit. Lunch: Tenders & Fries, Jello & Cream. Dinner: Mongolian Beef Meatballs, Fried Rice, Spring Rolls, Ice Cream. Wednesday, 10/22/2025, Breakfast: Biscuits & Gravy, Tots, Fruit. Lunch: Louisiana Dirty Rice, Cornbread, Homemade Poptarts. Dinner: Ham & Potato Casserole, Fried Oreos. Thursday, 10/23/2025, Breakfast: Breakfast Sausage Casserole, Tots, Fruit. Lunch: Tri Tip Pasta, Side Salad, Garlic Toast, Pudding. Dinner: BBQ Chicken Sandwich, Baked Beans, Mashed Potatoes, Cake. Friday, 10/24/2025, Breakfast: Oatmeal, Scrambled Eggs, Bacon, Toast, Fruit. Lunch: Sweet and Sour Chicken, Rice, Springs Rolls, Ice Cream. Dinner: Beef Enchiladas Casserole, Bean, Rice, Parfaits Saturday, 10/25/2025, Breakfast: Strawberry French Toast, Scrambled eggs, Sausage, Fruit. Lunch: Italian Dogs, Fries, Cupcakes. Dinner: Chicken Chili, Cornbread, Rice, Pie. Sunday, 10/26/2025: Breakfast: Banana Pancakes, Scrambled Eggs, Bacon, Fruit. Lunch: Catfish & Fries, Slaw, Shakes. Dinner: Jambalaya, Rolls, Mash potatoes, Cake." 3. In an interview, E5 reported E5 prepared the food at the facility, but does not make the menus or order the food. E5 reported there have not been any menus since E5 has been working there and E5 just sees what food is in stock and makes the best food E5 can with what is available and what residents want. 4. In an interview, E1 was asked if there was a posted menu and E1 pointed to the menu from October posted in the kitchen area. 5. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review, observation and interview, the manager failed to ensure 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. Online research revealed the overnight low temperature on December 5, 2025 was 42° F in the Tucson area. 2. On December 6, 2025 between 12:15 PM and 12:45 PM, during an environmental tour of the facility, the Compliance Officer observed room 25 was equipped with a heater built into the wall between the bathroom and closet. However, the wall heater was not operational and no other heat source was available. The Compliance Officer observed the room was 57.9° F 3. On December 6, 2025 between 12:15 PM and 12:45 PM, during an environmental tour of the facility, the Compliance Officer observed room 35 was equipped with a heater built into the wall between the bathroom and closet. However, the wall heater was not operational and a space heater was being used to heat the resident's room. The Compliance Officer observed the room was 77° F. 4. On December 6, 2025 between 12:15 PM and 12:45 PM, during an environmental tour of the facility, the Compliance Officer observed room 45 was equipped with a heater built into the wall between the bathroom and closet. However, the wall heater was not operational and no other heat source was available. The Compliance Officer observed the room was 61° F. 5. On December 6, 2025 between 12:15 PM and 12:45 PM, during an environmental tour of the facility, the Compliance Officer observed room 52 was equipped with a heater built into the wall between the bathroom and closet. However, the wall heater was not operational and and a space heater was being used to heat the room. 6. On December 6, 2025 between 12:15 PM and 12:45 PM, during an environmental tour of the facility, the Compliance Officer observed room 55 was equipped with a heater built into the wall between the bathroom and closet. However, the wall heater was not operational and a space heater was being used to heat the room. 7. In an interview, E2 reported some rooms have more modern heaters, but some other rooms have the wall heaters, which are not functional. E2 reported all occupied rooms without a working heater now have a space heater as well. E2 reported there were supposed to be space heaters in storage, but E2 only found five space heaters. 8. In an interview, E4 reported having just checked every room and reported rooms 25, 45,47, 53, 55, and 57 do not have a working wall heater and have a space heater instead. 9. In an interview, E1 reported the wall heaters should be functional, but are gas fueled and have a pilot light that is shut off in warm weather and needs to be re-ignited before the units can be used. E1 reported E1 would contact the owner of the facility and have a HVAC repair person come as soon as possible to bring the heaters into working order. 10. In an exit interview with

Based on observation and interview the manager failed to ensure that common areas: a. Are lighted to ensure the safety of residents, and b. Have lighting sufficient to allow caregivers and assistant caregivers to monitor resident activity. Findings include: 1. A tour of the facility revealed a light on the wall outside of a resident apartment. The day of the inspection was rainy and overcast and the light outside the neighboring room was on and visible, however the light outside apartment 76 was off. 2. In an interview with O1 and O2, it was reported the light did not work. 3. In an interview, E1 acknowledged the light outside of apartment 76, which was a common area to be lighted to ensure the safety of the residents, was not working and reported maintenance would replace the light bulb.

Based on record review and interview, for one residency terminated, the manager failed to ensure the written notice of termination of residency in subsection (G) included the policy for refunding fees, charges, or deposits; the deposition of a resident's fees, charges, and deposits; and the contact information for the State Long-Term Care Ombudsman. The deficient practice posed a risk as a resident was not informed of the terms of termination. Findings include: 1. In an interview, E1 acknowledged R3’s residency was terminated by the facility. E1 believed a notice was provided to R3; however, E1 was unable to locate evidence of the termination notice. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance for two of three resident records reviewed. The deficient practice posed a risk as there was no completed service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed no initial service plan. Further review of R1’s medical record revealed, based on R1’s date of admission, a service plan was required. 2. A review of R3's medical record revealed no initial service plan. Further review of R3’s medical record revealed, based on R3’s date of admission, a service plan was required. 3. In an interview, E1 acknowledged the service plans were unable to be located and were not provided for review.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for two of three resident records reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a medication order dated May 18, 2025 that ordered “Cefdinir 300 MG Oral Capsule, Take 1 capsule by mouth every 12 hours for 5 days additional”. 2. A review of R1's medical record revealed a Medication Administration Record (MAR) dated May 2025. The MAR documented the administration of Cefdinir 300 MG twice on May 19, 20, 21, 22, and 23, 2025. The MAR also included administration of Cefdinir once on May 24, 25, 26, 27, 28, and 29, 2025. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat deficiency from the complaint inspection conducted 12/12/2024.

Based on documentation review, and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider. The deficient practice posed a health and safety risk. Findings include: 1. A review of the facility’s incident reports revealed an incident report dated July 24, 2025. The incident report detailed an unwitnessed fall. The resident was found laying on the floor. The caregiver documented a skin check was completed and only the manager and physician were notified. 2. Further review of incident reports revealed an incident report dated July 23, 2025. The report detailed an unwitnessed fall. The resident called for help and was found on the floor. The resident reported hitting their head and asked to be sent to the emergency room. The document detailed notification of the manager. There was no documentation of notification of the resident’s emergency contact or primary care physician. 3. A review of an incident report dated June 15, 2025, revealed another unwitnessed fall. The resident was found on the floor and complained of back pain. The caregiver noted no visible marks and checked on the resident “every hour” to ensure the resident was okay. The documentation detailed notification of the primary medical provider and the manager. There was no evidence the resident’s emergency contact was notified. 4. A review of an incident report dated June 10, 2025 revealed a resident reported to the caregiver station to advise the resident had called 911 due to the resident’s blood pressure being high. The documentation revealed the caregiver took the resident’s blood pressure and notified the manager and resident’s emergency contact. The documentation did not reveal contact with the primary care physician. 5. 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 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 egress dangers to residents. Findings include: 1. During a tour of the facility, the Compliance Officers observed a chain link fence along one side of the property, which was accessible to residents. The Compliance Officers observed several piles of cement blocks that used to be part of the fencing along the south wall of the property. The fence had a sign noting it to be a rented fence. In an interview, E1 reported the wall had been affected by a monsoon storm the previous year, and the facility was in the process of making repairs. 2. The Compliance Officers observed cracked and uneven concrete in several areas. One area also had a metal handrail which had been broken, and was laying on the ground, creating a potential trip hazard. 3. The Compliance Officers observed exposed wiring at the end of two buildings. E1 alerted maintenance to the issue to request repair. 4. The Compliance Officers observed the sprinkler system was exposed to create holes in the grassy area. One such hole was covered with a brick; others were not covered. 5. The Compliance Officers observed a wooden fence which had a broken board. 6. The Compliance Officers observed a trash dumpster behind one building, with stacks of boxes, several walkers, wheelchairs, a table, doors, and other equipment, which was accessible to residents. 7. In an interview, E1 acknowledged the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three resident records reviewed. Findings include: 1. A review of R2's medical record revealed a signed medication order, dated November 4, 2024, which stated, "LORazepam 0.5 MG Oral Tablet, 1 tablet qHS ..." 2. A review of R2's medical record revealed a Medication Administration Record (MAR) dated November 2024 and December 2024. The MAR revealed the facility received the medication and began administration of the Lorazepam on November 10, 2024. 3. Further review of the MAR revealed R2 was not administered Lorazepam 0.5 MG on November 18 and 22, 2024. 4. A review of R3's medical record revealed a signed medication order, dated July 16, 2024, which stated, "LORazepam 1 MG Oral Tablet, 1 tablet BID as needed." 5. A review of R3's medical record revealed a MAR dated November 2024 and December 2024. The MAR did not document any instances of administration of Lorazepam. A review of the "Controlled Drug Sign Out Log", revealed documentation of Lorazepam 1MG "given" to R2: - December 9, 2024 at 9 am, 3 pm, and twice at 9 pm; and - December 11, 2024 at 10 am, 1 pm, and 6 pm. 6. In an interview, E1 acknowledged R2's and R3's medication was not administered in compliance with an order. E1 was unaware of the error and stated E1 would investigate the matter.

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 resident records reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order and false and misleading information was provided to the Department. Findings include: 1. A review of R2's medical record revealed a signed medication order, dated November 4, 2024, which stated, "LORazepam 0.5 MG Oral Tablet, 1 tablet qHS ..." 2. A review of R2's medical record revealed a Medication Administration Record (MAR) dated November 2024 and December 2024. The MAR revealed the medication was received and administration of the Lorazepam began on November 10, 2024. 3. Further review of the MAR revealed documentation R2 was administered Lorazepam 0.5 MG on: - November 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29, and 30, 2024; and - December 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12, 2024. 4. A review of the "Controlled Drug Sign Out Log", revealed the facility was provided a bubble pack containing fourteen tablets of Lorazepam on November 11, 2024. The documentation stated R2 was given: - One tablet on November 12, 2024; - One tablet on November 28, 2024; - One tablet on December 2 or 8, 2024; - One tablet on December 8, 2024; - Two tablets on December 9, 2024; - One tablet on December 10, 2024; and - One tablet on December 11, 2024. A total of eight tablets were documented as given from November 12, 2024 through December 11, 2024. 5. A review of the medication card revealed the medication matched the "Controlled Drug Sign Out Log." The Compliance Officer observed six tablets left in the bubble pack. 6. In an interview E1 acknowledged the medication administered to R2 was not accurately documented.

Based on record review and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C), for one of three personnel records reviewed. Findings include: 1. A.R.S. \'a7 36-411(C) states, "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency ..." 2. A review of E3's personnel record revealed an application for employment, which did not include any documentation of contacting previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution. 3. In an interview, E1 acknowledged the personnel record for E3 did not include documentation of contact with previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10) for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a documented residency agreement. However, the residency agreement did not include the following: - The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident's service plan; - The policy and procedure for an assisted living facility to terminate residency; - The complaint process; and -The date signed. 2. In an interview, E1 acknowledged R1's residency agreement did not include all requirements in R9-10-807(D)(1-10).

Based on document review, observation and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a potential elopement risk to residents. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care level services. 2. During a facility tour, the Compliance Officer observed the premises was fenced and secured. The Compliance Officer observed the residential units open directly to the facility grounds. The Compliance Officer observed no system to alert employees of the egress of a resident from the facility. The Compliance Officer observed the main gate had a camera and intercom allowing the caregivers to control the egress from the premises. 2. In an interview, E1 acknowledged the facility was authorized to provide directed care services and did not have a means to control egress or alert employees of the egress of a resident from the facility, though they controlled the egress from the premises.

Based on documentation review and interview, the governing authority failed to notify the Department according to Arizona Revised Statutes (A.R.S.) \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings include: 1. In an interview, E1 reported E1 became the new manager on August 22, 2023. E2 reported E7's appointment as manager ended on August 21, 2023. E1 reported an email was sent to the Department on August 22, 2023, the day after the previous manager's appointment ended. E1 was unable to provide evidence of the email at the time of the inspection. 2. A review of Department documentation revealed communication, on August 23, 2023, from E7 advising the Department E7's appointment as manager ended effective August 20, 2023. 3. A review of Department documentation revealed no evidence to indicate the governing authority notified the Department of the change in manager since E7's appointment ended.