Paradise Valley Senior Living

Based on record review and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk or harm, for one of eight residents sampled. The deficient practice posed a risk to health and safety as the resident's whereabouts were unknown. Findings include: 1. A review of R1's medical record revealed a document titled "Unusual Incident/Injury Report" that stated an incident occurred at 11:00 AM on December 26, 2025. This report stated, "It was reported that staff in cottage were unable to locate resident. CODE White was called, staff unable to locate resident on property. Community nurse, ED and community marketing director began diving around neighborhood and surrounding area, unable to locate resident. Community executive director called 911 to make a report and for assistance in locating resident Police were able to locate resident about 2 hours later in Scottsdale at Scottsdale Fashion Square Mall. Resident was retuned to the community by Phoenix Police Department. No injuries noted." 2. A review of R1's medical record revealed a service plan that reported R1 received directed care services and "receiving memory care services". Additionally, R1's service plan stated R1 had a diagnosis of "Major neurocognitive disorder; Vasular dementia; and Alzheimer." 3. In an interview with E1, E1 reported that R1 eloped from the community and a search was conducted. The facility contacted 911 when R1 could not be found on the facility's premises. 4. In an exit interview, findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to provide written notification to the Department of a resident’s elopement, within 24 hours of the elopement being discovered. The deficient practice posed a risk as the facility did not know the whereabouts of a resident. Findings include: 1. A review of R1's medical record revealed a document titled "Unusual Incident/Injury Report" that stated an incident occurred at 11:00 AM on December 26, 2025. This report stated, "It was reported that staff in cottage were unable to locate resident. CODE White was called, staff unable to locate resident on property. Community nurse, ED and community marketing director began diving around neighborhood and surrounding area, unable to locate resident. Community executive director called 911 to make a report and for assistance in locating resident Police were able to locate resident about 2 hours later in Scottsdale at Scottsdale Fashion Square Mall. Resident was retuned to the community by Phoenix Police Department. No injuries noted." 2. A review of R1's medical record revealed a service plan that reported R1 received directed care services and "receiving memory care services". Additionally, R1's service plan stated R1 had a diagnosis of "Major neurocognitive disorder; Vasular dementia; and Alzheimer." 3. A review of Department records revealed this elopement was reported to the Department on December 29, 2025 at 3:39 PM. 4. In an exit interview, findings were discussed with E1 and no additional information was provided.

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 six sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a service plan which indicated R1 received medication administration. The review revealed medication orders for “Gabapentin Oral Tablet 800 (MG)...Give 1 tablet by mouth every 8 hours” dated May 22, 2025, and "Gabapentin 800 mg Tab…1 tablet orally every 8 hours” dated June 5, 2025. The review revealed a series of medication administration records (MARs) dated between May 2025 and June 2025. However, the MARs revealed the following: - R1 received R1’s gabapentin at 8:00 AM, 3:00 PM, and 8:00 PM on May 23-30, 2025, instead of every eight hours as ordered; - R1 did not receive R1’s gabapentin between 3:00 PM on May 31, 2025, and 2:00 PM on June 6, 2025; and - R1 received R1’s gabapentin at 8:00 AM, 2:00 PM, and 10:00 PM on June 7-15, 2025, instead of every eight hours as ordered. 2. In an interview, E1 acknowledged R1’s gabapentin was not administered in compliance with the medication orders. E1 reported the pharmacy messed up when adding the times for R1’s gabapentin on R1’s MARs and facility personnel followed the times on the MARs. 3. A review of R2’s medical record revealed a service plan which indicated R2 received medication administration. The review revealed a medication order for “Pain Relief Roll-On 4 % Liquid” dated February 6, 2025. The review revealed a series of MARs dated between May 2025 and June 2025. However, the MARs revealed no documentation demonstrating R2 received “Pain Relief Roll-On 4 % Liquid.” 4. In an interview, E1 acknowledged R1’s and R2’s medications were not administered in compliance with the respective medication orders. This is an uncorrected deficiency from the complaint and compliance inspection conducted on April 30, 2025.

Based on observation, interview, and documentation review, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. Findings include: 1. The Compliance Officer observed several portable air conditioning units and a swamp cooler in the common area of cottage seven. 2. In an interview, E1 reported the air conditioning for the common areas in cottage seven stopped working properly in early May 2025. E1 reported the main air conditioning unit for the common area was set to be replaced the day after the inspection. E1 reported a controller in the attic was set to be repaired at the same time. 3. A review of facility documentation revealed an email between E1 and an air conditioning repair company dated the date of the inspection. The email stated: “Here is the additional amount to get the cottage 7 AC unit replaced…[W]e plan on starting this tomorrow.”

Based on documentation review and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented and implemented tuberculosis (TB) infection control activities required in R9-10-113(A)(2)(d). Findings include: 1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis per R9-10-113(A)(2)(d) was available for review. 2. In an interview, E2, E10, and E11 acknowledged that the health care institution had no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis per R9-10-113(A)(2)(d) was available for review.

Based on record review and interview, the manager failed to ensure identification of the patient's need for the opioid before the opioid was administered or assistance in the self-administration of medication for a prescribed opioid was provided for two of the nine residents sampled. Findings include: 1. In record review, R3's medication administration record (MAR) included Tramadol, 1 tab by mouth, every 12 hours as needed. Documentation showed Tramadol being administered on the 7th, 9th, 10th,13th,18th,21st, 24th, 25th and 26th of March and on the 4th,5th,9th,12th, 27, and 28th of April. However, the MAR did not show documentation of the the patient's need for the opioid before the opioid was administered. The patient's response to Tramadol was documented. 2. In record review, R6's MAR included Hydrocodone/APAP 5-325 MG, 1 tab by mouth, twice daily as needed. Documentation showed Hydrocodone being administered on the 13th, 14th, 15th, 16th, 18th, 20th, 21st, 23rd, 24th, 25th, 28th, 29th, 30th and 31st of March and on the 18th of April. However, the MAR did not show documentation of the patient's need for the opioid before the opioid was administered. The patient's response to Hydrocodone/APAP was documented. 3. In an interview, E2 acknowledged there was no documentation for R3 and R6's need for the opioid before the opioid was administered, or assistance in the self-administration of medication for a prescribed opioid. This is a repeat deficiency from the compliance inspection conducted on December 18, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that personnel records for four of nine employees sampled included required documentation verifying compliance with A.R.S. § 36-411(A); valid fingerprint clearance cards issued pursuant to Title 41, Chapter 12, Article 3.1, and A.R.S. § 36-411(C)(1) documented efforts to contact previous employers for information relevant to each individual's fitness to work. This deficient practice posed a risk to the health and safety of residents, as there was no evidence demonstrating that E6, E7, E8, and E9 were fit to work at the assisted living facility. Findings include: 1. A.R.S. § 36-411(A) states, "... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 ..." 2. A.R.S. § 36-411(C)(1) states: "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." 3. A review of E6's, E7's, E8's, and E9's personnel records revealed no documentation of evidence of a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 4. A review of facility documentation revealed E6 was on the work schedule for February, March, and April. 5. A review of E6's personnel record revealed E6 was hired as a caregiver on February 27, 2024. E6's personnel record revealed a fingerprint clearance card (FCC) with an expiration date of January 08, 2025. However, no further documentation was available for the current FCC. 6. A review of the website from the Arizona Department of Public Safety revealed E6's fingerprint clearance card expired on January 08, 2025, and the new card was issued on March 13, 2025. However, no documentation was available showing E6 had applied for a new FCC before the previous one expired, and there was no valid FCC on file from the date of expiration until the new card was issued. E6 continued working at the facility during this perio

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure manual. However, documentation to indicate that the policies and procedures were reviewed at least once every three years and updated as needed was not available for review. 2. In an interview, E2, E10, and E11 acknowledged that documentation to indicate the policies and procedures were reviewed at least once every three years and updated as needed was not available for review.

Based on observation and interview, the manager failed to ensure that the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection could be found was conspicuously posted. Findings include: 1. During the environmental tour with E2, the Compliance Officers observed no posting indicating where the most recent inspection report could be located. 2. In an interview, E2, E10, and E11 acknowledged that documentation of the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection could be viewed was not posted.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services for one of nine personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed E6 was on the work schedule for February, March, and April. 2. A review of E6's personnel record revealed that E6 worked as a caregiver. The personnel record revealed a first aid and CPR card with an expiration date of December 09, 2024. There was no other current documentation of first aid and CPR training in E6's personnel record. 3. In an interview, E2, E10, and E11 acknowledged that E6 did not have current documentation of first aid and CPR training.

Based on documentation review, record review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for five of nine employees 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 (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative..." 3. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 4. A review of E2's, E3's, E4's, E6's, and E7's personnel records revealed no documentation of negative TB skin tests, assessing risks of prior exposure to infectious TB, and determining if the individual has signs or symptoms of TB was available for review during the inspection. Based on E2's, E3's, E4's, E6's, and E7's hire dates, this documentation was required before providing services for the health care institution. 5. A review of E2's, E3's, E4's, E6',s and E7's personnel records revealed no documentation of initial TB training. Based on E2's, E3's, E4's, E6's, and E7's hire dates, this documentation was required. 6. A review of E2's, E3's, E4's, and E6's personnel records revealed no doc

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for five out of nine residents sampled. The deficient practice posed a TB exposure risk to residents. 1. A review of R1's and R7's medical records revealed no evidence of documentation of a negative TB skin test or blood test. 2. A review of R1, R3, R5, and R6's medical records revealed no evidence of signs, symptoms, or risk assessment. 3. In an interview, E1 acknowledged that R1, R3, R5, R6, and R7's medical records did not include documentation of freedom from infectious tuberculosis before or within seven calendar days after the resident's date of occupancy, as specified in R9-10-113.

Based on interview and record review, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident for one of nine residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to R9. Findings include: 1. In an interview, E10 reported that the staff repositioned R9 every 2 hours since R9 had a wound to the coccyx. Repositioning was done even while in a wheelchair and a recliner chair. 2. A review of R9's medical record revealed a service plan dated December 26, 2024. The service plan stated, "[R9] was total assist. [R9] seen by Haven Home Health for Wound Care - Wound to Coccyx." However, there was no documentation of the need for repositioning. 3. A review of R9's medical record revealed a repositioning Log. The log revealed repositioning was done every 2 hours, even while R9 was in a wheelchair and a recliner chair. 4. In an interview, E2, E10, and E11 acknowledged R9's written service plans did not include the amount, type, and frequency of the services that were provided to R9. This is a repeat deficiency from the compliance inspection conducted on December 18, 2023.

Based on documentation review, record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order for one of nine residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of the medication. Findings include: 1. A review of the facility’s policies and procedures revealed a section titled "MP17- Medication Refills", which states "Medication refills will be obtained in a timely manner to ensure residents have all physician or other healthcare practitioner ordered medications available.", "The Med Tech on-duty contacts the dispensing pharmacy to obtain a refill at least seven (7) days before a medication running out unless the medication is on a cycle refill with the pharmacy." 2. A review of the facility’s policies and procedures revealed a section titled MP20 - Missed or Refused Medications, which states "Residents cannot be forced to take any medication. Steps will be taken to avoid missed or refused doses of medications and related adverse reactions.", "The prescribing physician/practitioner is immediately notified of the missed or refused medications using the Refusal of Medication Notification Form.", "The Resident Care Director re-appraises the resident and contacts the resident's physician and responsible party if the resident continues to refuse medication(s)." 3. A review of R7's medical record revealed medication orders for various medications, such as Ferrous Gluconate 324mg 1 tab po bid, Polyethylene Glycol 3350 PWDR qd, and Rena-Vite RX 1 tab po qd. 4. A review of R7's medication administration record (MAR) revealed on April 1st, 9th, 17th, 19th, 23rd, and 25th at 8:00 pm Ferrous Gluconate was administered. However, Ferrous Gluconate showed no documentation as administered between April 1st and 30th at 8:00 am, an exception note showed a refill was requested. Ferrous Gluconate was also not administered on April 2nd-8th,10th,12th,14th-15th,18th, 20th-22nd, 24th, 26th-30th at 8:00 pm, an exception note showed a refill was requested. 5. A review of R7's MAR revealed on April 1st-24th and 27th-30th, Polyethylene Glycol was refused by the patient. No documentation showed if the primary care physician was contacted or the Resident Care Director reappraised the resident. 6. A review of R7's MAR revealed between April 1st and 30th, Rena-Vite RX showed no documentation of being administered. An exception note showed the family was notified to bring medication. 7. A review of R7's MAR revealed Senna-S was being administered on April 2nd, 5th, 9th,16th, and 23rd. The medication order did not show Senna-S. 8. In a review, E2 acknowledged medication was not administered to a resident in compliance with R7's medication order.

Based on observation and interview, the manager failed to ensure medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings Include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officers observed multiple ambulatory residents. 3. During an environmental inspection of a resident’s room in the secure memory care unit, the Compliance Officers observed a bottle Aleve, one bottle of Omeprazole, and Baza Antifungal Cream (prescribed to the resident). 4. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if personnel members were unable to safely evacuate residents in an emergency situation. Findings include: 1. The Compliance Officers requested the evacuation drills conducted for the last 12 months. 2. A review of facility documentation revealed no documentation of evacuation drills conducted within the last 12 months. 3. In an interview, E2, E10, and E11 acknowledged the facility had no documentation at the time of the inspection to indicate evacuation drills for employees and residents were conducted at least once every six months. This is a repeat deficiency from the compliance inspection conducted on May 8, 2024.

Based on documentation review and interview, the manager failed to ensure that documentation of the current fire inspection was maintained. Findings include: 1. A review of facility documentation revealed that documentation of a current fire inspection was not available for review during the inspection. 2. In an interview, E2, E10, and E11 acknowledged the facility's current fire inspection report had not been provided for review during the inspection. This is a repeat deficiency from the compliance inspection conducted on May 8, 2024.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility are maintained in a locked area separate from food preparation and storage, dining areas, and medications, and are inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Finding Include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officers observed multiple ambulatory residents. 3. During an environmental inspection of the facility, the Compliance Officers observed various materials in Cottages 1, 2, and 9 (secured memory care units) in the residents' bathrooms, such as Medline Aerosol Spray (included chemicals propane and alcohol), Lysol Multi-Purpose Cleaner (warning label stated "hazard to humans and domestic animals"). 4. In an interview, E2 acknowledged that the assisted living facility did not store poisonous or toxic materials in a locked area and were accessible to residents. This is a repeat deficiency from the complaint inspection conducted on December 18, 2023, and the compliance inspection conducted on May 8, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure compliance with A.A.C. R3-8-201(C)(4), as pest control and pesticide materials were present without evidence that they were used by certified applicators. The deficient practice posed a risk to the health and safety of residents, as A.A.C. R3-8-201(C)(4) requires pest control applications to be conducted by a licensed applicator. The use of improperly handled pesticide products by unlicensed staff raised concerns and could have resulted in unsafe exposure. Findings include: 1. A.A.C. R3-8-201(C)(4) stated "C. Applicator licensure. 4. An individual may not provide pest management services at a school, child care facility, health care institution, or food-handling establishment unless the individual is a certified applicator in the certification category for which services are being provided." 2. During the environmental tour with E2, the Compliance Officers observed the following pest control and pesticide materials stored in a locked maintenance room: -Hot Shot Bed Bug Killer (multiple containers) -Hot Shot Bed Bug Killer with Egg Kill -d-CON Rat Bait Pellets -Amdro Mole & Gopher Bait -Amdro Quick Kill Home Perimeter Insect Killer Granules -BioAdvanced Carpenter Ant & Termite Killer Plus -two hand-labeled “Ant Spray" The use of such products by unlicensed individuals raised concerns. According to A.A.C. R3-8-201(C)(4), pest control applications were required to be conducted by a licensed applicator. The use of improperly handled pesticide products by unqualified staff could have resulted in unsafe exposure. 3. In an interview, E2 reported that there was no licensed applicator among the facility staff. 4. In an interview, E2, E10, and E11 acknowledged that unqualified staff used pesticides, which could have caused unsafe exposure. Per A.A.C. R3-8-201(C)(4), only certified applicators may provide pest control in health care settings.

Based on record review, documentation review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E2's personnel record revealed documentation of fall prevention and fall recovery dated May 2022. However, no current documentation of fall prevention fall recovery training was available for review. 2. A review of the facility's policies and procedures revealed no policy on fall prevention and fall recovery training at the time of inspection. 3. In an interview, E1 acknowledged E2 did not have current fall prevention and fall recovery training available for review.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed an incident report dated May 2024 that indicated R1 sustained an injury and medical services were required. The documentation did not include any action taken to prevent the incident from occurring in the future. A section labeled, "Action taken or planned (By whom and anticipated results)" was left blank. 2. In an interview, E1 acknowledged R1's medical record did not include documentation of any action taken to prevent the incident from occurring in the future.