Pecan Elderly Carehome LLC

Based on record review and interview, the manager failed to ensure that an employee who was expected to have more than eight hours per week of direct interaction with residents, provided evidence 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, and as specified in R9-10-113, for three of four personnel records reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E1's personnel record revealed that E1 was hired on October 1, 2025. Further review revealed documentation of a two-step TB skin test (Mantoux method) that was performed in 2023. There was no other documentation of a single TB skin test that was required at the time of hire. 2. A review of E2's personnel record revealed documentation of a single negative TB skin test, but no documentation of a second skin test. 3. A review of E3's personnel record revealed documentation of a single negative TB skin test, but no documentation of a second skin test. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. Findings include: 1. A review of E3's personnel file revealed a CPR/FA certificate from ProTrainings issued on December 31, 2025. There was no other documentation of current CPR/FA training. 2. An online inquiry of the ProTrainings website indicated that all training courses were online, specifically CPR/FA. 3. A review of the facility's policies and procedures revealed a policy titled "CPR and First Aid." The policy stated, "In order to keep First Aid and CPR training and skills up to date, it is required that each employee...provide the following:...2. Method and contents of CPR training which includes the ability to perform and demonstrate Cardiopulmonary resuscitation." The policy continued to state, "Procedure:...2. Each employee will demonstrate and perform CPR by going through the motions of performing cardiopulmonary resuscitation...8. CPR and First Aid shall not be obtained from online sources." 4. A review of facility documentation revealed a "Staff Schedule" for February 2026 posted on the wall. The schedule indicated that E3 worked the entire month of February 2026, with the exception of February 1, 11, 14, and 15. 5. In an interview, E2 stated that E3 was the facility's lead (and live-in) caregiver. E2 also acknowledged that E3 did not have current in-person CPR/FA training available for review at the time of the inspection, as required by rule and in the facility's policies and procedures. 6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, interview, and documentation review, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, which was reviewed and updated at least once every three months for a resident receiving directed care services, for two of two residents reviewed. The deficient practice posed a risk as the outdated service plans may not have included the necessary services required by the resident or demonstrated the need for an increase in services. Findings include: 1. A review of R1's medical record revealed a service plan dated October 16, 2025. The service plan indicated that R1 received directed care services. There was no other service plan available for review at the time of the inspection. 2. A review of R2's medical record revealed a service plan dated October 21, 2025. The service plan indicated that R2 received directed care services. There was no other service plan available for review at the time of the inspection. 3. In an interview, E2 reported that E2 had texted the individual who normally completed the service plans, but had not heard anything back. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, as a facility authorized to provide directed care services, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the following: Skills and knowledge necessary for the personnel member to provide the expected memory care services; Interventions used for behavior management; Systems to accommodate visitors, staff, and residents who do not need controlled egress; The requirements in R9-10-815(C)(8) regarding the prevention of unsafe wandering or exit seeking, which may include the use of tracking systems; Promotion of nutrition and hydration care; Evacuation and emergency procedures specific to residents receiving memory care services, that include the requirements in R9-10-819(A)(5); Prevention techniques of elopement and responding to elopement incidents promptly and effectively; Monitoring residents receiving memory care services in outdoor areas on the premises; Specialized environmental features to support memory care that include: Secure areas to prevent wandering and spaces designed for cognitive stimulation and engagement; and strategies for providing person-centered care that aligns with the principles of dementia-friendly environments, including familiar surroundings, optimized sensory stimulation, and meaningful activities; and specialized accommodations and progressive support for activities of daily living tailored to persons living with dementia following evidence-based best practices. Findings Include: 1. A review of the facility’s policies and procedures revealed no policies on Memory Care Services. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 3. Technical assistance was provided regarding this rule during the complaint inspection conducted on October 20, 2025.

Based on documentation review, record review, and interview, in addition to the minimum eight hours of initial memory care services training, the manager failed to complete a minimum of four hours of memory care services training specific to assisted living facility managers. Findings include: 1. A review of Department documentation revealed that E7 provided written notification to the Department advising that E7 was no longer the manager of the facility, effective November 1, 2025. E7 did not provide any additional information that indicated who the new manager was. Further review revealed that E7 updated the portal on December 22, 2025, designating E1 as the manager. 2. A review of E1's personnel record revealed that E1 was hired on October 1, 2026. According to documentation in the file, it appeared that E1 took over as the manager as of November 1, 2025. Further review of E1's personnel record revealed that E1 had completed the minimum eight hours of initial memory care services training; however, there was no additional documentation available for review to indicate that E1 had completed the required additional four hours of memory care services training specific to assisted living facility managers. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 4. Technical assistance was provided regarding this rule during the complaint inspection conducted on October 20, 2025.

Based on documentation review and interview, as a facility authorized to provide directed care services, the manager failed to ensure that an elopement drill for employees was conducted every six months on each shift and that there was documentation of the date, time, and description of each drill. Findings include: 1. A review of facility documentation revealed that there was no documentation that any elopement drills had been conducted. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 3. Technical assistance was provided regarding this rule during the complaint inspection conducted on October 20, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as the required information could not be verified for E3. Findings include: 1. Record review revealed R3's date of hire listed as September 13, 2025. 2. Review of R3's personnel record revealed that it did not contain documentation of: Qualifications, including skills and knowledge applicable to the individual’s job duties; Education and experience applicable to the individual’s job duties; Orientation and in-service education required by policies and procedures; Evidence of freedom from infectious tuberculosis; and Compliance with the requirements in A.R.S. § 36-411. 3. In an interview, E1 reported that E3 was an assistant caregiver. 4. In an interview, E2 reported that E3 was an assistant/housekeeper/cook. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure a written service plan was available, for one of two residents sampled. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1. Record review revealed that R2's medical record did not include a service plan. 2. Documentation review revealed the facility's Service Plan Policy and Procedure that stated, "The service plan will be completed within 14 days of admit by a registered nurse; and updated at least every 12 months for a resident receiving supervisory care services, 6 months for a resident receiving personal care services, 3 months for a resident receiving directed care services." 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a written service plan included the signature and date by the resident or resident's representative and the manager, for one of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. Record review revealed that R1's medical record did not include a service plan. 2. During the inspection, the Compliance Officer observed R1's service plan, dated October 16, 2025, was brought to the facility. This service plan did not include a signature and date by the resident or resident's representative or the manager. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.