Red Mountain Assisted Living at Gilbert

Based on record review, interview, and documentation review, the manager failed to ensure that a resident had a service plan that was signed and dated by the resident or the resident’s representative, for two of two residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan dated December 23, 2025. However, the resident or the resident's representative did not sign and date the service plan. 2. A review of R2's medical record revealed a service plan dated December 3, 2025. However, the resident or the resident's representative did not sign and date the service plan. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 4. This is a repeat citation from the compliance and complaint inspection conducted on January 27, 2026.

Based on record review and interview, the health care institution failed to develop and administer 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 E2’s hire date as December 10, 2025. A review of E2’s personnel record revealed no documentation of fall prevention and fall recovery training completed. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section, for three of three residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R1, R2, and R3's medical records revealed documentation of the standardized EMS form however, it did not include the following: Whether the resident received medication services and, if the resident had provided this information to the assisted living, a list of all the resident's prescription and over-the-counter medications, their dosages, and how frequently they were administered; Basic information about the resident's physical and mental conditions and basic medical history, as well as dates of recent episodes, if known; The point-of-contact information for the assisted living home, including the telephone number, if available, cell phone number, and email address; A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living home to plan for the resident's discharge; A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. 2. In an exit interview, findings were reviewed with E1, and no additional information was provided. 3. Technical assistance was provided regarding this rule during the inspection conducted on October 9, 2024.

Based on record review and interview, the health care institution failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for two of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E2’s personnel record revealed a hire date of December 10, 2025. Further review of the personnel record revealed no documentation that training on recognizing the signs and symptoms of tuberculosis (TB) was completed. 2. A review of E3’s personnel record revealed a hire date of December 1, 2025. Further review of the personnel record revealed no documentation that training on recognizing the signs and symptoms of tuberculosis (TB) was completed. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the governing authority failed to ensure that the Department was notified when there was a change in the manager. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3’s manager's certificate posted within the facility. 2. In an interview, E1 reported that E3 took over as the facility's manager in December 2025, and E1 didn't know that E1 had to contact the Department immediately. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two employees reviewed. The deficient practice posed a safety risk to residents. Findings include: 1. A.R.S. § 36-411.C.3 states: "3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 2. A review of E2's personnel record did not include documentation that E2 was not on the adult protective services registry pursuant to section 46-459. 3. 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 that a resident had a service plan that was signed and dated by the resident or resident’s representative, for three of three residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan dated December 12, 2025. However, the resident or the resident's representative did not sign and date the service plan. 2. A review of R2's medical record revealed a service plan dated December 4, 2025. However, the resident or the resident's representative did not sign and date the service plan. 3. A review of R3's medical record revealed a service plan dated July 25, 2025. However, the resident or the resident's representative did not sign and date the service plan. 4. 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 that a medication administered to a resident was administered in compliance with a medication order, for one of three residents sampled. 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 signed medication order, which included, "Losartan POT TAB 100 milligrams (mg),1 tablet by mouth (po) every day for hypertension; hold for SBP < 110." However, there was no documentation that daily blood pressure readings were obtained before administering Losartan. 2. A review of R1's medical record revealed a January 2026 medication administration record (MAR). This MAR documented Losartan 100 mg was administered every day at 8 am, January 1st - present. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure a pet was licensed consistent with local ordinances, for one of one pet records reviewed. The deficient practice posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1. The Compliance Officer observed O1 at the facility. 2. A review of the O1's record revealed no documentation of a license with Maricopa County. 3. In an exit interview, E1 acknowledged that O1 did not have documentation of a Maricopa County license. 4. Technical assistance was provided regarding this rule during the inspection conducted on February 6, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure before providing assisted living services to a resident, a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults for two of three 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 a policy titled "First Aid and CPR Training." The policy stated "3. Method and content of CPR training which includes the ability to perform and demonstrate cardio-pulmonary resuscitation." The procedure stated "4. Each employee or volunteer will demonstrate and perform CPR by going through the motion of performing cardio pulmonary resuscitation, if the training is through a different training organization other than the National Safety Council, American Heart Association, or American Red Cross. The hiring person will document the skills demonstration." 2. A review of E1's personnel records revealed a CPR and first aid training certification from "NationalCPRFoundation" dated December 17, 2023 (valid for 2 years). However, training from "NationalCPRFoundation" is online only and does not include a demonstration of the employee's ability to perform CPR. 3. A review of E2's personnel records revealed a CPR and first aid training certification from "NationalCPRFoundation" dated October 31, 2023 (valid for 2 years). However, training from "NationalCPRFoundation" is online only and does not include a demonstration of the employee's ability to perform CPR. 4. A review of the website "nationalcprfoundation.com" revealed the following, "National CPR Foundation... We're a Premium Online Certification Provider for Healthcare Providers, Workplace Individuals and the Community. We offer a 100% risk-free, money-back guarantee on all Courses! Made Quick, Easy & Simple!" 5. The Compliance Officer found insufficient documentation regarding the CPR demonstration, as records lacked information on whether the demonstration occurred, who conducted it, if it included performing the motions, and the date and time of the event. 6. In an interview, E2 and E4 acknowledged E1's and E2's CPR was completed online and did not include a demonstration of E1's and E2's ability to perform CPR. However, E4 reported that demonstration was provided but the skills demonstration was not properly documented.

Based on documentation review, record review, and interview, for one of one resident reviewed, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was able to reasonably recover independently. The deficient practice posed a risk as the facility left a resident on the floor instead of providing first aid to a non-injured resident by assisting them off the floor after a fall. Findings include: 1. A review of facility documentation revealed a document titled, "Fall Prevention," reviewed and approved February 1, 2023. The policy and procedure stated " ... In the event of a fall, all personnel are trained to follow the accident, emergency, or injury procedures, including care to be provided to the resident and proper documentation." 2. A review of facility personnel records revealed documentation of an in-service training titled, "Red Mountain Assisted Living: Employee Fall Prevention and Recovery In Service." Under the title, "Recovery" the training stated, "...Simple falls, the resident may verbalize there [sic] ok, or you don't see anything visual. You still have to do a head to toe assessment t there o [sic] evaluate that there are no injuries needing immediate attention. If so you must dial 911. Once you have deemed the resident is safe to move you may proceed to slowly move resident. With gait belt on resident you would begin to roll resident and get them in a position that is near chair or bed, assisting them to their knees. then [sic] up to the bed or chair using the gait belt to assist you. If the person requires 2 person to assist to stand sit or move to bed you must use a gait belt or Hoyer lift if available. Once the resident has been returned to the safe location. You must do a complete set of vital signs RECORD THEM IN COMPUTER and observe him/her for minimum of 2 hours for any changes in condition, pain, mental status. An incident report is them [sic] completed with calls to Dr, Hospice, Supervisor, and family. Remember that you must call supervisor and complete the incident report as well as on line chart Notes." 3. In an interview, E1 reported E1 vaguely remembered hearing about the aforementioned incident. The Compliance Officer requested an associated incident report and was presented with an incident report dated February 9, 2023. Upon review, it was revealed that the incident report was minimally filled out, reporting the name of the resident, the date of the incident, and the location of the incident. Injury, Medication Error, and Hospital were all circled "no" indicating there was no injury, no medication error, and no hospital involved. Under "Briefly Describe Incident," the document stated, "the truth did not listen when he shut up. because I dindn't set the alarm Because I forgot it." In addition, the incident report wasn't signed by the author. 4. Further review of R1's medical record revealed no evidence that R1's vital signs were taken

Based on documentation review, record review, and interview, the manager failed to ensure the facility's policies and procedures were implemented to protect the health and safety of a resident that covered a quality management program, including incident report and supporting documentation. The deficient practice posed a risk as the facility's standards were not followed, the Department was unable to determine substantial compliance during the inspection, and the Department was provided false or misleading information. Findings include: 1. A review of the facility's policies and procedures, last reviewed February 1, 2023, revealed a policy titled, "Quality Management Program Including Incident Reports." This policy stated "... 1. Facility personnel will document and evaluate incidents at the facility to ensure quality services are provided ... Other instances that raise concern will be documented, such as: falls, elopement ... 2. Caregivers, assistant caregivers and volunteers will report to the manager any incidents that occur while assisting residents with their ADLs or providing residents with activities or performing duties assigned. ... 6. The individual reporting the incident or emergency will complete a "Report of Unusual Occurrence" and follow all instructions and corrective actions specified in the report." 2. A review of facility personnel records revealed documentation of an in-service training titled, "Red Mountain Assisted Living: Employee Fall Prevention and Recovery In Service." Under the title, "Recovery" the training stated, "...In the event that your [sic] find a resident has fallen here are your basic steps to follow. Simple falls, the resident may verbalize there [sic] ok, or you don't see anything visual. You still have to do a head to toe assessment t there o [sic] evaluate that there are no injuries needing immediate attention. If so you must dial 911. Once you have deemed the resident is safe to move you may proceed to slowly move resident. With gait belt on resident you would begin to roll resident and get them in a position that is near chair or bed, assisting them to their knees. then [sic] up to the bed or chair using the gait belt to assist you. If the resident requires 2 person to assist to stand sit or move to bed you must use a gait belt or Hoyer lift if available. Once the resident has been returned to the safe location, you must do a complete set of vital signs RECORD THEM IN COMPUTER and observe him/her for minimum of 2 hours for any changes in condition, pain, mental status. An incident report is them [sic] completed with calls to Dr, Hospice, Supervisor, and family. Remember that you must call supervisor and complete the incident report as well as on line chart Notes." 3. A review of R1's medical record revealed "Charting Notes," dated February 11, 2023. The Charting Notes stated, "R1 has had a great afternoon no signs of anything bad from the fall." Further review of the Charting Notes revealed no additional

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for two of four caregivers sampled. The deficient practice posed a risk to the health and safety of residents as E4 and E5 were not qualified to provide caregiver services and the Department was provided false or misleading information. Findings include: 1. A review of the facility's policies and procedures, reviewed and approved February 1, 2023, revealed a policy titled, "Policy Topic: Employees and Volunteers Qualifications." Under the title, "Procedures" the document stated, "... 2) A caregiver: ... Provides documentation of completion of a caregiver training program approved by the Department or by the NCIA Board." 2. A review of E4's personnel record (hired as a caregiver) revealed a caregiver training certificate from Arizona Medical Training Institute, ALTP 0141, dated February 9, 2011. 3. A review of E5's personnel record (hired as an assistant caregiver) revealed a caregiver training certificate from Arizona Medical Training Institute, no ALTP number, dated February 17, 2012. 4. Further review of E4's and E5's caregiver certificates revealed inconsistencies that prompted the Compliance Officer to send the certificates to the Arizona Medical Training Institute (now known as Lifework) for review. The Compliance Officer observed that although the two certificates were only dated eight days apart from each other, the two certificates were completely different in appearance, font, and format. The Compliance Officer observed a spacing mistake and the misspelling of the word "PERSONAL" as "PERSONA" on E4's certificate. The Compliance Officer noted E5's certificate did not include an Assisted Living Training Program (ALTP) number and there was still a line on the certificate that stated underneath, "Click to add text." 5. On February 29, 2024, the Compliance Officer reached out to Lifework via a telephone call and email requesting verification of the aforementioned caregiver certificates. Lifework responded on February 29, 2024 and stated, "... we were checking with our education team, and these don't seem to match what they have seen from our school before." 6. In an interview, E1 reported E1 verified E4's and E5's caregiver certificates on the Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA) website and did not determine that E4's and E5's caregiver certificates were invalid.

Based on documentation review, record review, and interview, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or assistant caregiver documented the time of the accident, emergency, or injury. The deficient practice posed a risk as critical information needed in an investigation regarding a resident's urgent medical needs were not obtained as required. Findings include: 1. A review of facility documentation revealed a document titled, "Fall Prevention," reviewed and approved February 1, 2023. The policy and procedure stated " ... In the event of a fall, all personnel are trained to follow the accident, emergency, or injury procedures, including care to be provided to the resident and proper documentation." 2. A review of facility personnel records revealed documentation of an in-service training titled, "Red Mountain Assisted Living: Employee Fall Prevention and Recovery In Service." Under the title, "Recovery" the training stated, "...Simple falls, the resident may verbalize there [sic] ok, or you don't see anything visual. You still have to do a head to toe assessment t there o [sic] evaluate that there are no injuries needing immediate attention. If so you must dial 911 ... An incident report is them [sic] completed with calls to Dr, Hospice, Supervisor, and family. Remember that you must call supervisor and complete the incident report as well as on line chart Notes." 3. A review of R1's medical record revealed an incident/accident report documenting a fall with emergency medical services called, dated February 24, 2023. Upon review, the Compliance Officer determined that the incident report was insufficiently filled out. The incident report included most of the required information. However, the incident report did not report the time of the fall, or the times when R1's primary care provider, hospice, and emergency contact were contacted. 4. In an interview, E1 acknowledged there was no documentation of the time of R1's fall or when R1's primary care provider, hospice, and emergency contact were contacted.