Rosemonte Assisted Living

Based on documentation review, observation, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, for three of three sampled staff. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of Department documentation revealed A.R.S. § 36-420.01(A) went into effect on October 1, 2021. 2. A review of facility documentation revealed a policy and procedure (P&P) titled "TRAINING FOR FALL PREVENTION AND RECOVERY.” The P&P stated: “This ALF, as a licensed healthcare institution, has developed and administers a training program for all caregiving staff regarding fall prevention and fall recovery. The training program requires initial training and continued competency review on an annual basis.” The P&P continued, “All employees will attend annual refresher training that meets the same guidelines as the initial training.” 3. The Compliance Officers observed E1 and E2 working at the facility. 4. A review of E1’s personnel record revealed E1 was hired as the manager on March 10, 2021, before the statute went into effect. However, the review revealed no training regarding fall prevention and fall recovery. 5. In an interview, E1 reported E1 completed several training sessions toward the end of 2025. However, E1 stated, “I don’t see them.” 6. In an interview, E2 stated E2 was a “volunteer” and that E2 “help[s] on and off.” E2 reported the regularly scheduled caregiver had to step out so E2 was at the facility filling in for that caregiver. 7. A personnel record review revealed no personnel record for E2, including no documentation of training regarding fall prevention and fall recovery. 8. A review of Department documentation revealed E2 was one of the facility’s governing authorities. 9. In an interview referring to E2, E1 stated, “Whenever I need help, I usually call [E2].” When the Compliance Officers requested E2’s personnel record, E1 reported E2 did not yet have one, stating, “I asked [E2] to update.” 10. A review of E3’s personnel record revealed E3 was hired as a caregiver on July 2, 2022, before the statute went into effect. The review revealed documentation of a training put on by a third-party company through another assisted living facility titled “About Falls” dated January 22, 2025. However, the review revealed no training regarding fall prevention and fall recovery by this facility upon hire or annually thereafter. 11. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment.

Based on documentation review, interview, and record review, the assisted living home failed to maintain a standardized form for each resident that includes the information prescribed in Arizona Revised Statutes (A.R.S) § 36-420.01(A)(1-9), for two of two 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.R.S. 36-420.04(A) states: "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: -The reason or reasons the emergency responder was requested on behalf of the resident; -Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered; -The name, address and telephone number of the resident's current pharmacy; -A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive; -The name and contact information for the resident's primary care physician and power of attorney or authorized representative; -Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known; -The point-of-contact information for the assisted living center or 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 center or assisted living home to plan for the resident's discharge; and -A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home.” 2. A review of the facility's policies and procedures revealed a policy titled "Emergency Responders." The policy stated: “Each assisted living center and assisted living home must maintain a standardized form for each resident that includes the information prescribed in subsection A of this section…Each assisted living center and assisted living home shall periodically update this form for each resident as necessary.” 3. In an interview, when the Compliance Officers asked what documentation facility personnel would give emergency responders when facility personnel contacted an emergency responder on behalf of a resident, E1 reported that facility personnel would provide the resident’s face sheet and the resident’s medication list. 4. A review of R1’s medical record revealed a document titled “Client Face Sheet.” However, the document did not includ

Based on documentation review, observation, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for two of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of Department documentation revealed this rule went into effect on May 4, 2022. 2. A review of facility documentation revealed a policy and procedure (P&P) titled "EMPLOYEES AND VOLUNTEERS’ QUALIFICATIONS.” The P&P stated: “All employees must complete in-service training upon hire based on the level of care provided, covering current resident needs. Annual topics include…TB Screening Training at employment and annually.” 3. The Compliance Officers observed E1 and E2 working at the facility. 4. A review of E1’s personnel record revealed E1 was hired as the manager on March 10, 2021, before the rule went into effect. However, the review revealed no training and education related to recognizing the signs and symptoms of TB. 5. In an interview, E1 reported E1 completed several training sessions toward the end of 2025. However, E1 stated, “I don’t see them.” 6. In an interview, E2 stated E2 was a “volunteer” and that E2 “help[s] on and off.” E2 reported the regularly scheduled caregiver had to step out so E2 was at the facility filling in for that caregiver. 7. A personnel record review revealed no personnel record for E2, including no training and education related to recognizing the signs and symptoms of TB. 8. A review of Department documentation revealed E2 was one of the facility’s governing authorities. 9. In an interview referring to E2, E1 stated, “Whenever I need help, I usually call [E2].” When the Compliance Officers requested E2’s personnel record, E1 reported E2 did not yet have one, stating, “I asked [E2] to update.” 10. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 5, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was incomplete documentation identifying the staff present each day to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "STAFFING AND RECORD KEEPING.” The P&P stated: “A work schedule of all staff members who provide assisted living services to residents and volunteers is developed and maintained at the facility for 12 months from the date of the work schedule. The work schedule must contain the facility name, dates, and a key of abbreviations for names of working staff and volunteers, hours scheduled, hours worked, etc.” 2. The Compliance Officers observed E1 and E2 working at the facility. 3. In an interview, E2 stated E2 was a “volunteer” and that E2 “help[s] on and off.” E2 reported that the regularly scheduled caregiver had to step out, so E2 was at the facility filling in for that caregiver. 4. A review of facility documentation revealed a series of personnel schedules dated between January 2025 and February 2026. However, the schedules did not include E2, nor did the schedules include the hours worked by the caregivers. 5. In an interview, E1 confirmed the personnel schedules did not include E2, nor did the schedules include the hours worked by the caregivers. 6. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 5, 2024.

Based on observation, interview, and record review, the manager failed to ensure a personnel record for each employee included the items required by this rule, for one of three sampled employees. The deficient practice posed a risk as required information could not be verified. Findings include: 1. The Compliance Officers observed E2 working at the facility. On multiple occasions, the Compliance Officers observed E2 alone with residents. 2. In an interview, E2 stated E2 was a “volunteer” and that E2 “help[s] on and off.” E2 reported that the regularly scheduled caregiver had to step out, so E2 was at the facility filling in for that caregiver. 3. A personnel record review revealed no personnel record for E2. 4. A review of Department documentation revealed E2 was one of the facility’s governing authorities. 5. In an interview referring to E2, E1 stated, “Whenever I need help, I usually call [E2].” When the Compliance Officers requested E2’s personnel record, E1 reported E2 did not yet have one, stating, “I asked [E2] to update.” 6. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for three of three residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) states: "A. 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…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 facility documentation revealed a policy and procedure (P&P) titled "TB Screening/Testing.” The P&P stated: “(1) The Manager will ensure that a TB risk assessment, (baseline screen for individuals is completed (see form Integrated TB Screening and Risk Assessment form for Newly Hired HCP, or a new resident admitted to the facility. (2) The Manager will ensure that a TB signs/symptoms screening (baseline screening for staff members and new residents) are completed (see form Annual Tuberculosis Symptom Screen). (3) The Manager will ensure that documentation is obtained indicating of freedom from infectious TB according to A.A.C. R9-10-113(B)(1).” 3. A review of R1's and R4’s medical records revealed R1 and R4 were admitted to the assisted living facility more than seven days prior to the date of the inspection. However, the review revealed no documentation of assessing risks of prior exposure to infectious TB, determining if R1 and R4 had signs or symptoms of TB, and documentation of R1’s and R4’s freedom from infectious TB. 4. A review of R2’s medical records revealed R2 was admitted to the assisted living facility more than seven days prior to the date of the inspection. However, the review revealed no documentation of R2’s freedom from infectious TB. 5. In an interview, when the Compliance Officers asked if E1 had the aforementioned documentation for R1, R2, and R4, E1 stated, “I don’t see them.” 6. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 5, 2024.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for two of three sampled residents. The deficient practice posed a risk if the facility was unable to meet the needs of a resident. Findings include: 1. A review of R1's medical record revealed a document titled "INITIAL PHYSICIAN RECOMMENDATION FORM.” The document revealed R1 did not require continuous medical services, continuous or intermittent nursing services, or restraints. However, the document was signed and dated approximately three months after R1’s date of occupancy. 2. A review of R4's medical record revealed a document titled "INITIAL PHYSICIAN RECOMMENDATION FORM.” The document revealed R4 did not require continuous medical services, continuous or intermittent nursing services, or restraints. However, the document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 3. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no comment. This is a repeat citation from the compliance inspection conducted on June 5, 2024.

Based on record review and interview, the manager accepted and retained a resident for which the assisted living facility did not have the ability to provide the assisted living services needed, for one of two sampled residents. The deficient practice posed a risk as employees were unable to meet the needs of a resident. Findings include: 1. A review of R1’s medical record revealed a document titled “RESIDENT HEALTH HISTORY.” The document stated R1 required “verbal” cuing to perform bathing, dressing, eating, toileting, and grooming. The review further revealed a service plan which stated, “[R1] does not speak English.” 2. In an interview, the Compliance Officers attempted to interview R1, but were unable to do so as R1 did not speak English. 3. In an interview, when the Compliance Officers asked how facility personnel communicated with R1, E1 stated, “We have challenges.” E1 reported E1 spoke a language with a few similar words to R1's language. However, E1 reported E1 did not speak R1's language nor did any other facility personnel. E1 reported facility personnel contacted a translator when needed. The Compliance Officers requested to speak with R1 via the translator. However, upon calling, E1 reported the translator did not answer the phone. Over the remainder of the inspection, E1 called the translator several more times. Upon reaching the translator, the Compliance Officers were able to speak with R1. When the Compliance Officers asked R1 if R1 knew where R1 was, the translator stated, “[R1] says [R1] doesn’t know.” 4. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no comment.

Based on documentation review, record review, interview, and observation, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for two of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to the administration of a non-ordered medication. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “MEDICATION SERVICES.” The P&P stated, “No medication or treatment will be administered to the residents without a physician or medical practitioner order and instruction.” 2. A review of R1’s medical record revealed a medication administration record (MAR) dated January 2026. The MAR revealed facility personnel administered acetaminophen, amoxicillin and clavulanate, atorvastatin, fluoxetine, gabapentin, pantoprazole, senna, and trazodone. However, the review revealed no medication order(s) for the eight medications. 3. In an interview, when the Compliance Officers asked if R1 had signed medication orders for the eight medications, E1 gestured toward the unsigned orders and stated, “These are the only medical orders I think I have.” 4. A review of R2’s medical record revealed a MAR dated January 2026. The MAR revealed facility personnel administered duloxetine and anti-fungal cream one to two times a day between January 1, 2026, and February 2, 2026. However, the review revealed no medication order(s) for the two medications. 5. The Compliance Officers observed R2’s pharmacy bottle of duloxetine and R2’s medication organizer. The Compliance Officers observed the duloxetine in the morning slots of the medication organizer. 6. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 5, 2024.

Based on documentation review, interview, record review, and observation, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the date and time of administration and the name and signature of the individual administering medication, for two of two sampled residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “MEDICATION SERVICES.” The P&P stated: “Medication administration is not documented until the resident has been seen taking them…The trained caregiver will initial the MAR for the date and time the medicine was given to the resident and the medications taken…Medication administration records will be filled out by authorized personnel administering or assisting in the self-administration of medication after observing the resident taking the medication. The period, time, and date will be recorded, along with the initials of the person who administered or assisted in the self-administration.” 2. In an interview, E1 reported facility personnel administered medication to R1. 3. A review of R1’s medical record revealed a medication administration record (MAR) dated January 2026. The MAR revealed R1 received amoxicillin and clavulanate 875-125 mg two times daily starting at 7:00 PM on January 22, 2026, and ending at 7:00 PM on January 29, 2026. The MAR revealed facility personnel administered the amoxicillin and clavulanate 875-125 mg a total of 15 times. 4. The Compliance Officers observed R1’s pharmacy bottle of amoxicillin and clavulanate 875-125 mg. The Compliance Officers observed the label indicated the medication was to be administered two times daily for seven days for a total of 14 times. The Compliance Officers observed one tablet of amoxicillin and clavulanate 875-125 mg in the pharmacy bottle. 5. In an interview, E1 confirmed R1’s amoxicillin and clavulanate 875-125 mg was not administered per the medication label and was documented as administered 15 times even though it was only administered 13 times. E1 acknowledged the medication was not documented as administered accurately. 6. A review of R1’s medical record revealed no MAR for medications administered in February 2026. 7. In an interview, E1 reported believing E1 had made a MAR for February. However, E1 reported not knowing where it was. The documentation was not provided for review. 8. A review of R2’s medical record revealed a series of MARs dated January 2026 and February 2026. The MARs revealed facility personnel administered insulin to R2 two times daily and gabapentin three times daily on January 1-31, 2026, and February 1-2, 2026. 9. The Compliance Officers observed one gabapentin capsule in R2’s medication organizer in the morning and

Based on record review and interview, the manager failed to ensure that the service plans for two of two residents sampled receiving directed care services included cognitive stimulation and activities to maximize functioning; strategies to ensure a resident's personal safety; documentation of resident's weight; and coordination of communication with the resident’s representative, family members, and if applicable, other individuals identified in the resident’s service plan. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a current written service plan dated January 1, 2026, which indicated R1 received directed care services. However, the service plan did not include cognitive stimulation and activities to maximize functioning; strategies to ensure R1’s personal safety; documentation of R1’s weight; and coordination of communication with R1’s representative or family members. 2. A review of R2's medical record revealed a current written service plan dated January 1, 2026, which indicated R2 received directed care services. However, the service plan did not include cognitive stimulation and activities to maximize functioning; documentation of R2’s weight; and coordination of communication with R2’s representative or family members. 3. In an interview, E1 acknowledged that the service plans were missing the aforementioned components. 4. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. Upon arriving and entering the facility at approximately 8:50 AM on February 3, 2026, the Compliance Officers observed the front door was unlocked and the key was in the lock. The Compliance Officers observed the door had a functioning alert installed. However, the Compliance Officers observed the front yard was not secure. 3. The Compliance Officers further observed a door leading from a bathroom connected to an unlocked caregiver room to the back yard. The Compliance Officers observed the door had an alert installed. However, upon opening the door, the Compliance Officers heard a faint alert, unable to reasonably be heard in the kitchen, garage, halls, and bedrooms on the opposite side of the facility. 4. In an interview, the Compliance Officers informed E1 of this rule and the requirement that any point outdoors directly accessible through a point of egress needed to be secure. The Compliance Officers explained locking the front door rendered the door unusable as a point of egress, therefore making securing the front yard unnecessary. The Compliance Officers explained the back yard was large enough for residents to get 30 feet away from the facility as required by this rule. The Compliance Officers explained the facility could be in compliance with the rule under several circumstances, including locking the front door or keeping the front door unlocked and securing the surrounding area in the front yard. 5. At approximately 4:35 PM, the Compliance Officers observed the key to the front door again in the lock. 6. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. This is a repeat citation from the compliance inspection conducted on June 5, 2024.

Based on record review, observation, 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 two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings included: 1. A review of R2’s medical record revealed a current service plan which indicated R2 received medication administration. The review further revealed a signed medication list dated November 7, 2025, which included “3 ML insulin glargine 300 UNT/ML Pen Injector…28 units Pen Injector…2 x daily” and “gabapentin 300 MG Oral Capsule…1 Oral Capsule…3x day.” 2. A review of R2’s medication administration record (MAR) for January and February 2026 revealed facility personnel administered R2’s insulin at 8:00 AM and 8:00 PM on January 1-31, 2026, and February 1-2, 2026. The MAR further revealed facility personnel administered R2’s gabapentin three times daily on January 1-31, 2026, and February 1-2, 2026. 3. The Compliance Officers observed one gabapentin capsule in R2’s medication organizer in the morning and bedtime slots of R2’s medication organizer. 4. In an interview, R2 reported R2 was self-injecting the insulin once daily. 5. In an interview, E1 confirmed R2 self-injecting R2’s insulin once daily at 8:00 PM, and not two times daily as ordered. E1 reported E1 allowed R2 to self-inject R2’s insulin because R2’s family member wanted R2 to do it. E1 acknowledged R2 received two capsules of gabapentin daily and not three as ordered. 6. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 5, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure a current toxicology reference guide was available for use by personnel members. The deficient practice posed a risk if residents gained access to poisonous or toxic materials. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “MEDICATION SERVICES.” The P&P stated, “The facility manager must ensure a current drug reference guide and toxicology reference guide are available for use.” 2. The Compliance Officers observed no toxicology reference guide at the facility. 3. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 5, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed the following: - In the facility’s unlocked kitchen fridge, stored in the door, was Lantus SoloStar and a bottle of Lorazepam. - In the facility’s unlocked garage, Rosuvastatin Calcium, Famotidine, Acetaminophen, and a bottle of Metformin. - In an unlocked kitchen fridge in the unlocked garage, stored in the door, was Lantus SoloStar. 2. A review of the facility's policies and procedures revealed a policy titled “MEDICATION SERVICES.” The policy stated, “2. Medication will be locked in the medication storage area.” 3. In an interview, E1 reported facility personnel did not store medications requiring refrigeration in a locked area. When the Compliance Officers asked if E1 had a way to store the medications requiring refrigeration in a locked area, E1 stated the facility “used to have [a] black box” for locking up refrigerated medications. E1 further reported the medications in the unlocked garage belonged to a prior resident. The Compliance Officers informed E1 the door to the garage needed to remain locked as long as the garage contained accessible medications. 4. Later in the inspection, the Compliance Officers again observed the door to the garage. The Compliance Officers observed a sign on the door which read, “Employees Only” as well as two locks on the door. However, the Compliance Officers observed the key to the bottom lock left in the lock. The Compliance Officers further observed both locks on the door were again not locked. 5. In an interview, the Compliance Officers reminded E1 the door needed to be locked. 6. The Compliance Officers observed R2 enter the unlocked garage. 7. In an interview, R2 reported R2 went into the garage frequently to grab snacks and to have privacy in administering R2’s own insulin. 8. In an interview, E1 confirmed R2 frequently went into the garage to administer R2’s own insulin. 9. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. This is a repeat citation from the compliance inspection conducted on June 5, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure a food menu was prepared at least one week in advance, conspicuously posted at least one calendar day before the first meal on the food menu was served, and included any food substitution no later than the morning of the day of meal service with a food substitution. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(54)(a-b) states: "'Conspicuously posted' means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. A review of facility documentation revealed a policy and procedure (P&P) titled "FOOD SERVICES.” The P&P stated, “A food menu is…posted conspicuously at least one day before service [and] includes a food substitution on the morning of the day it’s served.” 3. The Compliance Officers observed a food menu posted in the kitchen and not conspicuously posted. The Compliance Officers observed the posted menu was dated the week of the inspection. 4. A review of facility documentation conducted at approximately 5:15 PM, revealed the food menu dated the week of the inspection. The menu included no food substitutions and indicated facility personnel the residents’ choice of served orange juice, hot or cold cereal, choice of egg, toast, margarine, jelly, and milk for breakfast and served roast beef and cheese sandwiches, summer salad, dressing, oatmeal cookies, and milk or juice for lunch. 5. In an interview, R2 reported facility personnel served eggs and waffles for breakfast. 6. In an interview, E1 stated facility personnel served “some macaroni and cheese and meatballs” for lunch.” E1 confirmed facility personnel did not serve breakfast and lunch on the date of the inspection according to the posted food menu. E1 further confirmed the food menu did not include any food substitution no later than the morning of the day of meal service with a food substitution. 7. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 5, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure that foods requiring refrigeration were maintained at 41° F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "FOOD SERVICES.” The P&P stated, “Refrigerated foods must be kept at 41° F or below.” 2. During an environmental inspection of the facility, the Compliance Officers observed the following: - A block of cheese and a jar of mayonnaise, both warm to the touch, on the facility’s kitchen counter; and - In the facility’s kitchen cabinet, an opened jar of mayonnaise, an opened bottle of ranch dressing, and an opened jar of green chili salsa, all with labels stating “refrigerate after opening.” 3. During an environmental inspection of the facility, the Compliance Officers observed the facility’s thermostat, which read 78 degrees Fahrenheit. 4. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment.

Based on documentation review, interview, and documentation review, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "Emergency Safety & Disaster/Evacuation Plan.” The P&P stated, “A disaster drill for personnel and staff is conducted during each shift at least once every three months, with documentation maintained on file for twelve months.” 2. In an interview, E1 reported the facility utilized two shifts. 3. A review of facility documentation revealed a series of personnel schedules. The schedules revealed two shifts: 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM between January 2025 and September 2025 and 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM between October 2025 and February 2026. 4. A review of facility documentation revealed documentation of four disaster drills for employees. However, the review revealed all four disaster drills were conducted on the first shift. The review revealed no disaster drills conducted on the second shift dated within one year before the date of the inspection. 5. In an interview, E1 confirmed all four drills were conducted on the first shift and none were conducted on the second shift. 6. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 5, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure that garbage and refuse were stored in covered containers lined with plastic bags. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection. Findings include: 1. During an environmental inspection of the facility the Compliance Officers observed the following: - In the living room, an uncovered trash container with garbage inside; - In E1’s bathroom an uncovered and unlined trash container with garbage inside; - In the facility's kitchen area, a full trash bag sitting on the kitchen floor with no container; and - In R2 and R3’s bedroom, full uncovered trash containers. 2. A review of the facility’s policies and procedures revealed a policy titled “ENVIRONMENTAL AND PHYSICAL PLANT SAFETY." The policy stated, “10. Garbage and refuse must be stored in covered containers lined with plastic bags and removed at least weekly or sooner if necessary.” 3. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 5, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour, the Compliance Officers observed the following: - A magnet key attached to the resident's restroom mirror, the Compliance Officers were able to unlock the restroom cabinet with the key. The cabinet contained bottles of Lysol, Clorox, Fabric Refreshener, Fabuloso, and fine fragrance mist. - In an unlocked garage, Shop Pro brake fluid, Rain-x, Plumber’s Faucet and Valve Grease, Titlebond wood glue, WD-40, OdoBan floor cleaner, Febreze, Clorox bleach, Clorox ColorLoad, OxiClean, and WindFresh laundry detergent. - An unlocked employee room that contained Clorox Disinfecting wipes and a bottle of Fabric Refreshener. - In a bathroom attached to an unlocked bedroom, a bottle of disinfectant wipes and a bottle of fabric refresher 2. A review of the facility’s policies and procedures revealed a policy titled “ENVIRONMENTAL AND PHYSICAL PLANT SAFETY." The policy stated, “15. Poisonous and toxic materials must be labeled and stored in a locked area separate from food and medication.” 3. In an interview, the Compliance Officers informed E1 the door to the garage needed to remain locked as long as the garage contained poisonous or toxic materials. 4. Later in the inspection, the Compliance Officers again observed the door to the garage. The Compliance Officers observed a sign on the door which read, “Employees Only” as well as two locks on the door. However, the Compliance Officers observed the key to the bottom lock left in the lock. The Compliance Officers further observed both locks on the door were again not locked. 5. In an interview, the Compliance Officers reminded E1 the door needed to be locked. 6. The Compliance Officers observed R2 enter the unlocked garage. 7. In an interview, R2 reported R2 went into the garage frequently to grab snacks and to have privacy in administering R2’s own insulin. 8. In an interview, E1 confirmed R2 frequently went into the garage to administer R2’s own insulin. 9. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment. This is a repeat citation from the compliance inspection conducted on June 5, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure the swimming pool had a life preserver or shepherd’s crook available and accessible in the swimming pool area. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed a pool in the back yard of the facility. However, the Compliance Officers observed no life preserver or shepherd’s crook available and accessible in the swimming pool area. 2. A review of the facility's policies and procedures revealed a policy titled,"SWIMMING POOL SAFETY." This policy stated, "3. A life preserver or shepherd's crook must be available in the pool area.” 3. In an interview, E1 reported E1 did not have a life preserver or shepherd's crook in the pool area. 4. In the exit interview, the Compliance Officers reviewed the findings and E1 and E1 offered no further comment.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of the facility's policies and procedures (reviewed and approved January 1, 2023) revealed a training program for staff regarding fall prevention was developed. However, the training program did not include the initial training and continued competency component. 2. A review of E1's and E2's personnel records revealed initial training and continued competency training in fall prevention and fall recovery were not available for review. 3. In an interview, E1 acknowledged initial training and continued competency training in fall prevention and fall recovery for E1 and E2 was not available for review. This is a repeat deficiency from the compliance inspection conducted on June 16, 2022.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completing 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 one of two caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. Upon arrival at the facility at 8:45 AM, the Compliance Officer was greeted by E2. The Compliance Officer observed E2 was the only personnel member on the premises with three residents. 2. A review of E2's personnel record showed no caregiver certificate. 3. A review of facility documentation revealed E2 was regularly scheduled to work twenty four hour shifts. E2 was the only caregiver scheduled in the facility from May 21 to May 25. 4. A review of the NCIA Board verification of caregiver training portal (https://azcg.tmutest.com/search) revealed E2 had not completed a caregiver training program after August 3, 2013. 5. In an interview, E1 reported E2 had a caregiver certificate, however E1 had misplaced it. E1 acknowledged documentation was not available that showed E2 completed a caregiver training program approved by the Department or the NCIA Board.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a trained caregiver was present on the assisted living facility's premises when the manager was not present. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. Upon arrival at the facility at 8:45 AM, the Compliance Officer was greeted by E2. The Compliance Officer observed E2 was the only personnel member on the premises with three residents. 2. The Compliance Officer observed, E1 arrived on-site at approximately 9:00 AM. 3. A review of E2's personnel record showed no caregiver certificate. 4. A review of the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers verification of caregiver training portal (https://azcg.tmutest.com/search) revealed E2 had not completed a caregiver training program after August 3, 2013. 5. A review of facility documentation revealed E2 was regularly scheduled to work twenty four hour shifts. E2 was the only caregiver scheduled in the facility from May 21 to May 25. 6. In an interview, E1 reported E2 had a caregiver certificate, however E1 had misplaced it. E1 acknowledged documentation was not available that showed E2 was a trained caregiver, therefore a trained caregiver was not present on the assisted living facility's premises when the manager was not present.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C), for one of two employees sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(C) states: "Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card." 2. A review of E2's personnel record revealed a fingerprint card, however documentation was not available that showed a good faith effort to verify the current status of E2's fingerprint clearance card. 3. In an interview, E1 acknowledged E2's personnel record did not include documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(2). Technical assistance was provided on this Rule during the compliance inspection conducted on June 16, 2022.

Based on record review and interview, the manager failed to ensure 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 two residents sampled. The deficient practice posed a risk to the health and safety of residents if residents required services the facility was unable to provide. Findings include: 1. A review of R1's medical record revealed no documentation to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. A review of R2's medical record revealed a document to include whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. However the document was dated but it was not signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 3. In an interview, E1 acknowledged R1 and R2 did not provide documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on documentation review, record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), for two of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1) states, "The department shall... (d) Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized." 2. A review of R1's and R2's medical records revealed no indication that flu and pneumonia vaccinations were received or refused. Based on R1's and R2's acceptance dates, this documentation was required. 3. In an interview, E1 reported that the families of R1 and R2 did not want them to receive the flu and pneumonia vaccinations. E1 reported that E1 was not able to find the refusal at the time of the inspection. E1 acknowledged R1's and R2's medical records did not include current documentation that showed the flu and pneumonia vaccinations were received or refused.

Based on observation, documentation review, record review, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the 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 risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. The Compliance Officer observed when exiting from the patio door to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility. 2. The Compliance Officer observed an unlocked door leading out to the patio from the unlocked caregiver's room. The Compliance Officer observed an alert system was installed on the caregiver's door. However, the alert system was not functioning. 3. A review of Department documentation revealed the facility was authorized to provide directed care services. 4. A review of R2's service plan dated January 2024, revealed R2 has dementia and was ambulatory. 5. In an interview, E1 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed one ambulatory resident in the facility. 2. The Compliance Officer observed medications in an open drawer in an unlocked caregiver's room. The list provided was a sampled list of medications that were found. - Biktarvy 50/200/25 MG - Piefeltro 100 MG - Levothyroxine 25 MCG - Levothyroxine 0.100 MG - Ezetimibe 10 MG - Cholecalcif 25 MCG - Tivicay 50 MG 3. The Compliance Officer observed a bottle of Valproic Acid 250 MG stored in the unlocked pantry. 4. The Compliance Officer observed Vitamin A&D cream and Ketoconazole cream in an unlocked empty room accessible to the residents. 5. During an interview, E1 acknowledged the medications were stored unlocked. Technical assistance was provided on this Rule during the compliance inspection conducted on June 16, 2022.

Based on observation and interview, the manager failed to ensure the premises at the assisted living facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents. Findings include: 1. The Compliance Officer observed one ambulatory resident. 2. During the environmental tour of the facility, the Compliance Officer observed a shed in the backyard. The shed's door consisted of horizontal wood slats approximately six inches apart. The Compliance Officer was able to reach inside the shed and had access to the various gardening tools and paint stored within. 3. In an interview, E1 acknowledged the shed door was not safe and the premises at the assisted living facility was not free from a condition or situation that may cause a resident or other individual to suffer physical injury. This is a repeat deficiency from the compliance inspection conducted on June 16, 2022.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed one ambulatory resident in the facility. 2. The Compliance Officer observed a spray can of Black Flag Flying Insect Killer in an unlocked cabinet in an unlocked caregiver's room. 3. The Compliance Officer observed an unlocked cabinet in a resident bathroom containing toxic materials. Below was a sample of the toxic materials that were found. - A spray bottle of Lysol Power Bathroom Foamer - Two bottles of Lysol Toilet Bowl Cleaner - A spray bottle of Clorox Cleaner 4. The Compliance Officer observed a small canister of Lysol disinfectant spray in a bathroom available to the residents in an unlocked drawer. 5. The Compliance Officer observed a bottle of Clorox bleach located in an unlocked laundry room. 6. A documentation review of the facility's policy and procedures (reviewed and approved January 1, 2023) revealed a policy titled, "Environmental and Physical Plant Safety" revealed in subsection 15, "Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dining areas, and medications and are inaccessible to residents." 7. In an interview, E1 acknowledged the toxic materials were not stored in a locked area inaccessible to residents. This is a repeat deficiency from the compliance inspection conducted on June 16, 2022.