Sally Johnson

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident’s acceptance by the assisted living facility, for two of two residents sampled. Findings include: 1 . A review of R1's and R2's medical records revealed no documentation of an orientation to the exits of the facility were available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a fire extinguisher in the garage and in the kitchen. Both fire extinguishers had tags that expired on September 2025. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure 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 an policies and procedures manual reviewed in 2019. However, documentation of policies and procedures were reviewed in 2022 were not available for review at the time of inspection. 2. In an interview, E1 reported E1 was unsure if the policies and procedures were reviewed at least once every three years and updated as needed.

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 Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), 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(A) states: "A. Except as provided in subsection F of this section, 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of E2's personnel record revealed documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) expired on February 27, 2019. 3. In an interview, E1 reported E2 had not submitted their application to renew their fingerprint clearance card. 4. 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(A).

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB) as required in Arizona Administrative Code (A.A.C.) R9-10-807(A), for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed documentation of negative TB tests. However, documentation of TB screening conducted by the facility was not available for review at the time of inspection. 2. In an interview, E1 acknowledged R1's and R2's medical records did not contain documentation of freedom from TB as required in A.A.C. R9-10-807(A).

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1's and R2's medical record revealed documentation of the resident's orientation to exits from the assisted living facility was not available for review at time of inspection. 2. In an interview, E2 acknowledged R1's and R2's medical record did not contain documentation of the resident's orientation to exits from the assisted living facility at the time of the inspection.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food or medication contained a thermometer, accurate to plus or minus 3 \'b0F, placed at the warmest part of the refrigerator. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a refrigerator in the kitchen and in a pathway leading towards the garage which stored resident food. Both refrigerators did not contain a thermometer placed at the warmest part of the refrigerator. 2. In an interview, E1 acknowledged a thermometer was not placed in the refrigerator in the kitchen and in a pathway leading towards the garage.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a container of "Member's Mark Dual Action Grease Fighter and Rinse Aid" detergent pods and a can of "Bar Keepers Friend" cookware cleanser and polish in an unlocked cabinet under the sink in the kitchen. 2. In an interview, E1 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents.

Based on observation and interview, the manager failed to ensure hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a biohazard sharps container in an unlocked cabinet under the sink in the kitchen. The inside of the container contained discarded needles. 2. In an interview, E1 acknowledged a biohazard sharps container was not stored in a locked area inaccessible to residents.