Scottsdale Foothills Assisted Living

Based on documentation review, record review, and interview, the manager failed to ensure that if a manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation had occurred on the premises the manager documented the immediate action to stop the suspected abuse, neglect, or exploitation and the report of the suspected abuse, neglect, or exploitation to a peace officer or to the adult protective services central intake unit. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. A.R.S. § 46-454. stated, "Duty to report abuse, neglect and exploitation of vulnerable adults; duty to make medical records available; violation; classification A. A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online. B. If an individual listed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law, the individual is deemed to have complied with the requirements of subsection A of this section by reporting or causing a report to be made to the health care institution in accordance with the health care institution's procedures." 2. In an interview, E1 revealed they had knowledge of an incident of possible abuse or neglect that occurred involving R2 on March 16, 2026, however, no documentation of the immediate action to stop the suspected abuse, neglect, or exploitation and the report of the suspected abuse, neglect, or exploitation to a peace officer or to the adult protective services central intake unit was available for review. 3. In an interview, E1 reported the staff member (E2) involved with R2's incident was no longer employed at the facility, however, there was no documentation of E2's termination from the facility. E1 also reported that E1 did not report it to a peace officer or to the adult protective services central intake unit upon knowledge of the related incident. 4. 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 caregiver provided documentation of completing 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. A review of E2's personnel record revealed E2 was hired as a caregiver and had a caregiver training certificate from Platinum Training Services, LLC (ALTP #0152) dated June 20, 2013. 2. A review of the NCIA Board's website revealed a training program titled Comprehensive Training Services, LLC, when looking up ALTP #0152, not Platinum Training Services, LLC as listed on E2's caregiver training certificate. 3. A review of the azcg.tmutest.com website revealed no documentation of a caregiver training certificate for E2. 4. In an interview, O1, a representative from the NCIA board, stated the following, "..the numbers on the certificate do not match our website. The ALCTP# on the certificate is for a different training program..." 5. In an interview, E1 reported and acknowledged that E2 has been employed at the facility and giving care to residents since November 5, 2022 according to E2's personnel record documentation. 6. In an exit interview, the findings were reviewed with E1 and no additional information or evidence of verification for E2's caregiver certification status was provided.

Based on record review, and interview, for three of five personnel reviewed, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident, if all personnel were not trained on fall prevention and fall recovery. Findings include: 1. In record review, the personnel records for E3, (hired as a caregiver on May 20, 2022), E4 (hired as a caregiver on March 5, 2018), and E5, (hired as a caregiver on July 2, 2022), did not include documentation the personnel received training on fall prevention and fall recovery. 2. During an interview, the findings were reviewed with E1, who reported all personnel received training on fall prevention and fall recovery; however, acknowledged the training was not documented for E3, E4, and E5.

Based on documentation review, record review, and interview, for one of five employees reviewed, the manager failed to have a personnel record for an employee as required by this Article. The deficient practice posed a risk to resident health and safety, if the facility did not maintain documentation showing an employee met the requirements to provide services for the residents. Findings include: 1. In documentation review, E6's name was documented as [E6] participated in a disaster drill at the facility in 2023. 2. In record review, the facility did not have a personnel record for E6. 3. In an interview, E1 and E2 reported E6 worked at the facility as a cook and housekeeper, and E6's documents might be located at another facility where E6 worked. E2 reported E6 worked at the facility sometimes more than once a week. E1 reported having documentation of E6's freedom from tuberculosis, fingerprint clearance and job description. The compliance officer requested to review the documentation, and requested E6's work hours, and hire date, however, no further documentation was provided.

Based on observation and interview, for the facility which provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a health and safety risk to residents as an unlocked and open door provided access to the outside and street area, without alerting employees. Findings include: 1. Upon arrival at the facility, the compliance officer observed the front door to the facility was wide open, and no staff were present in the area. Two residents were observed sitting in the common area unattended by staff. The compliance officer signed the visitor log, and then called out to announce entrance to the facility. E2 called back and came to the door. 2. During an interview, the finding was discussed with E2, who reported the door was left open because E2 was cooking fish, and the house smelled. 3. During an interview, E1 acknowledged the facility was licensed for directed care, and had residents who received directed care services. E1 reported the door was left open because the staff were bringing groceries in and out of the facility. E1 reported having an alarm that was to be installed on the door; however, acknowledged the door was left open, and did not have a system for controlling or alerting employees of the egress of a resident.

Based on observation and interview, the manager failed to ensure equipment used on a resident toilet was maintained in a clean manner, to prevent or minimize illness or infection. Findings include: 1. During an environmental inspection with E1, the compliance officer observed a cushioned toilet seat cover in a resident bathroom, which was torn and peeled back in several areas, exposing the foam cushion. The cushion had black and brown discolored areas. 2. During an interview, E1 acknowledged the cushioned toilet seat cover was torn and stained, and reported the family is responsible for purchasing the toilet seat cushion.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'ba F and 120\'ba F. Findings include: 1. During an environmental inspection with E1, hot water temperatures were measured in resident bathrooms. The hot water temperature measured at 127.2\'ba F in R1's bathroom. 2. In documentation review, a facility document titled, "Hot Water Temperature (resident bathrooms) Log, documented the hot water temperatures in resident bathrooms were documented as "ok," during the months of January through June, 2023. 3. During an interview, E1 acknowledged the hot water temperature in the resident bathroom was above 120\'ba F, and reported the thermostat was to be adjusted in June, when the outside weather became hot.