Serene Haven Living LLC

Based on observation, interview, record review, and documentation review, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. The facility had a census of seven residents at the time of the inspection. 2. In an interview, E3 reported that E3 was a live-in caregiver and stayed with the residents alone at night but did not provide care. 3. In an interview, E1 reported that E3 worked alone in the facility at night but did not provide care to the residents during nighttime hours. 4. A review of R1's and R2’s residency agreement stated, ‘There are NO AWAKE Night Staff. Residents may provide night staff at their discretion and must be approved by the manager.” 5. A review of the personnel schedule revealed E3 was scheduled as the only employee for the nighttime shift. 6. A review of E3's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the NCIA Board. 7. A review of the https://azcg.tmutest.com/search website revealed no documentation of a caregiver training certificate for E3. 8. 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 the caregiver documented the services provided in the resident's medical record for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed no documentation of the services provided from October 5, 2025, - October 20, 2025. 2. A review of R2's medical record revealed no documentation of the services provided from October 5, 2025, - October 20, 2025. 3. In an interview, E1 reported that R1 and R2 received assisted living services from the caregivers. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a food menu included the food substitutions no later than the morning of the day of meal service with a food substitution. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled “Food Services Policy" that stated “1. A food menu: a. Is prepared at least one week in advance, b. Includes the foods to be served each day, c. Is conspicuously posted at least one day before the first meal on the food menu is served, [and] d. Includes a food substitution no later than the morning of the day of meal service that includes the food substitution.” 2. A review of facility documentation revealed the food menu dated October 2025. The lunch menu stated “Enchiladas, rice, beans, and fruit”. 3. At approximately 12:15 PM on October 20, 2025, the Compliance Officer observed residents eating what appeared to be cheese pizza, salad, watermelon, and water for lunch. 4. In an interview, E1 stated the residents were eating “cheese pizza, salad, watermelon, and water” for lunch. 5. A review of facility documentation conducted after 1:00 PM on October 20, 2025, revealed no documentation of the food substitutions. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that food requiring refrigeration was maintained at 41°F or below. The deficient practice posed a risk of potential foodborne illness. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed milk, eggs, and cheese in the refrigerator. 2. During the environmental inspection, the Compliance observed the thermometer in the door of the refrigerator. The temperature on the thermometer read 58°F. 3. In an interview, E1 reported that E1 did not realize the temperature was so high and went to turn the temperature down during the inspection. 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 that appropriate first aid was provided in accordance with its certification training for first aid before the arrival of emergency medical services to a non-injured resident who had fallen, appeared to be uninjured and was unable to reasonably recover independently. Findings include: 1. A review of R2's medical records revealed that on June 14, 2025 an incident report was completed that showed that Emergency Medical Services were called for R2 who was uninjured, fell on the floor, and could not get up. 2. A documentation review of the facility's Policies and Procedures titled, "Fall Prevention and Recovery Training: Residents Without Injuries" and "How to Help Someone Up From the Floor" provided 13 steps on how to assist a resident off of the floor. 3. A review of E2's orientation checklist revealed that the employee received Fall Prevention and Recovery Training. 4. In an interview, E2 acknowledged that the facility failed to ensure that appropriate first aid was provided in accordance with its certification training for first aid before the arrival of emergency medical services to a resident who had fallen.

Based on observation, documentation review, record review, and interview, the governing authority failed to notify the Department according to A.R.S. § 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings includes: 1. During the environmental inspection upon entry into the facility, the Compliance Officer observed the manager's certificate hanging on the wall. The name on the certificate was E1. 2, A Department review of the facility's information revealed that an email was received from the prior manager who identified their first date of part-time employment started on August 1, 2024. 3. A review of E1's personnel record revealed that E1's hire date was in April 2025. 4. A review of documentation provided to the Department by the facility revealed no notification of change in manager for E1. 5. In an interview, E2 acknowledged that the Department was not notified of the change in the manager.

Based on record review, documentation review, and interview, the manager failed to ensure that an employee and/or resident provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "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 employed by the health care institution, provides volunteer services for the health care institution, or 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1’s personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. 4. In an interview, E2 acknowledged E1 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility.

Based on record review, documentation review, and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, for R1. 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 record revealed the initial and most recent written service plan for personal care services dated February, 2024. However, this service plan did not include a signature and date from the resident or representative. 2. In an interview, E2 acknowledged R1's service plan did not include a signature and date from the resident or representative.