Seven Haven LLC

Based on documentation review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services for one of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of E2's personnel record revealed E2's role as a caregiver, however, documentation verifying E2's skills and knowledge was not available. 2. In an interview E2 acknowledged that the manager failed to ensure that a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility that included the manager's signature and date signed for 1 of 4 residents sampled. Findings include: 1. A review of R1's medical record revealed a residency agreement signed by R1's representative on October 9, 2024. However, the residency agreement was not signed or dated by the manager. 2. In an interview, E2 acknowledged that the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility that included the manager's signature and date signed.

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 3 of 4 residents sampled. Findings include: 1. A review of R1's medical record revealed a document titled "Emergency Orientation Reviewed & *Signed within 24 hours after resident moves in*," however, this document was not dated within twenty four hours after the resident's acceptance by the assisted living facility. 2. A review of R3's medical record revealed a document titled "Emergency Orientation Reviewed & *Signed within 24 hours after resident moves in*," however, this document was not dated within twenty four hours after the resident's acceptance by the assisted living facility. 3. A review of R4's medical record revealed a document titled "Emergency Orientation Reviewed & *Signed within 24 hours after resident moves in*," however, this document was not dated within twenty four hours after the resident's acceptance by the assisted living facility. 4. In an interview, E2 acknowledged 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 twenty four hours after the resident's acceptance by the assisted living facility.

Based on documentation review, interview, and record review, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings include: 1. A review of Department documentation revealed the facility provided notification that E3's final day as the manager of the AL7214 was August 31, 2022. 2. In an interview, E1 reported E2 was the facility's manager. 3. A review of E2's personnel record revealed E2's effective date as the facility's manager was September 22, 2022. 4. In an interview, E1 reported to have notified the Nursing Care Institution (NCIA) Board of the facility's change in manager. E1 was unaware of the need to notify the Department.