Sonoran Sky Assisted Living Care Home

Based on documentation review and interview, the health care institution failed to provide appropriate 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 facility documentation revealed an incident report dated July 14, 2024. The report stated: "[R1] attempted to get out of bed w/o calling for assistance & slid off the bed. 3 caregivers tried to lift [R1] & could not. Fire department was called…No injuries & was not sent to the hospital.” 2. In an interview, E3 confirmed the caregivers on duty called 911 because the caregivers could not lift R1.

Based on documentation review and interview,, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A review of facility documentation revealed an incident report dated March 22, 2025. The report stated: “As [R2’s] Caregiver, I [E4] have endured months of recial [sic] and verbal abuse. [R2] attacked me while I removed [R7] From [R2’s] room and later Struck me while using recial [sic] slure [sic] and threats. Despite this, I reminded [sic] professional. [R2’s] behavior worsened when [R2] began choking other Resident [R5], [illegible] has told to stop.” 2. In an interview, E4 expounded on the incident. E4 reported E4 was washing dishes when R2 approached E4 calling E4 names and racial slurs. E4 reported E4 was afraid because R2 had kicked E4 in the past so E4 grabbed a glass of water. E4 stated, “I threw the water off [R2] to remove [R2].” E4 reported R2 then walked over to R5 and began choking R5. E4 reported E4 asked R2 to stop choking R5 but R2 would not stop. E4 reported E4 stepped in between R2 and R5, yelled at R2, and sent R2 to R2’s bedroom. 3. In an interview, E3 reported E3 was not aware E4 had thrown water on R2. E3 agreed R2 was not treated with dignity, respect, and consideration.

Based on documentation review, record review, and interview, the governing authority failed to ensure a caregiver provided documentation of completion 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 three caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings: 1. A review of Department documentation revealed a Statement of Deficiencies (SOD) from a complaint inspection conducted on January 30, 2023, at AL12276 Sage House - Straight Arrow I. The SOD revealed this rule was cited for E4 (E6 in the Sage House SOD). The review further revealed a Plan of Correction (POC) for this citation dated February 1, 2023. The POC stated: “The manager and governing authority shall immediately suspend the employment of caregiver E6 upon identifying the deficiency.” 2. A documentation review revealed a policy and procedure (P&P) titled “CERTIFIED CAREGIVER.” The P&P stated a caregiver must “Be a trained and certified caregiver in the State of Arizona as documented by completion of a caregiver training program approved by the Arizona Department of Health Services or the [NCIA Board].” The review further revealed a series of personnel schedules dated between March 2024 and March 2025. The schedules revealed E4 worked on a weekly basis between March 2024 and June 2024 and between September 2024 and March 2025. 3. A review of E4's personnel record revealed E4 was hired as a caregiver in 2023. The review revealed a photocopy of a caregiver certificate reportedly given by Adult Care Learning Systems, Incorporated. The certificate identified the "Start Date" as May 20, 2013, and "Completed" date as June 22, 2013. However, E4's name was off center and inconsistent with the surrounding text; E4's name was in a different font than the surrounding text; a faint, short vertical line followed E6's name; a black, ornate border different than the rest of the certificate covered a simple, straight, red border; and a copyright of "2021 Great Papers" was present at the bottom-right of the certificate, eight years after the certificate was reportedly issued. The review further revealed E4 first received a fingerprint clearance card in 2021, even though having one was a requirement for caregivers in 2013. 4. In an interview regarding the inconsistencies in E4's certificate, the Compliance Officer requested to review the original certificate. E4 reported E4 had a picture of the original on E4’s phone. E4 showed the Compliance Officer pictures of the original certificate. 5. A review of the picture of E4’s original caregiver certificate revealed the same inconsistencies as the photocopy, including the copyright date on “2021,” eight years after the certificate was reportedly issued. 6. In an interview, E4 claimed the caregiver certificate was valid, even though it co

Based on documentation review and interview, the manager failed to ensure an assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety of a resident. The deficient practice posed a risk if the employees were unable to ensure the health and safety of a resident. Findings include: 1. A review of facility documentation revealed an incident report dated July 14, 2024. The report stated: "[R1] attempted to get out of bed w/o calling for assistance & slid off the bed. 3 caregivers tried to lift [R1] & could not. Fire department was called…No injuries & was not sent to the hospital.” 2. In an interview, E3 confirmed the caregivers on duty called 911 because the caregivers could not lift R1. 3. A review of facility documentation revealed an incident report dated March 22, 2025. The report stated: “As [R2’s] Caregiver, I [E4] have endured months of recial [sic] and verbal abuse. [R2] attacked me while I removed [R7] From [R2’s] room and later Struck me while using recial [sic] slure [sic] and threats. Despite this, I reminded [sic] professional. [R2’s] behavior worsened when [R2] began choking other Resident [R5], [illegible] has told to stop.” 4. In an interview, E4 expounded on the incident. E4 reported E4 was washing dishes when R2 approached E4 calling E4 names and racial slurs. E4 reported E4 was afraid because R2 had kicked E4 in the past so E4 grabbed a glass of water. E4 stated, “I threw the water off [R2] to remove [R2].” 5. A review of facility documentation revealed a series of personnel schedules dated between March 2024 and March 2025. The schedules revealed E4 worked on a weekly basis between March 2024 and June 2024 and between September 2024 and March 2025. 6. A review of E4's personnel record revealed E4 was hired as a caregiver in 2023. The review revealed a photocopy of a caregiver certificate reportedly given by Adult Care Learning Systems, Incorporated. The certificate identified the "Start Date" as May 20, 2013, and "Completed" date as June 22, 2013. However, E4's name was off center and inconsistent with the surrounding text; E4's name was in a different font than the surrounding text; a faint, short vertical line followed E6's name; a black, ornate border different than the rest of the certificate covered a simple, straight, red border; and a copyright of "2021 Great Papers" was present at the bottom-right of the certificate, eight years after the certificate was reportedly issued. The review further revealed E4 first received a fingerprint clearance card in 2021, even though having one was a requirement for caregivers in 2013. 7. In an interview regarding the inconsistencies in E4's certificate, the Compliance Officer requested to review the original certificate. E4 reported E4 had a picture of the original on E4’s phone. E4 showed the Compliance Officer pictures of the original certificate. 8. A review of the pictur

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of three sampled caregivers. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "CARDIOPULMONARY RESUSCITATION.” The P&P stated: "The Manager shall verify that applicable personnel have valid cardiopulmonary resuscitation training documentation specific to adults upon hiring that includes demonstration and that the time-frame for renewal has not expired…The documentation must be current and renewed before the date of expiration noted on the card…No personnel will be able to provide services to a resident with an expired or invalid CPR documentation.” The review revealed a P&P titled "FIRST AID” which stated: "The Manager shall verify that applicable personnel have valid first aid training documentation upon hiring and that the time-frame for renewal of first aid training will be emt…The documentation must be current and renewed before the date of expiration noted on the card…No personnel will be able to provide services to a resident with an expired or invalid First Aid documentation.” 2. The review further revealed a series of personnel schedules dated October-November 2024. The schedules revealed E4 worked nearly every day between October 4, 2024, and November 15, 2024, including a shift spanning the entirety of November 15, 2024. 3. A review of E4's personnel record revealed E4 was hired as a caregiver. The review revealed a first aid and CPR certification with a Renewal Date of October 4, 2024. The review further revealed a printout of E4’s current first aid and CPR certification dated as issued on November 15, 2024, even though E4 was working at the facility during the entirety of that date. 4. In an interview, E3 acknowledged E4 did not provide current documentation of first aid training and CPR training certification specific to adults before providing assisted living services to a resident.

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "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 vulnerable 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...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. A review of facility documentation revealed an incident report dated March 22, 2025. The report stated: “As [R2’s] Caregiver, I [E4] have endured months of recial [sic] and verbal abuse. [R2] attacked me while I removed [R7] From [R2’s] room and later Struck me while using recial [sic] slure [sic] and threats. Despite this, I reminded [sic] professional. [R2’s] behavior worsened when [R2] began choking other Resident [R5], [illegible] has told to stop.” 4. In an interview, E4 expounded on the incident. E4 reported E4 was washing dishes when R2 approached E4 calling E4 names and racial slurs. E4 reported E4 was afraid because R2 had kicked E4 in the past so E4 grabbed a glass of water. E4 stated, “I threw the water off [R2] to remove [R2].” E4 reported R2 then walked over to R5 and began choking R5. E4 reported E4 asked R2 to stop choking R5 but R2 would not stop. E4 reported E4 stepped in between R2 and R5, yelled at R2, and sent R2 to R2’s bedroom. 5. A review of facility documentation revealed no report made to a peace officer or to the adult protective services (APS) central intake unit. 6. In an interview, E3 reported E3 did not call the police or APS to report the suspected abuse, neglect, or exploitation of R2 by E4 or that of R5 by R2. 7. In a telephonic interview, E1 stated, “I did not call APS.”

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of three sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a series of personnel schedules dated between September 2024 and March 2025 which revealed E5 worked on a regular basis. 2. A review of E5's personnel record revealed E5 was hired as a caregiver. However, the review revealed no documentation demonstrating the manager ensured E5's skills and knowledge were verified and documented before E5 provided physical health services. 3. In an interview, E3 acknowledged E5’s skills and knowledge were not verified and documented before E5 provided physical health services.

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 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 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. During an environmental inspection of the facility, the Compliance Officer observed the front door had a control and an alert installed. However, the control was not in use and the alert was in the “Off” position and did not sound when the Compliance Officer opened the door. 3. In an interview, E4 stated, "I turned it off."

Based on documentation review and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered how a caregiver would respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled PROTOCOL FOR UN-CONTROLLED BEHAVIORS.” The P&P stated: “Approach slowly from the front in a friendly relaxed manner. Do not reason with resident - can no longer think logically. Redirect! Don’t argue! NEVER SAY NO OR RAISE YOUR VOICE!” The review further revealed an incident report dated March 22, 2025. The report stated: “As [R2’s] Caregiver, I [E4] have endured months of recial [sic] and verbal abuse. [R2] attacked me while I removed [R7] From [R2’s] room and later Struck me while using recial [sic] slure [sic] and threats. Despite this, I reminded [sic] professional. [R2’s] behavior worsened when [R2] began choking other Resident [R5], [illegible] has told to stop.” 2. In an interview, E4 expounded on the incident. E4 reported E4 was washing dishes when R2 approached E4 calling E4 names and racial slurs. E4 reported E4 was afraid because R2 had kicked E4 in the past so E4 grabbed a glass of water. E4 stated, “I threw the water off [R2] to remove [R2].” E4 reported R2 then walked over to R5 and began choking R5. E4 reported E4 asked R2 to stop choking R5 but R2 would not stop. E4 reported E4 stepped in between R2 and R5, yelled at R2, and sent R2 to R2’s bedroom. 3. In a telephonic interview, E3 acknowledged E4 did not implement the P&P. E3 stated, “Absolutely no yelling back.”

Based on documentation review and interview, the manager of an assisted living home failed to maintain a copy of the document provided to the emergency responder which included the items listed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Emergency Responders.” The P&P stated, “The assisted living home will maintain a copy of the document provided to the emergency responder and documentation(s) acquired.” The review further revealed three incident reports from June-July 2024 which indicated R1 had accidents, emergencies, or injuries that resulted in the facility requesting emergency responders for R1. However, the review revealed no copies of the documents provided to the emergency responders for the aforementioned incidents. 2. In an interview, E3 reported the facility did not have copies of the documents provided to the emergency responders.