St Joseph Assisted Living LLC

Based on observation, record review, and interview, 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. The Compliance Officer entered the facility around 5:55 pm and observed E2, E3, and E4 in the facility. It was approximately 6:07 pm when E1 was observed in the facility. 3. A review of E2’s, E3’s, and E4’s personnel records revealed E2 and E3 were hired as assistant caregivers. E4’s personnel record revealed E4 was hired as a caregiver however, E4 did not have a caregiver certificate available at the time of inspection. 4. In an interview, E4 reported that the Compliance Officer caught them at a bad time, as E1 leaves from 4 pm to 9 pm. 5. In an interview, E2 was heard talking to E1 when E1 rounded the corner into the kitchen. E2 was heard saying, “You got here fast” to E1. 6. In an interview, E1 reported that E1 was helping R2 to bed. However, R2 was unable to participate in an interview to confirm E1 was helping R2 to bed. 7. In an interview, R1 reported that E1 left around 4 pm - 4:30 pm that night. 8. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat deficiency from the inspections conducted on January 27, 2025, and July 1, 2025.

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, that monitored 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. The Compliance Officer observed that the alarm on the door leading to the backyard of the facility was not working. The alarm did not sound when the Compliance Officer opened the door. The Compliance Officer observed no monitoring system in place. 3. The Compliance Officer observed residents sitting outside of the facility in the backyard. 4. In an interview, E1 reported that the sensor had to be pushed back a little for it to work. When E1 pushed the sensor, the alarm faintly sounded when opened. 5. In an interview, E1 acknowledged the alarm was not working before E1 pushed the sensor. 6. In an exit interview, the findings were reviewed with E1 and no additional information was provided. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on June 26, 2025; this is an uncorrected citation from the complaint inspection conducted on January 29, 2025 and July 1, 2025; and this is a repeat citation from the compliance inspection conducted on June 17, 2024.

Based on observation and interview, the manager failed to ensure pets were controlled to prevent endangering the residents. This deficient practice posed a risk to the health and safety of the residents’ well-being. Findings include: 1. The Compliance Officer observed a dog in the facility. E2 chased the dog around the kitchen and managed to place the dog behind a locked door. 2. In an interview, R1 reported the dog bit one of R1’s nurses. 3. In an interview, E1 reported APS was out at the facility investigating the incident with the dog. E1 reported E1 did not know the department also investigated incidents when a dog bites a visitor. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, interview, and observation, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as residents were alone with an individual who was not a certified caregiver. Findings include: 1. Arizona Revised Statutes § 36-401(A)(49) states, "'Supervision' means directly overseeing and inspecting the act of accomplishing a function or activity." 2. In an interview, E1 reported E3 was an assistant caregiver. E1 and E3 reported E3 recently took the caregiver certification course and failed but was planning to retake the test soon. 3. During an environmental inspection of the facility, the Compliance Officer observed residents in several areas of the facility, including common areas. On several occasions during the inspection, the Compliance Officer observed E3 was not within sight of E1 and the Compliance Officer. 4. In an interview, when the Compliance Officer reminded E1 that E3 could not interact with residents without being under the supervision of a manager or caregiver, E1 stated, “I know.” 5. On several occasions after the aforementioned interview with E1, the Compliance Officer observed E3 interacting with residents without being under the supervision of a manager or caregiver. Furthermore, the Compliance Officer observed E1 exit through the front door of the home for a short time while E3 was still inside with the residents. 6. In an interview, E1 reported E1 had gone outside to go around the side of the house to another entrance to obtain resident records. E1 reported E1 did not have the key to the door leading to the room with the resident records and had to go outside the facility and around to get them. While E1 was outside, residents were left without a certified caregiver in the facility. 7. In a separate interview, E1 acknowledged E3 interacted with residents without being under the supervision of a manager or caregiver.

Based on documentation review, observation, and interview, 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 residents were alone with an individual who was not a certified caregiver and the Department was provided false or misleading information. Findings include: 1. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint inspection conducted on January 27, 2025. The POC indicated this deficiency was corrected on April 15, 2025. The POC stated: “The Owner…and any certified caregivers shall not leave the facility even for a grocery run when there are no caregivers left with the residents. Moving forward, the Owner shall ensure that at all times at least the manager or certified caregiver is always present in the facility when a resident is present.” 2. The Compliance Officer observed E1 and E3 were the only personnel at the facility during the inspection. The Compliance Officer observed residents in several areas of the facility, including common areas. On several occasions during the inspection, the Compliance Officer observed E3 was not within sight of E1 and the Compliance Officer. 3. In an interview, E1 reported E3 was an assistant caregiver. E1 reported E1 was the only caregiver currently in the facility. 4. The Compliance Officer later observed E1 exit through the front door of the home for a short time while E3 was still inside with the residents. 5. In an interview, when the Compliance Officer informed E1 that E1 could not leave the residents without a manager or caregiver in the home, E1 reported E1 had gone outside to go around the side of the house to another entrance to obtain resident records. E1 reported E1 did not have the key to the door leading to the room with the resident records and had to go outside and around to get them. This is a repeat citation from the complaint inspection completed on January 27, 2025.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that was reviewed and updated at least once every six months for a resident receiving personal care services, for one of two sampled residents receiving personal care services. The deficient practice posed a risk if the service plan did not include current, accurate information. Findings include: 1. A review of R2's medical record revealed a service plan dated December 23, 2024, which indicated R2 received personal care services. The service plan stated the “Service Plan renewal date” was June 22, 2025. However, the review revealed no updated service plan dated within six months after December 23, 2024, or thereafter. 2. In an interview, E1 acknowledged R2’s service plan should have been updated and reviewed by June 22, 2025, more than one week before the date of the inspection. E1 reported E1 still needed to send out to a third party company to get R2’s service plan updated. This is a repeat citation from the complaint inspection completed on January 27, 2025.

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 that monitored 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. The Compliance Officer observed a door in the kitchen leading to the back yard (the same door for which technical assistance was given during an inspection five days prior, and which was cited two other times prior). The Compliance Officer observed the facility did not have a monitoring system in place but the door did have an alert installed. However, the alert did not sound when the Compliance Officer opened the door and walked outside. The Compliance Officer observed no facility personnel within sight. 3. While outside and around the corner of the facility, the Compliance Officer overheard E3 state, “I don’t know where [the Compliance Officer] went.” 4. During the course of the inspection, the Compliance Officer observed multiple residents egress through the kitchen door. The Compliance Officer further observed three sets of double doors leading to the backyard without monitoring systems or alerts installed. The Compliance Officer observed the first set in the living room behind a couch, the second set in an occupied bedroom behind two nightstands, and the third set in another occupied bedroom. 5. In an interview regarding the three double doors, E1 stated, "There’s no chimes." E1 further stated, “We didn’t put the chimes ‘cause we don’t use these ones.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on June 26, 2025; this is an uncorrected citation from the complaint inspection conducted on January 29, 2025; and this is a repeat citation from the compliance inspection conducted on June 17, 2024.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation required by this rule, for one of three personnel sampled. The deficient practice posed a risk as required information for a personnel member could not be verified. Findings include: 1. A review of personnel records revealed a personnel record for E3 was not available for review at the time of the inspection. 2. In an interview, E2 reported E3 mainly helped E2 with lifting residents when E2 could not do it alone, but sometimes provided other assistance as well. E2 acknowledged E3 had no documentation required by rule.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of R1's medical record revealed documentation of evidence of freedom from infectious tuberculosis was not available for review at the time of inspection. Based on R1's date of acceptance, this documentation was required. 2. In an interview, E2 acknowledged R1 had no TB documentation.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to indicate whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of four sampled residents. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed documentation stating whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints was not available for review at the time of inspection. 2. In an interview, E1 acknowledged R1 had no documentation showing if R1 needed continuous medical services, nursing services, or restraints.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility to include the requirements in Arizona Administrative Code (A.A.C.) R9-10-807(D)(1)-(10), for one of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's medical record revealed documentation of a residency agreement between R1 and the facility was not available for review. Based on R1's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged documentation of R1's residency agreement was not available for review.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. The deficient practice posed a risk as there was no service plan to direct the services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed an initial service plan was not available for review at the time of inspection. Based on R1's date of acceptance, this documentation was required. 2. In an interview, E2 acknowledged R1 had no service plan documented at the time of inspection.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months for a resident receiving personal care services, for one sampled resident who received personal care services. The deficient practice posed a risk if the service plan did not include current, accurate information. Findings include: 1. A review of R2's medical record revealed a service plan dated April 30, 2024. However, documentation of a service plan completed six months after was not available for review at the time of inspection. 2. In an interview, E2 reported E2 thought they misplaced the service plan. E2 acknowledged R2's medical record had not contained an updated service plan.

Based on record review and interview, the manager failed to ensure a medical record is maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1. The deficient practice posed a risk as required information could not be verified for one resident. Findings include: 1. A review of medical records revealed a medical record for R1 was not available for review. 2. The Compliance Officer requested to review R1's medical record. However, R1's medical record was not provided for review. 3. In an interview, E2 reported the facility had never obtained the documentation for R1's medical record and was unable to provide any documentation.

Based on record review and interview, the manager failed to ensure a medical record included all required information for one of two sampled residents. Findings include: 1. During an inspection, the Compliance Officers requested the medical record for R1. However, the documentation of R1's medical record was not available for review at the time of inspection. 2. In an interview, E2 reported the facility never obtained the documentation for R1's medical record and was unable to provide any documentation.

Based on interview, 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. In an interview, E2 reported E2 had to go to the store to pick up some groceries for the facility. E2 reported E2 left another person on site who was not a caregiver or manager to watch over the residents while E2 was gone. E2 reported E2 left the facility around 2:45 PM and returned to the facility around 4:00 PM after being informed the ombudsman was on site. 2. In an interview, E2 acknowledged a manager or caregiver was not present at the assisted living home when a resident was present at the assisted living home.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of two sampled residents. The deficient practice posed a health and safety risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's current service plan revealed R1 required assistance with "Bathing/Hygeine: Shower 2/Week." However, a review of R1's Activities of Daily Living (ADL) sheet revealed R1received a shower every day from June 1, 2024 through June 17, 2024. 2. A review of R2's current service plan revealed R2 required assistance with "Bathing/Hygeine: Shower 2/Week." However, a review of R2's Activities of Daily Living (ADL) sheet revealed R2 received a shower every day from April 1, 2024 through April 21, 2024. 3. In an interview, E2 reported E2 had been marking the ADL sheets every day to indicate the service was offered to R1 and R2. However, E2 reported R1 and R2 had not taken a shower every day between the aforementioned dates. E2 acknowledged the services were not accurately recorded on R1's and R2's ADL sheets.

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 one of two sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation route to be used in an emergency. Findings include: 1. A review of R1's medical record revealed documentation titled "Resident Orientation." The document stated "Please check in each space below as the corresponding task is completed." However, not all items listed on the "Resident Orientation" were checked to indicate the task was completed at time of inspection. 2. In an interview, E2 acknowledged documentation of R1's orientation was incomplete.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does 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 to the outside area allowing the resident to be at least 30 feet away from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of facility documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed a door leading from the kitchen to the back yard. However, the alert placed on the door was not functional at the time of inspection. The Compliance Officer also observed a door with a double-sided deadbolt leading from a resident bedroom to the back yard. However, the door was unlocked at the time of inspection. 3. In an interview, E2 acknowledged means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, did not control or alert employees of the egress of a resident from the facility at the time of the inspection.

Based on observation, documentation review, and interview, the manager failed to ensure a food menu included any food substitutions no later than the morning of the day of meal service with a food substitution. The deficient practice posed a risk if the origin of a food-borne illness could not be identified. Findings include: 1. At approximately 11:30 AM, The Compliance Officer observed a staff member making lunch for the residents. The Compliance Officer observed the staff member preparing spaghetti and meatballs in a pan. 2. In an interview, E2 reported the residents were having spaghetti and meatballs for lunch. 3. A review of facility documentation revealed a menu for the week of June 17, 2024 through June 23, 2024. On June 17, 2024 (the date of the inspection), the menu stated "Roast Chicken, Mashed Potato" would be served for lunch. 4. In an interview, E2 acknowledged the food menu did not include any food substitutions no later than the morning of the day of meal service with a food substitution.

Based on observation and interview, the manager failed to ensure poisonous or 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 an environmental inspection of the facility, the Compliance Officer observed a container of "Suavitel" fabric softener, two containers of "Arm and Hammer Oxi Clean" and a bottle of "Clorox" performance bleach in an unlocked cabinet above the washer and dryer. The washer and dryer were accessible to residents of the facility. 2. In an interview, E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked area and inaccessible to residents at the time of the inspection. This is a repeat citation from the previous compliance inspection conducted on December 15, 2022.