Sue's Place, LLC

Based on documentation review, record review, and interview, the manager failed to ensure compliance with A.R.S. § 36-411, for five of five personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states: " C. Each residential care institution, nursing care institution and home health agency shall make documented, good-faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 2. A review of personnel records revealed there was no documentation of verification that E1, E2, E3, E4, and E5 were not on the adult protective services (APS) registry. Based on the date of hire of E1, E2, E3, E4, and E5, a verification should have been completed. 3. In an interview, E1 reported being unaware that a verification was required and acknowledged E1 failed to ensure compliance with A.R.S. § 36-411.

Based on documentation review, record review, and interview, the manager 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. Findings include: 1. A review of E4's personnel record contained a caregiver training certificate issued by True Joy Healthcare Training Center LLC with program license number ALTP 115 issued November 19, 2016. 2. A review of Department documentation revealed ALTP 115 belonged to the Cactus Wren Training program, valid from August 11, 2006, through August 2, 2013. 3. A review of the facility's documentation contained a document titled "Manager's Designee Letter" dated October 1, 2025, which reflected that E4 was designated as being in charge while E1 was away from the facility. 4. In an interview, E1 reported being unaware that E1's caregiver certification was not valid.

Based on record review, documentation review, and interview, the manager failed to ensure accurate documentation of the caregivers and assistant caregivers working each day, including the hours worked by each, was maintained. Findings include: 1. A review of E7's personnel record revealed a document titled "Application for employment" dated September 1, 2022, which reflected E7 applied for an assistant caregiver position and started the position on September 17, 2022. 2. A review of facility documentation revealed a "Monthly Work Schedule". The document did not reflect any hours worked by E7 in the facility. 3. In an interview, E1 reported E7 was currently employed and working as an assistant caregiver. E1 reported being unaware hours worked by assistant caregivers were required to be reflected on the facility's schedule.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed before providing assisted living services to a resident, for one of eight sampled caregivers and assistant caregivers. Findings include: 1. A review of E6's personnel record revealed no documentation of completed orientation. 2. A review of R3's medical record revealed E6 provided medication administration services to R3 during August 2023. 3. In an interview, E1 acknowledged E6's personnel record did not include documentation of orientation.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a "Lantus" insulin pen stored inside the refrigerator in the kitchen. The refrigerator was unlocked and accessible to residents. 2. In an interview, E1 acknowledged the insulin pen was not stored in a locked area.