Sun City Care LLC

Based on documentation review, observation, interview, and record review, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, for three of three sampled staff. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of Department documentation revealed A.R.S. § 36-420.01(A) went into effect on October 1, 2021. 2. A review of facility documentation revealed a policy and procedure (P&P) titled “FALL PREVENTION AND FALL RECOVERY TRAINING.” The P&P stated: “E. Medical Director/Administrator/Manager - is responsible for ensuring that falls and fall-related injury prevention is: 6. Ensuring that all health care staff receive education about the falls and injury prevention program at the facility and understand the importance of complying with the interventions.” 3. The Compliance Officer observed E5 working at the facility. 4. In a series of interviews, E5 reported E5 started working at the facility on February 5, 2026. E3 reported E5 started on Saturday, February 7, 2026, and not on February 5, 2026. 5. A review of E5’s personnel record revealed E5 was hired as a caregiver on February 7, 2026. The review revealed documentation of training regarding fall prevention and fall recovery completed on December 15, 2025, before E5 was hired at this facility. However, the review revealed no such training upon hire. 6. In an interview, E3 reported E5 transferred to this facility from another and had not yet redone all required training. E3 further reported E7 was hired as a caregiver on January 23, 2026, and E8 was hired as an assistant caregiver on January 24, 2026. E3 reported E7 and E8 worked a little over a week. 7. A review of E7’s personnel record revealed E7 was hired as a caregiver on January 23, 2026. The review revealed documentation of training regarding fall prevention and fall recovery completed on April 23, 2024, before E7 was hired at this facility. However, the review revealed no such training upon hire. 8. In an interview, when the Compliance Officer requested E8’s personnel record, E3 reported E3 did not have it, stating, “[E8] took it.” 9. A review of personnel records revealed no personnel record for E8, including no documentation of training regarding fall prevention and fall recovery upon hire. 10. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. This is an uncorrected citation from the complaint and compliance inspection conducted on January 21-22, 2026.

Based on documentation review and interview, the health care institution failed to provide appropriate first aid before the arrival of emergency medical services (EMS) to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. The deficient practice posed a risk as a caregiver was unable to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “CPR, FIRST AID AND DUTY TO CARE.” The P&P stated: “The facility as a licensed healthcare institution, has an affirmative duty to care. Caregiving staff on duty are required to respond to resident emergencies by notifying emergency services and initiating CPR and/or First Aid to a resident until first responders arrive and relieve them…2. Should a resident experience a fall, appears to be uninjured, and is unable to reasonably recover independently, caregiving staff on duty will provide first aid following instructions received in their validated first aid training and in accordance with the residents advanced directives.” 2. In an interview, R2 reported R2 fell, called for help, did not get help from facility personnel, and called 911 for assistance getting back up. R2 reported EMS arrived and helped R2 back up. R2 reported R2 had not been hurt and had only needed help getting back up. 3. In an interview, E3 confirmed R2’s report. E3 reported R2 fell on February 1, 2026, and was unable to get back up without assistance. E3 reported R2 called for help but did not get any. E3 reported R2 then called 911 who showed up and helped R2 back up. E3 reported having a text message thread with E7 who was present at the facility when R2 fell. 4. A review of facility documentation revealed a text message thread between E3 and E7 dated February 2, 2026, between 12:12 AM and 9:34 AM. In the thread E7 stated, “[R2] call the police and they send over fire department and they break into the house this is not cool [R2] call them because [R2] was ringing [R2’s] bell and no one answered I’ve work all day today I must be tired [R2] doesn’t want nothing other than to sit in [R2’s] chair.” 5. In an interview, E3 confirmed E7 did not provide appropriate first aid before the arrival of EMS to R2 who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. 6. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. This is an uncorrected citation from the complaint and compliance inspection conducted on January 21-22, 2026.

Based on documentation review, observation, and interview, the governing authority failed to designate, in writing, a manager who had a certificate as an assisted living facility manager. The deficient practice posed a risk as the assisted living facility did not have a certified manager for more than eight days. Findings include: 1. A review of Department documentation revealed an email from E2 dated December 24, 2025, which stated, “Hi this email is to inform you that we extended my employment at sun city care llc.” The email stated E2’s new “End date [was] 01/31/2026.” 2. The Compliance Officer observed a copy of E2’s “DUPLICATE CERTIFICATE” as manager hanging on the wall in the entryway of the facility. 3. In an interview conducted before 11:00 AM, when the Compliance Officer asked who the current manager was, E3 stated it was E2 “as far as I know.” 4. In a telephonic interview conducted before 11:00 AM, when the Compliance Officer asked who the current manager was, O1 reported it was E2. When the Compliance Officer informed E1 of E2’s email to the Department on December 24, 2025, E1 reported not knowing E2 was no longer the manager. 5. In an interview, E3 reported having an email from E2 to the Department. 6. A review of facility documentation conducted at approximately 11:35 AM revealed a printout of a cell phone screenshot containing an email from E2 to the Department. The printout revealed the screenshot was taken at 11:14 AM, after the aforementioned interviews with E3 and O1. The printout revealed the email stated, “Hello im sorry to inform you late but the owner [E1] asked me to still be the manager of this grouphome until further notice.” 7. In an interview, when the Compliance Officer asked if E2 had sent the email during the inspection, E3 stated, “Yeah.” 8. A review of Department documentation confirmed E2 sent the email at 11:14 AM on the date of the inspection, after the interviews with E3 and O1. The review confirmed the contents of the email as well. 9. In the exit interview, when the Compliance Officer informed E3 the facility did not have a manager between February 1, 2026, and February 9, 2026, at 11:14 AM, E3 stated, “We don’t have one.”

Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C)(1-4), for three of three sampled employees. The deficient practice posed a risk as an employee was a documented danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(1-4) 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 [and] 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.” 2. The Compliance Officer observed E3 and E5 working at the facility. 3. A review of E3's personnel record revealed E3 was hired on December 17, 2024. The review revealed two printouts from the Adult Protective Services (APS) registry dated January 15, 2025, and September 16, 2025, respectively. The printout revealed documentation demonstrating E3 was not on the APS registry. 4. A review of the APS registry website revealed E3 was on the registry for neglect. The website stated: “Between approximately November 20 and December 17, 2019, [E3] failed to provide supervision to a vulnerable adult, which caused the vulnerable adult to need emergency intervention. Such conduct constitutes neglect pursuant to A.R.S. 46-451(A)(7).” 5. In an interview, E3 reported E3 was aware E3 was on the APS registry. 6. In a series of interviews, E5 reported E5 started working at the facility on February 5, 2026. E3 reported E5 started on Saturday, February 7, 2026, and not on February 5, 2026. 7. A review of E5’s personnel record revealed E5 was hired as a caregiver on February 7, 2026. The review revealed documentation of previous employment as well as a printout from the APS registry website. However, review revealed no documentation demonstrating a facility representative contacted E5’s previous employers. The review further revealed an individual from a different facility checked the APS registry on December 1, 2025. The review revealed a representative from this facility did not check the APS registry before E5 was hired. 8. In an interview, E3 reported the printout from the APS registry website was from a different facility before E5 was hired at this facility. E3 reported E5 transferred to this facility from another and had not yet redone all required documentation. E3 further reported E7 was hired as a caregiver on January 23, 2026, and worked a little over a week. 9. A review of E7’s personnel record revealed E7

Based on observation, interview, and documentation review, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility’s premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as there was incomplete documentation identifying the staff present and accountable for the assisted living facility and its residents. Findings include: 1. Upon arriving at the facility and entering at approximately 10:00 AM on February 9, 2026, the Compliance Officer observed E3, E4, E5, and E6 working at the facility. 2. The Compliance Officer observed a document titled “DELEGATION OF AUTHORITY,” dated December 15, 2024, posted in the entryway of the facility. The document stated: “Trained caregivers who are 21 years of age, to act in my behalf and to sign all documents as if I were physically present…Trained Caregivers Designee.” The document then listed E3 and three other caregivers as designees. 3. In an interview, E3 reported E3 had not fixed the delegation posting since the Compliance Officer brought it to E3’s attention during the inspection conducted on January 21-22, 2026. 4. A review of facility documentation revealed a series of personnel schedules dated between January 19, 2026, and February 9, 2026. The schedules did not include the names of the individuals listed on the “DELEGATION OF AUTHORITY” document other than E3. The schedules revealed the following: - E3 worked between 9:00 AM and 11:00 AM on January 1-23 and 26-30, 2026, and February 2-6 and 9, 2026; - E3 worked between 6:00 AM and 6:00 PM on February 1 and 8, 2026; and - E4, E5, E6, E7, E8, and E9 worked when E3 was not present at the facility. 5. In an interview, E3 reported E3 fixed the delegation posting during the inspection. 6. The Compliance Officer observed the newly created “DELEGATION OF AUTHORITY,” dated February 1, 2026, posted in the entryway of the facility. The document stated: “Trained caregivers who are 21 years of age, to act in my behalf and to sign all documents as if I were physically present…Trained Caregivers Designee.” The document then listed E3, E4, E5, E6, and E9 as designees. 7. A review of facility documentation revealed a series of personnel schedules dated between February 1, 2026, and February 9, 2026. The schedules revealed E8 and E9 worked when E3, E4, E5, E6, and E9 were not present at the facility. 8. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on January 21-22, 2026.

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. In an interview, R2 reported R2 fell, called for help, did not get help from facility personnel, and called 911 for assistance getting back up. 4. In an interview, E3 confirmed R2’s report. E3 reported R2 fell on February 1, 2026, and was unable to get back up without assistance. E3 reported R2 called for help but did not get any. E3 reported R2 then called 911 who showed up and helped R2 back up. E3 reported EMS searched the home for facility personnel and could not find any. In the process, E3 reported EMS banged on the caregiver bedroom door, heard no response, then broke into the caregiver room where E7 and E8 were. E3 reported having a text message thread with E7. 5. A review of facility documentation revealed a text message thread between E3 and E7 dated February 2, 2026, between 12:12 AM and 9:34 AM. In the thread E7 stated, “[R2] call the police and they send over fire department and they break into the house this is not cool [R2] call them because [R2] was ringing [R2’s] bell and no one answered I’ve work all day today I must be tired [R2] doesn’t want nothing other than to sit in [R2’s] chair.” 6. In an interview regarding the aforementioned incident with R2, E7, and E8, E3 reported believing E7 and E8 neglected R2. E3 reported E3 had spoken to E7 and E8 and stated, “You [two] are neglecting the residents.” When the Compliance Officer asked if E3 reported the suspected neglect to a peace officer or to the Adult Protective Services (APS) central intake unit. E3 stated, “The boss said [the boss] is going to report [E7 and E8] to APS.” E3 reported O1 was the boss and one of the governing authorities of the facility. 7. In a telephonic interview with O1, when the Compliance Officer asked if O1 reported the suspected neglect to a peace officer or APS, O1 stated, “No.” O1 reported O1 was not the governing authority of the facility or the “boss” as stated by E3. 8. A review of Department documentation in conjunction with the Arizona Corporation Commission website revealed O1 was not the one of the governing authorities of the facility.

Based on documentation review, observation, interview, and record review, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the individual provided physical health services, for one of two 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 and as the deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “CAREGIVER, ASSISTANT CAREGIVER AND VOLUNTEER.” The P&P stated: “The hiring person or manager will ensure, check, and document that each caregiver or assistant caregiver providing physical health services or behavioral health services have the required skills and knowledge before providing any service…The skills and knowledge are verified by the manager at the time of the orientation, before providing assisted living services to a resident, and documented based on the care levels and type of assisted living services expected to be provided by the facility and within the facility's scope of service, in accordance with the residents needs and to ensure the health and safety of the resident.” 2. A review of facility documentation revealed a personnel schedule which indicated E5 worked from 6:00 AM to 6:00 PM on February 7-9, 2026. The schedules revealed E5 worked no other times or dates. 3. The Compliance Officer observed E5 working at the facility. 4. In a series of interviews, E5 reported E5 started working at the facility on February 5, 2026. E3 reported E5 started on Saturday, February 7, 2026, and not on February 5, 2026. 5. A review of E5’s personnel record revealed E5 was hired as a caregiver on February 7, 2026. The review revealed a document titled “CAREGIVER SKILLS.” The document revealed an unknown individual verified and documented E5’s skills and knowledge on December 12, 2025, before E5 was hired at this facility. 6. In an interview, E3 reported the document was from another facility and not from this one. E3 reported E5 had not yet filled out all required documentation for this facility. 7. A review of E5’s personnel record revealed a newly created document titled “CAREGIVER SKILLS.” The document revealed E2 verified and documented E5’s skills and knowledge on February 7, 2026. The document indicated E2 and E5 signed and dated the document on February 7, 2026, two days before the date of the inspection. 8. In a series of interviews, E3 reported the document was signed and dated during the inspection and not on February 7, 2026, as documented. When the Compliance Officer asked when E5 signed and dated the document, E5 stated, “Today.” E3 further reported E2 was not at the facility on February 7, 2026. 9. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed medication administration records (MARs) and documentation of as

Based on documentation review, observation, record review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was incomplete documentation identifying the staff present each day to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING AND RECORD KEEPING.” The P&P stated: “7. A work schedule of all staff members who provides assisted living services to residents and volunteers is developed and maintained at the facility for at least 12 months from the date of the work schedule. The work schedule must contain facility name, dates and a key of abbreviation (for names of working staff/volunteers, hours scheduled, hours worked etc.) and the hours worked by each.” 2. Upon arriving at the facility and entering at approximately 10:00 AM on February 9, 2026, the Compliance Officer observed E3, E4, E5, and E6 working at the facility. 3. A review of facility documentation revealed a series of personnel schedules dated between January 19, 2026, and February 9, 2026. The schedules indicated the following: - E4 worked between 6:00 AM and 6:00 PM on January 19-21, 23-24, 26, and 31, 2026, and February 3-4, 6-7, and 9, 2026; - E5 worked between 6:00 AM and 6:00 PM February 7-9, 2026; - E6 worked between 6:00 AM and 6:00 PM on January 19-23 and 26-3, 2026, and February 2-6 and 9, 2026; - E7 worked between 6:00 AM and 6:00 PM on January 23-26 and 28-31, 2026, and February 1-2, 2026; - E8 worked between 6:00 PM and 6:00 AM on January 24-26 and 28-31, 2026, and February 1-2, 2026; - E9 worked between 6:00 PM and 6:00 AM on February 3-8, 2026; - No one worked between 6:00 PM and 6:00 AM on January 19-23 and 27, 2026. 4. In an interview, E6 reported E7 and E8 would often take very long lunches, stating, “[E7 and E8] left me alone for three or four hours.” 5. A review of E5’s personnel record revealed E5 was hired as a caregiver on February 7, 2026. 6. In an interview, E3 reported E5 started on Saturday, February 7, 2026, and not on February 5, 2026. E3 further reported E8 was hired as an assistant caregiver on January 24, 2026, and worked a little over a week. 7. A review of personnel records revealed no personnel record for E8, including no documentation 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). 8. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed medication administration records (MARs) and documentation of assisted living services (ADLs) provided to the eight residents, dated January 2026 through February 2026. However, the review revealed inconsistencies between the MARs and ADLs an

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled caregivers. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) 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…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. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)." 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 4. A review of facility documentation revealed a policy and procedure titled “INFECTION CONTROL.” The P&P stated: “All employees and residents of this facility are required to provide a report of a negative Mantoux Tuberculin (TB) skin test within 12 months of the date of employment or residence in the facility.” 5. A review of facility documentation revealed a series of personnel schedules that indicated E7 worked on January 23-26 and 28-31, 2026, and February 1-2, 2026. 6. In an interview, E3 reported E7 was hired as a caregiver on January 23, 2026, and worked for a little over a week. 7. A review of E7’s personnel record revealed E7 was hired as a caregiver on January 23, 2026. However, the review revealed no

Based on documentation review, observation, interview, and record review, the manager failed to ensure a caregiver received orientation specific to the duties to be performed by the caregiver before providing assisted living services to a resident, for one of two sampled caregivers. The deficient practice posed a risk if a caregiver or an assistant caregiver was unable to meet a resident's needs and as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “NEW EMPLOYEE ORIENTATION.” The P&P stated: “1. Before providing services by the assisted living facility to a resident, a manager, caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the manager, caregiver or assistant caregiver based upon the specified requirements in the policies and procedures as defined by the ‘Scope of Services.’...M. The New Orientation Checklist will be used to document the orientation process.” 2. A review of facility documentation revealed a personnel schedule that indicated E5 worked from 6:00 AM to 6:00 PM on February 7-9, 2026. The schedules revealed E5 worked no other times or dates. 3. The Compliance Officer observed E5 working at the facility. 4. In a series of interviews, E5 reported E5 started working at the facility on February 5, 2026. E3 reported E5 started on Saturday, February 7, 2026, and not on February 5, 2026. 5. A review of E5’s personnel record revealed E5 was hired as a caregiver on February 7, 2026. The review revealed an “EMPLOYEE ORIENTATION FORM.” The document revealed an unknown individual provided orientation to E5 on December 12, 2025, before E5 was hired at this facility. 6. In an interview, E3 reported the document was from another facility and not from this one. E3 reported E5 had not yet filled out all required documentation for this facility. 7. A review of E5’s personnel record revealed a newly created “EMPLOYEE ORIENTATION FORM.” The document revealed E2 provided orientation to E5 on February 7, 2026. The document indicated E2 and E5 signed and dated the document on February 7, 2026, two days before the date of the inspection. 8. In a series of interviews, E3 reported the document was signed and dated during the inspection and not on February 7, 2026, as documented. When the Compliance Officer asked when E5 signed and dated the document, E5 stated, “Today.” E3 further reported E2 was not at the facility on February 7, 2026. 9. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed medication administration records (MARs) and documentation of assisted living services (ADLs) provided to the eight residents, dated January 2026 through February 2026. The MARs and ADLs revealed E5 provided services on February 1-9, 2026. 10. In an interview, E5 reported E5 started working at the facility on February 5, 2026, then later reported E5 started working o

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of two sampled caregivers. The deficient practice posed a risk as 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 (CPR) AND FIRST AID.” The P&P stated: “1. Each manager, caregiver , and other applicable employees shall: a. Obtain CPR training specific to adults which includes a demonstration of the individual’s ability to perform CPR. (On-line programs do not meet this requirement unless they include a demonstration of the individual’s ability to perform CPR. b. Obtain first aid training specific to adults [and] c. Maintain current training in CPR and First Aid.” 2. A review of facility documentation revealed a series of personnel schedules which indicated E7 worked on February 1-2, 2026. 3. In an interview, E3 reported E7 was hired as a caregiver on January 23, 2026. 4. A review of E7’s personnel record revealed E7 was hired as a caregiver on January 23, 2026. The review revealed documentation of first aid and CPR training certification. However the training certification expired at the end of January 2026. The review revealed no current documentation of first aid and CPR training certification. 5. In an interview, when the Compliance Officer asked for E7’s current documentation of first aid and CPR training certification, E3 reported E3 told E7 to get retrained but E7 did not. 6. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. This is an uncorrected citation from the complaint and compliance inspection conducted on January 21-22, 2026, and a repeat citation from initial monitoring inspection conducted on September 21, 2023.

Based on documentation review, interview, and record review, the manager failed to ensure a personnel record for each employee included the items required by this rule, for one of four sampled employees. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of facility documentation revealed a series of personnel schedules dated between January 19, 2026, and February 9, 2026. The schedules indicated E8 worked on January 24-26, and 28-31, 2026, as well as on February 1-2, 2026. 2. In an interview, E3 reported E8 worked at the facility a little over a week. When the Compliance Officer requested E8’s personnel record, E3 reported E3 did not have it, stating, “[E8] took it.” 3. A review of personnel records revealed no personnel record for E8. 4. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. This is an uncorrected citation from the complaint and compliance inspection conducted on January 21-22, 2026, and a repeat citation from the initial monitoring inspection conducted on September 21, 2023.

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established and documented that included the amount, type, and frequency of assisted living services being provided to the resident, for two of two sampled residents. The deficient practice posed a risk as a service plan guides a resident’s care. Findings include: 1. A review of R1's and R2’s medical records revealed current service plans which indicated R1 and R2 were to receive assistance dressing. However, the service plans did not include the frequency of dressing assistance. 2. In an interview, E3 reported R1 and R2 received assistance with dressing two times per day. E3 acknowledged the service plans did not include the frequency dressing assistance. 3. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on January 21-22, 2026.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for one of two sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated November 15, 2025. The service plan indicated facility personnel were to “Check [R1’s] finger nails daily and clean as needed.” The review further revealed documentation of assisted living services (ADLs) provided to R1 dated January 2026 through February 2026. However, the ADLs indicated R1 did not receive nail care. 2. In an interview, E5 and E6 reported facility personnel did not check R1’s nails. E5 and E6 reported hospice provided this service. 3. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment.

Based on documentation review, interview, observation, and record review, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for eight of eight total residents. The deficient practice posed a risk as services could not be verified as provided against a service plan, and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “SERVICE PLANS.” The P&P stated: “B. A manager shall ensure that: 1. A caregiver or an assistant caregiver: f. Documents the services provided in the resident’s medical record.” 2. A review of facility documentation revealed a personnel schedule which indicated E5 worked from 6:00 AM to 6:00 PM on February 7-9, 2026. The schedules revealed E5 worked no other times or dates. 3. In a series of interviews, E5 reported E5 started working at the facility on February 5, 2026. E3 reported E5 started on Saturday, February 7, 2026, and not on February 5, 2026. E3 further reported R8 had been discharged and was no longer at the facility. 4. The Compliance Officer did not observe R8 at the facility. 5. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records conducted at approximately 3:00 PM revealed documentation of assisted living services (ADLs) provided to the eight residents, dated January 2026 through February 2026. The ADLs revealed documentation demonstrating the following: - E5 provided services on February 1-6, 2026, before E5’s date of hire and before E5 was included on the personnel schedules; - E5 provided services on the date of the inspection at 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM (in the future), including to R8 who had already been discharged; and - Facility personnel did not document all provided services on February 3-5 and 9, 2026. 6. In an interview, E5 reported E5 started working at the facility on February 5, 2026, then later reported E5 started working on February 7, 2026 . When the Compliance Officer asked why E5’s initials were present on the ADLs for February 1-6, 2026, E5 looked at the Compliance Officer and gave no response. Regarding the services documented as provided in the future, E5 reported E5 documented them by mistake. 7. In an interview, E3 reported facility personnel provided all services. However, E3 reported facility personnel did not document all services provided on February 3-5 and 9, 2026. 8. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. This is an uncorrected citation from the complaint and compliance inspection conducted on January 21-22, 2026, and a repeat citation from the compliance inspection conducted on April 14, 2025.

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 physical health and safety of residents. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “RESIDENT RIGHTS.” The P&P stated: “B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration.” The review further revealed a P&P titled “CPR, FIRST AID AND DUTY TO CARE.” The P&P stated: “The facility as a licensed healthcare institution, has an affirmative duty to care. Caregiving staff on duty are required to respond to resident emergencies by notifying emergency services and initiating CPR and/or First Aid to a resident until first responders arrive and relieve them…2. Should a resident experience a fall, appears to be uninjured, and is unable to reasonably recover independently, caregiving staff on duty will provide first aid following instructions received in their validated first aid training and in accordance with the residents advanced directives.” 2. In an interview, R2 reported R2 fell, called for help, did not get help from facility personnel, and called 911 for assistance getting back up. R2 reported emergency medical services (EMS) arrived and helped R2 back up. 3. In an interview, E3 confirmed R2’s report. E3 reported R2 fell on February 1, 2026, and was unable to get back up without assistance. E3 reported R2 called for help but did not get any. E3 reported R2 then called 911 who showed up and helped R2 back up. 4. A review of facility documentation revealed a text message thread between E3 and E7 dated February 2, 2026, between 12:12 AM and 9:34 AM. In the thread E7 stated, “[R2] call the police and they send over fire department and they break into the house this is not cool [R2] call them because [R2] was ringing [R2’s] bell and no one answered I’ve work all day today I must be tired [R2] doesn’t want nothing other than to sit in [R2’s] chair.” 5. In an interview regarding the aforementioned incident with R2, E7, and E8, E3 reported believing E7 and E8 neglected R2. E3 reported E3 had spoken to E7 and E8 and stated, “You [two] are neglecting the residents.” 6. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. This is an uncorrected citation from the complaint and compliance inspection conducted on January 21-22, 2026.

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. The Compliance Officer observed E5 open a drawer in the kitchen, grab a magnet key, open a cabinet in the kitchen, and return the magnet key to the drawer. 2. Later, the Compliance Officer opened the unlocked drawer and observed the magnet key. Using the magnet key, the Compliance Officer opened the cabinet E5 previously opened as well as one other cabinet nearby. Inside the cabinets, the Compliance Officer observed resident medical records. 3. In an interview, E3 reported knowing resident medical records needed to be protected from loss, damage, or unauthorized use. 4. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on January 21-22, 2026.

Based on documentation review, interview, record review, and observation, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the date and time of administration or assistance, and the name and signature of the individual administering or providing assistance in the self-administration of medication, for five of eight total residents, including one discharged resident. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "MEDICATION SERVICES.” The P&P stated: “[A.] Medication administration is not documented until the resident is seen taking them…14. The caregiver will put an initial in the MAR for the date and time the medication was given to the resident and the medications taken…28. Medication administration records will be filled out by the authorized personnel that are doing medication administration and/or assisting in self-administration only after observing the resident taking the medication. 29. Time and date will be recorded as well as the initials of the person that administered the medication or assisted in the self-administration of medication.” 2. A review of facility documentation revealed a personnel schedule which indicated E5 worked from 6:00 AM to 6:00 PM on February 7-9, 2026. The schedules revealed E5 worked no other times or dates. 3. In a series of interviews, E5 reported E5 started working at the facility on February 5, 2026. E3 reported E5 started on Saturday, February 7, 2026, and not on February 5, 2026. E3 further reported R8 had been discharged and was no longer at the facility. 4. A review of E5’s personnel record revealed E5 was hired as a caregiver on February 7, 2026. 5. The Compliance Officer did not observe R8 at the facility. 6. A review of R1’s, R3’s, R6’s, R7’s, and R8’s medical records conducted at approximately 3:00 PM revealed medication administration records (MARs) dated February 2026. The MARs revealed documentation demonstrating the following: - E5 administered medication on February 1-6, 2026, before E5’s date of hire and before E5 was included on the personnel schedules; - E5 administered medication to R1, R3, R6, and R7 on the date of the inspection at 8:00 PM (in the future); - E5 administered medication to R6 on February 10-11, 2026, at 8:00 AM (in the future); and - E5 administered medication to R8 on the date of the inspection at 8:00 PM (in the future and after R8s’ discharge) as well as on February 10, 2026, at 8:00 AM (also in the future). 7. In an interview, E5 reported E5 started working at the facility on February 5, 2026, then later reported E5 started working on February 7, 2026 . When the Compli

Based on record review, observation, interview, and documentation review, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. A review of R1’s and R2’s medical records revealed R1 and R2 were at the personal level of care and received personal care services. 2. The Compliance Officer observed a call button attached to R1’s bed. 3. In an interview, R1 reported R1’s call bell had not been working. R1 reported R1 had pressed it repeatedly after watching the superbowl on February 8, 2026. However, R1 stated, “No one came.” 4. In an interview, E3 reported the battery in R1’s call button had died. Turning to another caregiver, E2 asked if the caregiver had changed the battery. The caregiver reported the caregiver changed the battery. 5. In an interview, R2 reported R2 fell, called for help, did not get help from facility personnel, and called 911 for assistance getting back up. 6. In an interview, E3 confirmed R2’s report. E3 reported R2 fell on February 1, 2026, and was unable to get back up without assistance. E3 reported R2 called for help but did not get any. E3 reported R2 then called 911 who showed up and helped R2 back up. E3 reported EMS searched the home for facility personnel and could not find any. In the process, E3 reported EMS banged on the caregiver bedroom door, heard no response, then broke into the caregiver room where E7 and E8 were. E3 reported having a text message thread with E7. 7. A review of facility documentation revealed a text message thread between E3 and E7 dated February 2, 2026, between 12:12 AM and 9:34 AM. In the thread E7 stated, “[R2] call the police and they send over fire department and they break into the house this is not cool [R2] call them because [R2] was ringing [R2’s] bell and no one answered I’ve work all day today I must be tired [R2] doesn’t want nothing other than to sit in [R2’s] chair.” 8. In an interview, the Compliance Officer asked how facility personnel knew a resident pushed the resident’s call button. E5 reported a device in the kitchen displayed the resident’s room number and sounded an alert. 9. The Compliance Officer observed a call button in R2’s bedroom. Upon pushing the button, the Compliance Officer heard an alert sound in the kitchen. The Compliance Officer observed a device on one of the kitchen counters displaying R2’s bedroom number. After a moment, the Compliance Officer pushed the button again. However, the Compliance Officer heard no alert. The Compliance Officer pushed the button several more times and heard no further alerts. 10. In an interview, the Compliance Officer requested E6 push R1’s call button. 11. The Compliance Officer observed E6 walk away from the kitc

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. Upon arriving at the facility and entering at approximately 10:00 AM on February 9, 2026, the Compliance Officer observed the front door was unlocked and had an alert installed. However, the Compliance Officer observed the key was in the lock and the area outside the door was not secure. 3. In an interview, E3 reported the key had been stuck in the lock since the last time the Compliance Officer was at the facility on January 22, 2026, for a total of approximately 18 days. 4. The Compliance Officer observed a door leading from an accessible hallway to the backyard. The Compliance Officer observed the back door was unlocked, unable to be locked, and had an alert installed. However, the alert was set to the “Off” position and the door did not sound when the Compliance Officer opened it. The Compliance Officer further observed no monitoring system in place. 5. In an interview, E2 stated the alert on the back door was turned off “again.” 6. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. This is an uncorrected citation from the complaint and compliance inspection conducted on January 21-22, 2026.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident’s medical record, for one of two sampled residents. The deficient practice posed a risk as the medication could not be verified as administered against a medication order. Findings include: 1. A review of R2’s medical record revealed a current service plan that indicated R2 received medication administration. The review further revealed a medication administration record (MAR) dated February 2026. However, the MAR revealed no documentation demonstrating facility personnel administered R2’s medications on February 3-4 and 9, 2026. 2. In an interview, E3 reported facility personnel administered R2’s medications on February 3-4 and 9, 2026, but did not document the administration. 3. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on January 21-22, 2026.

Based on documentation review, observation, and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “MEDICATION SERVICES.” The P&P stated, “All resident medications must be secured in a locked storage area.” 2. The Compliance Officer observed a plastic bag on a shelf in the office area. In the bag, the Compliance Officer observed pharmacy bottles of divalproex, Eliquis, quetiapine, sodium chloride, and tamsulosin. 3. The Compliance Officer observed an unlocked refrigerator in the kitchen. Upon opening the refrigerator, the Compliance Officer observed a bottle of Visine eye drops in one of the door compartments and a medication lock box on the top shelf. The Compliance Officer observed the number wheel on the lock box was set to the code and the box was not locked. Upon opening the lock box, the Compliance Officer observed a variety of medication inside, including a bottle of Geri Care Artificial Tears, a bottle of bismuth subsalicylate, two bottles of insulin, and eight insulin pens. 4. In an interview, when the Compliance Officer asked why the medication lock box in the refrigerator was unlocked, E6 reported E6 did not know the code. E6 then asked, “[The medication lock box] needs to be locked?” The Compliance Officer reminded E6 the Compliance Officer informed E6 on both of those days the medication lock box needed to be locked when not in use. 5. The Compliance Officer observed a box of loperamide tablets on a tote in R1’s bedroom. 6. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no comment. This is an uncorrected citation from the complaint and compliance inspection conducted on January 21-22, 2026, and a repeat citation from the initial monitoring inspection conducted on September 21, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure a food menu was prepared at least one week in advance, conspicuously posted at least one calendar day before the first meal on the food menu was served, and included any food substitution no later than the morning of the day of meal service with a food substitution. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(54)(a-b) states: "'Conspicuously posted' means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. A review of facility documentation revealed a policy and procedure (P&P) titled “FOOD SERVICES.” The P&P stated: “1. A food menu: 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.” The review further revealed a P&P titled “MENU SUBSTITUTIONS.” The P&P stated: “A written, posted menu must be followed, with documentation made of any substitutions to the menu on the written menu…1. When changes are made to the pre-prepared menu by staff, ensure that the substitute items are selected from similar food groups…2. Document the date, original food served, nutritionally equivalent food served, and the reason for the substitution on the menu. Then, initial or sign next to the substitution.” 3. The Compliance Officer observed no food menu posted in the area where the public entered the premises of the health care institution. In the kitchen approximately 20 feet from the front door, the Compliance Officer observed a posted food menu dated February 2-8, 2026. 4. In an interview, E3 reported the current food menu was not posted. E3 reported E3 did not have the menu for the week of the inspection yet. 5. A review of facility documentation conducted at approximately 3:25 PM revealed a newly prepared food menu dated February 9-15, 2026. The menu included no food substitutions and indicated facility personnel were to have served barbeque chicken, mixed vegetables, ice cream, and juice or water for lunch and were to serve ham and cheese sandwiches, chips, and juice or water for dinner on the date of the inspection. 6. In an interview, E5 reported serving egg salad sandwiches, chips, fruit, ice cream or pudding, and orange juice or soda for lunch. E5 stated, “I didn’t give them what’s on the menu…even for dinner.” E5 reported E5 was not planning on serving ham and cheese sandwiches, chips, and juice or water for dinner. 7. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no further comment. This is an uncorrected citation from the complaint and compliance inspection conducted on January 21-22, 2026, a

Based on documentation review, observation, and interview, the manager failed to ensure meals and snacks provided by the assisted living facility were served according to posted menus. The deficient practice posed a risk as the governing authority and manager did not provide meals and snacks for the residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(54) states, “‘Conspicuously posted’ means placed at a location that is visible and accessible, and unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution.” 2. A review of facility documentation revealed a policy and procedure (P&P) titled “FOOD SERVICES.” The P&P stated: “Meals and snacks provided by the assisted living facility are served according to posted menus.” 3. The Compliance Officer observed no food menu posted in the area where the public entered the premises of the health care institution. In the kitchen approximately 20 feet from the front door, the Compliance Officer observed a posted food menu dated February 2-8, 2026. 4. In an interview, E3 reported the current food menu was not posted. E3 reported E3 did not have the menu for the week of the inspection yet. 5. A review of facility documentation conducted at approximately 3:25 PM revealed a newly prepared food menu dated February 9-15, 2026. The menu indicated facility personnel were to have served barbeque chicken, mixed vegetables, ice cream, and juice or water for lunch and were to serve ham and cheese sandwiches, chips, and juice or water for dinner on the date of the inspection. 6. In an interview, E5 reported serving egg salad sandwiches, chips, fruit, ice cream or pudding, and orange juice or soda for lunch. E5 stated, “I didn’t give them what’s on the menu” and “even for dinner.” E5 reported E5 was not planning on serving ham and cheese sandwiches, chips, and juice or water for dinner. 7. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on January 21-22, 2026.

Based on interview and record review, the manager failed to ensure a resident was provided a diet that met the resident’s nutritional needs as specified in the resident’s service plan, for one of two sampled residents. The deficient practice posed a risk as a resident was placed at risk of harm. Findings include: 1. In an interview, R1 reported a new caregiver had tried to give R1 fish as part of a meal. R1 reported R1 was allergic to fish. When asked if R1 ate the fish, R1 stated, “No.” 2. A review of R1’s medical record revealed a current service plan which stated R1 was allergic to “Seafood.” 3. In an interview, E3 reported the new caregiver did not know R1 was allergic to seafood before giving R1 fish to eat. 4. In the exit interview, the Compliance Officer reviewed the findings and E3 and E3 offered no comment.

Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented the items required by this rule. The deficient practice posed a potential risk as an incident was not documented in a timely manner. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “REPORT OF UNUSUAL OCCURRENCE.” The P&P stated: “In the event of a resident accident, incident or injury involving residents and might results in resident requiring medical services, the Report of Unusual Occurrence will be filled out completely to document the incident and address corrective actions to prevent future reoccurrence. Incident Reports must be filled out completely and accurately and must not contain opinions or conclusions. They must consist only of facts, direct observations, and witness statements. The form must be filled out immediately following the incident. The following is a list of common incidents requiring completion of an Incident Report: fall with no apparent injury.” The review further revealed a P&P titled “INCIDENT REPORTS.” The P&P stated: “An incident report will be completed if a resident, staff member, or visitor experiences an accident, emergency, or injury that results in the resident needing medical services, incident that is unusual, improper or harmful. Examples are: Falls…5. Documentation will include the following: a. The date and time of the accident, emergency, or injury. b. A description of the accident, emergency, or injury. C. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver. E. The individuals notified by the caregiver or assistant caregiver; and f. Any action taken to prevent accidents, emergencies, or injury from occurring in the future.” 2. In an interview, R2 reported R2 fell, called for help, did not get help from facility personnel, and called 911 for assistance getting back up. 3. In an interview, E3 confirmed R2’s report. E3 reported R2 fell on February 1, 2026, and was unable to get back up without assistance. E3 reported R2 called for help but did not get any. E3 reported R2 then called 911 who showed up and helped R2 back up. E3 reported having a text message thread with E7 who was present at the facility when R2 fell. 4. A review of facility documentation revealed a text message thread between E3 and E7 dated February 2, 2026, between 12:12 AM and 9:34 AM. In the thread E7 stated, “[R2] call the police and they send over fire department and they break into the house this is not cool [R2] call them because [R2] was ringing [R2’s] bell and no one answered I’ve work all day today I must be tired [R2] doesn’t want nothing other than to sit in [R2’s] chair.” At 9:34 AM, E3 responded, stating, “Hey forgot can you make an incident report what happened la

Based on documentation review, observation, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, for ten of ten sampled staff. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of Department documentation revealed A.R.S. § 36-420.01(A) went into effect on October 1, 2021. 2. The Compliance Officer observed E2, E3, and E4 working at the facility. 3. A review of facility documentation revealed a policy and procedure (P&P) titled “FALL PREVENTION AND FALL RECOVERY TRAINING.” The P&P stated: “E. Medical Director/Administrator/Manager - is responsible for ensuring that falls and fall-related injury prevention is: 6. Ensuring that all health care staff receive education about the falls and injury prevention program at the facility and understand the importance of complying with the interventions.” 4. A review of E1’s personnel record revealed E1 was hired as the manager on October 13, 2023. The review revealed documentation of training regarding fall prevention and fall recovery completed on January 21, 2025. However, the review revealed no such training upon hire. 5. A review of E2’s personnel record revealed E2 was hired as a caregiver/manager designee on December 17, 2024. The review revealed documentation of training regarding fall prevention and fall recovery completed on June 20, 2025. However, the review revealed no such training upon hire. 6. A review of E3’s personnel record revealed E3 was hired as a caregiver on July 16, 2025. The review revealed documentation of training regarding fall prevention and fall recovery completed on October 27, 2025. However, the review revealed no such training upon hire. 7. A review of E4’s personnel record revealed E4 was hired as a caregiver on January 20, 2026. However, the review revealed no documentation of training regarding fall prevention and fall recovery upon hire. 8. In an interview, E4 stated, “I just working for two days here” then clarified E4 started working at the facility on January 20, 2026. 9. In a separate interview, E2 reported not knowing E4 had been hired. E2 reported E4 was still in the process of filling out an application and E2 did not yet have E4’s credentials including E4’s training regarding fall prevention and fall recovery. 10. A review of E5’s personnel record revealed E5 was hired as a caregiver on December 15, 2024. The review revealed documentation of training regarding fall prevention and fall recovery completed on June 29, 2024, and March 18, 2025. However, the review revealed no such training upon hire. 11. A review of E6’s personnel record revealed E6 was hired as an assistant caregiver on April 1, 2025. The review revealed documentation of training regarding fall prevention and fall recovery completed on May 17, 2024. However, the review r

Based on documentation review, record review, and interview, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder (EMS). The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “EMERGENCY RESPONDERS; RESIDENT INFORMATION; HOSPITAL DISCHARGE SB1157.” The P&P stated: “Staff shall document when emergency responders are contacted and provide a copy of the documentation to emergency responders and hospital personnel. 36-420.04. PROCEDURES: 1. An assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency provider a written document that includes all of the following.” The P&P continued by listing the items required by this statute then stated, “If the emergency responder transports the resident to a hospital, the emergency responder shall be provided with a copy of all the above documents listed.” 2. A review of R2’s medical record revealed a document titled "PROGRESS NOTE.” The document included a note for January 6, 2026, which stated: “[R2] went to hospital by 911 at 1:55 AM. [R2] can’t breath and over fluid.” 3. A review of facility documentation revealed no standardized form for R2 or copy of such a form given to EMS, which included the information prescribed in this statute. 4. In an interview, when the Compliance Officer asked if R2 had a standardized form in compliance with this statute, E2 stated, “No.” E2 reported facility personnel did not provide any written document with all required information to EMS because the facility did not have one. 5. In the exit interview, the Compliance Officer reviewed the findings and E2 and E2 offered no further comment.

Based on documentation review, record review, and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9), for two of two sampled residents. The deficient practice posed a risk if an emergency responder was not aware of critical health information for a resident. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “EMERGENCY RESPONDERS; RESIDENT INFORMATION; HOSPITAL DISCHARGE SB1157.” The P&P stated: “Staff shall document when emergency responders are contacted and provide a copy of the documentation to emergency responders and hospital personnel. 36-420.04. PROCEDURES: 1. An assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency provider a written document that includes all of the following.” The P&P continued by listing the items required by this statute, then stated, “The assisted living home must maintain a standardized form for each resident that includes the information prescribed above and shall periodically update this form for each resident as necessary.” However, the review revealed no such standardized forms for R1 and R2. 2. A review of R1’s and R2’s medical records revealed no standardized forms for R1 and R2 which included the information prescribed in A.R.S. § 36-420.04(A)(1-9). 3. In an interview, when the Compliance Officer asked if R1 and R2 had standardized forms in compliance with this statute, E2 stated, “No.” 4. In the exit interview, the Compliance Officer reviewed the findings and E2 and E2 offered no further comment. This is a repeat citation from the compliance inspection conducted on April 14, 2025.

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. The deficient practice posed a risk as a caregiver was unable to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “CPR, FIRST AID AND DUTY TO CARE.” The P&P stated: “The facility as a licensed healthcare institution, has an affirmative duty to care. Caregiving staff on duty are required to respond to resident emergencies by notifying emergency services and initiating CPR and/or First Aid to a resident until first responders arrive and relieve them…2. Should a resident experience a fall, appears to be uninjured, and is unable to reasonably recover independently, caregiving staff on duty will provide first aid following instructions received in their validated first aid training and in accordance with the residents advanced directives.” 2. In an interview conducted on January 21, 2026, the Compliance Officer asked if any residents had experienced falls recently. E2 reported no residents had fallen recently. The Compliance Officer requested quality management documentation, including documentation of any recent incidents, including falls. E2 again reported no residents had fallen recently. 3. A review of facility documentation conducted on January 21, 2026, revealed no quality management documentation regarding recent incidents, including falls. 4. In an interview conducted on January 21, 2026, R6 reported R6 fell out of bed late at night on January 19, 2026, or early in the morning on January 20, 2026. R6 reported the caregiver on duty tried to help R6 back into bed but was unable to do so. R6 stated another resident called 911 for R6 “because [the caregiver] couldn’t get me up.” 5. In an interview conducted on January 21, 2026, E3 reported R6 slid out of bed on Monday, January 19, 2026. E3 reported asking R6 if R6 was injured then stated, “[R6] told me no injury.” E3 reported E3 checked the facility for a hoyer lift. E3 reported calling E10 who was working at a nearby assisted living home at the time of the incident. E3 reported E10 told E3 not to use the hoyer lift and that E10 would come to the facility to help lift R6 instead. E3 reported E3 had waited for E10 for one hour when E3 noticed emergency medical services (EMS) inside the facility. E3 reported another resident let EMS into the facility so EMS could assist R6. E3 stated, “[EMS] lifted [R6] up.” When the Compliance Officer asked how long R6 had been on the floor, E3 stated, “More than an hour.” 6. In an interview conducted on January 21, 2026, E2 reported E2 had been unaware of the incident and confirmed having no documentation of the incident. 7. A review of facility documentation conducted on January 22, 2026, revealed a document ti

Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C)(1-4), for six of ten sampled employees. The deficient practice posed a risk as an employee was a documented danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(1-4) 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 [and] 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.” 2. On January 21, 2026, the Compliance Officer observed E2 and E4 working at the facility. 3. A review of facility documentation revealed a series of personnel schedules which indicated the following: - E2 worked multiple shifts each week between January 1, 2025, and January 22, 2026; - E4 worked on January 16, and 19-21, 2026; - E6 worked multiple shifts nearly each week between March 31, 2025, and January 22, 2026; - E7 worked multiple shifts nearly each week between March 17, 2025, and January 11, 2026; - E9 worked multiple shifts nearly each week between December 1, 2025, and January 4, 2026; and - E10 worked on January 16-19, 2026. 4. A review of E2's personnel record revealed E2 was hired on December 17, 2024. The review revealed two printouts from the Adult Protective Services (APS) registry dated January 15, 2025, and September 16, 2025, respectively. The printout revealed documentation demonstrating E2 was not on the APS registry. 5. A review of the APS registry website revealed E2 was on the registry for neglect. The website stated: “Between approximately November 20 and December 17, 2019, [E2] failed to provide supervision to a vulnerable adult, which caused the vulnerable adult to need emergency intervention. Such conduct constitutes neglect pursuant to A.R.S. 46-451(A)(7). 6. In an interview, E2 reported E2 was aware of a case against E2 and had gone to court for it. E2 stated “the case was dropped.” When the Compliance Officer requested documentation demonstrating the case was dropped and E2 was no longer on the APS registry, E2 reported E2’s boss at the time reported having documentation verifying E2’s claims. However, E2 reported E2’s boss provided no such documentation to E2. 7. A review of E4’s personnel record revealed E4 was hired as a caregiver on January 20, 2026, in opposition to the personnel schedule. The review revealed a current fingerprint clearance card (FCC). However, the re

Based on documentation review, observation, record review, and interview, the manager failed to ensure a caregiver's and assistant caregiver’s skills and knowledge were verified and documented before the individual provided physical health services, and according to policies and procedures, for two of five sampled caregivers and one of four sampled assistant caregivers. The deficient practice posed a risk if a caregiver or an assistant 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 policy and procedure (P&P) titled “CAREGIVER, ASSISTANT CAREGIVER AND VOLUNTEER.” The P&P stated: “The hiring person or manager will ensure, check, and document that each caregiver or assistant caregiver providing physical health services or behavioral health services have the required skills and knowledge before providing any service…The skills and knowledge are verified by the manager at the time of the orientation, before providing assisted living services to a resident, and documented based on the care levels and type of assisted living services expected to be provided by the facility and within the facility's scope of service, in accordance with the residents needs and to ensure the health and safety of the resident.” 2. A review of the facility's personnel schedules indicated the following: - E4 worked on January 16, and 19-21, 2026; - E9 worked multiple shifts nearly each week between December 1, 2025, and January 4, 2026; and - E10 worked on January 16-19, 2026. 3. The Compliance Officer observed E4 working at the facility. 4. A review of E4’s personnel record revealed E4 was hired as a caregiver on January 20, 2026. However, the review revealed no documentation of E4’s skills and knowledge. 5. In an interview, E4 stated, “I just working for two days here” then clarified E4 started working at the facility on January 20, 2026. 6. In a separate interview, E2 reported not knowing E4 had been hired. E2 reported E4 was still in the process of filling out an application, and E2 did not yet have E4’s credentials including E4’s documented and verified skills and knowledge. 7. A review of E9’s personnel record revealed E9 was hired as an assistant caregiver on December 1, 2025. However, the review revealed no documentation of E9’s skills and knowledge. 8. In an interview, E2 reported E9’s entire personnel record was for another facility. 9. In an interview, E3 and E4 reported E10 came to the facility to help lift a resident. E3 and E4 reported E10 worked at another assisted living facility nearby. 10. A review of facility documentation revealed a document titled “INCIDENT REPORT FORM” which indicated R6 fell out of bed on January 20, 2026. The document listed E10 as an individual “who observed the accident, incident, or injury.” 11. A review of E10’s personnel record revealed no documentation of E9’s skills and knowledge. 12. In an interview, E2 confirmed E10’s enti

Based on documentation review and interview, the manager failed to ensure an assisted living facility had caregivers and assistant 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 to the physical health and safety of the residents. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING AND RECORDKEEPING.” The P&P stated: “5. The facility licensee/governing authority will hire personnel: manager, caregivers, assistant caregivers, will contact services with outside companies to: b. Meet the needs of the residents and c. Ensure the health and safety of the residents.” The review further revealed a P&P titled “CPR, FIRST AID AND DUTY TO CARE.” The P&P stated: “The facility as a licensed healthcare institution, has an affirmative duty to care. Caregiving staff on duty are required to respond to resident emergencies by notifying emergency services and initiating CPR and/or First Aid to a resident until first responders arrive and relieve them…2. Should a resident experience a fall, appears to be uninjured, and is unable to reasonably recover independently, caregiving staff on duty will provide first aid following instructions received in their validated first aid training and in accordance with the residents advanced directives.” 2. In an interview conducted on January 21, 2026, the Compliance Officer asked if any residents had experienced falls recently. E2 reported no residents had fallen recently. The Compliance Officer requested quality management documentation, including documentation of any recent incidents, including falls. E2 again reported no residents had fallen recently. 3. A review of facility documentation conducted on January 21, 2026, revealed no quality management documentation regarding recent incidents, including falls. 4. In an interview conducted on January 21, 2026, R6 reported R6 fell out of bed late at night on January 19, 2026, or early in the morning on January 20, 2026. R6 reported the caregiver on duty tried to help R6 back into bed but was unable to do so. R6 stated another resident called 911 for R6 “because [the caregiver] couldn’t get me up.” 5. In an interview conducted on January 21, 2026, E3 reported R6 slid out of bed on Monday, January 19, 2026. E3 reported asking R6 if R6 was injured then stated, “[R6] told me no injury.” E3 reported E3 checked the facility for a hoyer lift. E3 reported calling E10 who was working at a nearby assisted living home at the time of the incident. E3 reported E10 told E3 not to use the hoyer lift and that E10 would come to the facility to help lift R6 instead. E3 reported E3 had waited for E10 for one hour when E3 noticed emergency medical services (EMS) inside the facility. E3 reported another resident let EMS into the facility so EMS could assist R6. E3 stated, “[EMS] lifted [R6] up.” Wh

Based on documentation review, observation, record review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was incomplete documentation identifying the staff present each day to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING AND RECORD KEEPING.” The P&P stated: “7. A work schedule of all staff members who provides assisted living services to residents and volunteers is developed and maintained at the facility for at least 12 months from the date of the work schedule. The work schedule must contain facility name, dates and a key of abbreviation (for names of working staff/volunteers, hours scheduled, hours worked etc.) and the hours worked by each.” 2. Upon arriving at the facility and entering at approximately 1:15 PM on January 21, 2026, the Compliance Officer observed E3 and E4 working at the facility. The Compliance Officer observed no other facility personnel. At approximately 1:45 PM, the Compliance Officer observed E2 enter the facility. 3. A review of R1’s and R2’s medical records revealed medication administration records (MARs) dated January 2026. The MARs indicated the following: - E5 administered medications as early as 6:00 AM and as late as 10:00 PM on January 1-9, 2026; - E2 administered medications as early as 6:00 AM and as late as 10:00 PM on January 10-19, 2026; and - E3 administered medications as early as 6:00 AM and as late as 10:00 PM on January 19-21, 2026. 4. A review of facility documentation revealed a series of personnel schedules that indicated the following: - E2 worked from 9:00 AM to 11:00 AM on January 1-2, 5-9, 12-15, and 19-21, 2026; - E2 did not work before 9:00 AM or after 11:00 AM on January 10, 12-15, and 19, 2026, in opposition to the MARs; - E2 did not work on January 11 and 16-18, 2026, in opposition to the MARs; - E3 worked from 6:00 AM to 6:00 PM on January 19-21, 2026; - E3 did not work after 6:00 PM on January 19-21, 2026, in opposition to the MARs; - E4 was not on the schedule for January 21, 2026; - E5 worked from 6:00 AM to 6:00 PM on January 1-21, 2026; and - E5 did not work after 6:00 PM on January 1-9, 2026, in opposition to the MARs. 5. In an interview, E3 and E4 reported E10 came to the facility to help lift a resident. E3 and E4 reported E10 worked at another assisted living facility nearby. 6. A review of facility documentation revealed a document titled “INCIDENT REPORT FORM” which indicated R6 fell out of bed on January 20, 2026. The document listed E10 as an individual “who observed the accident, incident, or injury.” 7. In an interview conducted on January 21, 2026, when the Compliance Officer brought the aforementioned discrepancies to E2’s attention, E2 reported the MARs were cor

Based on documentation review, observation, record review, and interview, the manager failed to ensure a manager, a caregiver, and an assistant caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for five of seven sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) 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…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. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)." 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 4. A review of facility documentation revealed a policy and procedure titled “INFECTION CONTROL.” The P&P stated: “All employees and residents of this facility are required to provide a report of a negative Mantoux Tuberculin (TB) skin test within 12 months of the date of employment or residence in the facility.” 5. A review of the facility's personnel schedules indicated the following: - E3 worked on July 15-19, 2025, and January 14-22, 2026; - E4 worked on January 16, and 19-21, 2026; - E6 worked multiple shifts nearly each week between March 31, 2025, and January 22, 2026; - E7 worked multiple shifts nearly each week between March 17, 2025, and Janu

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver and an assistant caregiver received orientation specific to the duties to be performed by the caregiver and assistant caregiver before providing assisted living services to a resident, for one of five sampled caregivers and one of four sampled assistant caregivers. The deficient practice posed a risk if a caregiver or an assistant caregiver was unable to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “NEW EMPLOYEE ORIENTATION.” The P&P stated: “1. Before providing services by the assisted living facility to a resident, a manager, caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the manager, caregiver or assistant caregiver based upon the specified requirements in the policies and procedures as defined by the ‘Scope of Services.’...M. The New Orientation Checklist will be used to document the orientation process.” 2. A review of the facility's personnel schedules indicated E9 worked multiple shifts nearly every week between December 1, 2025, and January 4, 2026, and E10 worked on January 16-19, 2026. 3. A review of E9’s personnel record revealed E9 was hired as an assistant caregiver on December 1, 2025. However, the review revealed no documentation demonstrating E9 received orientation training. 4. In an interview, E2 reported E9’s entire personnel record was for another facility. 5. In a separate interview, E3 and E4 reported E10 came to the facility to help lift a resident. E3 and E4 reported E10 worked at another assisted living facility nearby. 6. A review of facility documentation revealed a document titled “INCIDENT REPORT FORM” which indicated R6 fell out of bed on January 20, 2026. The document listed E10 as an individual “who observed the accident, incident, or injury.” The review further revealed a personnel schedule which indicated E10 worked on January 16-19, 2026. 7. A review of E10’s personnel record revealed documentation from another facility and not this one. The review revealed no documentation demonstrating E10 received orientation training. 8. In an interview, E2 confirmed E10’s entire personnel record was for another facility. E2 reported E10 did not really start working at this facility and only came a few times to help the caregivers here. 9. In the exit interview, the Compliance Officer reviewed the findings and E2 and E2 offered no further comment. This is a repeat citation from the compliance inspection conducted on April 14, 2025, and the on-site abbreviated initial follow-up inspection conducted on September 21, 2023.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for three of five 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 (CPR) AND FIRST AID.” The P&P stated: “1. Each manager, caregiver , and other applicable employees shall: a. Obtain CPR training specific to adults which includes a demonstration of the individual’s ability to perform CPR. (On-line programs do not meet this requirement unless they include a demonstration of the individual’s ability to perform CPR. b. Obtain first aid training specific to adults [and] c. Maintain current training in CPR and First Aid.” 2. A review of the facility's personnel schedule indicated the following: - E3 worked on July 15-19, 2025, and January 14-22, 2026; - E4 worked on January 16, and 19-21, 2026; and - E5 worked daily since November 1, 2025. 3. The Compliance Officer observed E3 and E4 working at the facility. 4. A review of E3’s personnel records revealed E3 was hired as a caregiver on July 16, 2025. The review revealed a printout of E3's CPR training certification from NationalCPRFoundation dated as issued on July 14, 2025. However, the review revealed no other CPR training certification. 5. A review of the NationalCPRFoundation website revealed the CPR training was online-only and did not include a demonstration of the recipient's ability to perform CPR. 6. In an interview, when the Compliance Officer asked if E3 had any CPR training certification that included a demonstration of E3's ability to perform CPR, E3 stated, “Not yet.” 7. A review of E4’s personnel record revealed E4 was hired as a caregiver on January 20, 2026. However, the review revealed no documentation of first aid training and CPR training certification specific to adults. 8. In an interview, E4 stated, “I just working for two days here” then clarified E4 started working at the facility on January 20, 2026. 9. In a separate interview, E2 reported not knowing E4 had been hired. E2 reported E4 was still in the process of filling out an application, and E2 did not yet have E4’s credentials, including E4’s first aid training and CPR training certification specific to adults. 10. A review of E5’s personnel record revealed E5 was hired as a caregiver on December 15, 2024. The review revealed documentation of first aid and CPR certification dated as expired at the end of October 2025. However, the review revealed no first aid training and CPR training certification after October 2025. 11. In the exit interview, the Compliance Officer reviewed the findings and E2 and E2 offered no

Based on documentation review, 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 residents were alone with an individual who was not a certified caregiver. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING AND RECORD KEEPING.” The P&P stated: “6. At least one manager or caregiver is present at the facility when a resident is on the premises. For nighttime hours the manager or caregiver present at the facility is awake and able to hear and respond to the resident needing assistance.” 2. A review of the facility's personnel schedules dated between March 17, 2025, and January 22, 2026, revealed the following: - E6 worked alone as an assistant caregiver from 6:00 PM to 6:00 AM on March 31, 2025, through April 30, 2025; May 5, 2025, through November 30, 2025; and January 5-15, 2026; - E7 worked alone as an assistant caregiver from 6:00 PM to 6:00 AM on March 17-18, 21, 26, and 29, 2026; and April 2 and 5, 2025; and - E9 worked alone as an assistant caregiver from 6:00 PM to 6:00 AM on December 1, 2025, through January 4, 2026. The review further revealed no documentation demonstrating the manager or a caregiver was present at the facility on the above dates and times when only an assistant caregiver was scheduled to work. 3. A review of E6’s personnel record revealed E6 was hired as an assistant caregiver on April 1, 2025. The review revealed no 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 (caregiver certificate) for E6. 4. A review of E7’s personnel record revealed E7 was hired as an assistant caregiver on February 24, 2025. The review revealed no caregiver certificate for E7. 5. A review of E9’s personnel record revealed E9 was hired as an assistant caregiver on December 1, 2025. The review revealed no caregiver certificate for E9. 6. A review of the caregiver certificate verification website (azcg.tmutest.com) revealed no valid caregiver certificates under E6's and E7’s names. The website revealed E9 received a caregiver certificate on January 9, 2026. 7. In an interview, E2 reported E9 quit the week of the inspection. E2 stated, “Sometimes we don’t have a caregiver.” E2 reported caregivers did not want to work at the facility due to R2’s behavior. E2 reported E9 became a certified caregiver shortly before E9 quit. E2 stated, “Before that, we didn’t have anybody here.” 8. In the exit interview, the Compliance Officer reviewed the findings and E2 and E2 offered no further comment.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a personnel record for each employee included the items required by this rule, for four of ten sampled employees. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING AND RECORD KEEPING.” The P&P stated: “1. The facility manager shall ensure that the personnel record for each employee or volunteer: a. Includes: i. The individual’s name, date of birth, and contact telephone number; ii. The starting date of employment or volunteer service and, if applicable, the ending date; [and] iii. Documentation of: the individual’s completed orientation [and] documentation of compliance with the requirements in A.R.S. §36-41 1(A) and (C) (DPS fingerprinting clearance requirements). 2. The Compliance Officer observed E4 working at the facility. 3. A review of E4’s personnel record revealed E4 was hired as a caregiver. However, the review revealed no documentation of E4’s contact telephone number, E4’s starting date of employment, and documentation of E4’s completed orientation. 4. In an interview, E4 stated, “I just working for two days here” then clarified E4 started working at the facility on January 20, 2026. 5. In a separate interview, E2 reported not knowing E4 had been hired. E2 reported E4 was still in the process of filling out an application and E2 did not yet have E4’s credentials. including E4’s contact telephone number. E2 reported E4 completed orientation training but did not have have the orientation documented. 6. A review of E5’s personnel record revealed E5 was hired as a caregiver. However, the review revealed no documentation of E5’s ending date of employment. 7. In an interview, E2 reported E5 recently terminated E5’s employment at the facility. E2 confirmed E5’s personnel record did not include E5’s ending date of employment. 8. A review of E9’s personnel record revealed E9 was hired as a caregiver. However, the review revealed no documentation of E9’s ending date of employment. 9. In an interview, E2 reported E9 quit the week of the inspection. E2 confirmed E9’s personnel record did not include E9’s ending date of employment. 10. In an interview, E3 and E4 reported E10 came to the facility to help lift a resident. E3 and E4 reported E10 worked at another assisted living facility nearby. 11. A review of facility documentation revealed a document titled “INCIDENT REPORT FORM” which indicated R6 fell out of bed on January 20, 2026. The document listed E10 as an individual “who observed the accident, incident, or injury.” The review further revealed a personnel schedule which indicated E10 worked on January 16-19, 2026. 12. A review of E10’s personnel record revealed no documentation of E10’s starting date of employment. 13. In an interview, E2 confirmed E10’s entire personnel record was for another faci

Based on documentation review, record review, and interview, the manager failed to ensure a resident had a service plan that was established and documented that, when initially developed and when updated, was signed and dated by all required parties, for two of two sampled residents. The deficient practice posed a health and safety risk if the required individuals did not acknowledge and agree to the services that were to be provided. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “SERVICE PLANS.” The P&P stated: “[A] manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident’s representative [and] b. The manager.” 2. A review of R1’s medical record revealed a service plan dated December 17, 2025. However, the service plan was not signed and dated by the manager. 3. A review of R2’s medical record revealed a service plan dated July 19, 2025. However, the service plan was not dated by R2 or R2’s representative. 4. In the exit interview, the Compliance Officer reviewed the findings and E2 and E2 offered no further comment. This is a repeat citation from the compliance inspection conducted on April 14, 2025, and the on-site abbreviated initial follow-up inspection conducted on September 21, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for nine of nine total residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “SERVICE PLANS.” The P&P stated: “B. A manager shall ensure that: 1. A caregiver or an assistant caregiver: f. Documents the services provided in the resident’s medical record.” 2. A review of R1’s medical record conducted at approximately 3:20 PM on January 21, 2026, revealed documentation of assisted living services (ADLs) provided to R1 dated January 2026. The ADLs revealed no documentation of any assisted living services provided to R1 on January 21, 2026, other than encouraging R1 to drink fluids. The review revealed documentation demonstrating facility personnel provided a variety of services to R1 several times a day on other days. A secondary review of the ADLs conducted at approximately 4:00 PM on January 22, 2026, revealed documentation demonstrating the following - R1 had a bowel movement at 6:00 PM on January 22, 2026, two hours in the future; - R1 received 6 night checks; and - Facility personnel did not provide oral care on January 1-9, 2026. 3. In an interview, when the Compliance Officer asked who brushed R1’s teeth, E3 stated, “We clean them.” 4. In a separate interview, E4 reported R2 left for a medical appointment at approximately 10:30 AM on January 20, 2026, and did not return. E2 reported terminating R2’s residency agreement effective immediately on January 20, 2026. 5. A review of R2’s medical record conducted at approximately 1:50 PM on January 22, 2026, revealed ADLs provided to R2 dated January 2026. The ADLs revealed R2 ate lunch and dinner and E3 provided multiple assisted living services to R2 as late as 10:00 PM, even though R2 was not at the facility after 10:30 AM on January 20, 2026. 6. A review of R3’s medical record conducted at approximately 3:20 PM on January 21, 2026, revealed ADLs provided to R3 dated January 2026. The ADLs revealed the following: - E3 encouraged R3 to drink fluids at 6:00 PM on January 21, 2026, more than two hours in the future; - E3 checked on R3 at 8:00 PM and 10:00 PM on January 21, 2026, each several hours in the future; and - E3 turned R3 in bed at 10:00 PM on January 21, 2026, several hours in the future. 7. In an interview regarding the night check documented in the future, E3 stated, “That’s wrong.” E3 reported E3 documented the service by mistake. 8. A review of R4’s medical record conducted at approximately 3:20 PM on January 21, 2026, revealed ADLs provided to R4 dated January 2026. The ADLs revealed E3 provided oral care to R4 at 8:00 PM on January 21, 2026, several hours in the future. 9. A review of R5’s medical record conducted at approximately 3:25 PM on Jan

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 physical health and safety of residents. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “RESIDENT RIGHTS.” The P&P stated: “B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration.” The review further revealed a P&P titled “CPR, FIRST AID AND DUTY TO CARE.” The P&P stated: “The facility as a licensed healthcare institution, has an affirmative duty to care. Caregiving staff on duty are required to respond to resident emergencies by notifying emergency services and initiating CPR and/or First Aid to a resident until first responders arrive and relieve them…2. Should a resident experience a fall, appears to be uninjured, and is unable to reasonably recover independently, caregiving staff on duty will provide first aid following instructions received in their validated first aid training and in accordance with the residents advanced directives.” 2. In an interview conducted on January 21, 2026, the Compliance Officer asked if any residents had experienced falls recently. E2 reported no residents had fallen recently. The Compliance Officer requested quality management documentation, including documentation of any recent incidents, including falls. E2 again reported no residents had fallen recently. 3. A review of facility documentation conducted on January 21, 2026, revealed no quality management documentation regarding recent incidents, including falls. 4. In an interview conducted on January 21, 2026, R6 reported R6 fell out of bed late at night on January 19, 2026, or early in the morning on January 20, 2026. R6 reported the caregiver on duty tried to help R6 back into bed but was unable to do so. R6 stated another resident called 911 for R6 “because [the caregiver] couldn’t get me up.” 5. In an interview conducted on January 21, 2026, E3 reported R6 slid out of bed on Monday, January 19, 2026. E3 reported asking R6 if R6 was injured then stated, “[R6] told me no injury.” E3 reported E3 checked the facility for a hoyer lift. E3 reported calling E10 who was working at a nearby assisted living home at the time of the incident. E3 reported E10 told E3 not to use the hoyer lift and that E10 would come to the facility to help lift R6 instead. E3 reported E3 had waited for E10 for one hour when E3 noticed emergency medical services (EMS) inside the facility. E3 reported another resident let EMS into the facility so EMS could assist R6. E3 stated, “[EMS] lifted [R6] up.” When the Compliance Officer asked how long R6 had been on the floor, E3 stated, “More than an hour.” 6. In an interview conducted on January 21, 2026, E2 reported E2 had been unaware of the incident and confirmed having no documentation of the incident. 7. A review of facility documentation conducted on January 22,

Based on documentation review, observation, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the date and time of administration or assistance, and the name and signature of the individual administering the medication, for three of nine total residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "MEDICATION SERVICES.” The P&P stated: “[A.] Medication administration is not documented until the resident is seen taking them…14. The caregiver will put an initial in the MAR for the date and time the medication was given to the resident and the medications taken…28. Medication administration records will be filled out by the authorized personnel that are doing medication administration and/or assisting in self-administration only after observing the resident taking the medication. 29. Time and date will be recorded as well as the initials of the person that administered the medication or assisted in the self-administration of medication.” 2. The Compliance Officer observed R1’s medication bottles and R1’s medication organizer. The Compliance Officer observed the following: - One tablet each of Amlodipine Besylate 5 mg, Aspirin 81 mg, Famotidine 20 mg, Losartan 50 mg, Omeprazole 40 mg, and one multi-vitamin in the 8:00 AM slots of the medication organizer; - One tablet each of Cetirizine HCL 10 mg and Sertraline HCL 50 mg in the 8:00 PM slots of the medication organizer; and - No medication bottle or pharmacy-provided multi-dose package of Olanzapine 7.5 mg. 3. A review of R1’s medical record revealed a medication administration record (MAR) dated January 2026. The MAR revealed documentation demonstrating the following: - Facility personnel documented administering R1’s Famotidine daily at both 8:00 AM and 8:00 PM and not solely at 8:00 AM as observed in the medication organizer; - Facility personnel documented administering R1’s Sertraline daily at 8:00 AM and not at 8:00 PM as observed in the medication organizer; and - Facility personnel documented administering R1’s Olanzapine daily at 8:00 PM without having the medication at the facility. 4. In a series of interviews, E3 reported E3 did not administer R1’s Olanzapine but documented it as administered by mistake. E3 reported not knowing the last time R1 received R1’s Olanzapine. When the Compliance Officer asked who filled R1’s medication organizer, E2 stated, “Me.” E2 reported taking over filling the medication organizers from E5 after E5 terminated E5’s employment. E2 stated R2’s bottle of Olanzapine was empty “this Saturday past.” E2 acknowledged facility personnel documented the incorrect times and dates of medication adminis

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. At approximately 2:15 PM on January 21, 2026, the Compliance Officer observed the front door was unlocked and had an alert installed. However, the key was in the lock, the alert was set to the “Off” position, and the door did not sound when the Compliance Officer opened it. The Compliance Officer further observed no monitoring system in place. The Compliance Officer observed a door leading from an accessible hallway to the backyard. The Compliance Officer observed the back door was unlocked, unable to be locked, and had an alert installed. However, the alert was set to the “Off” position and the door did not sound when the Compliance Officer opened it. The Compliance Officer further observed no monitoring system in place. 3. In an interview, when the Compliance Officer asked why the alerts on the front and back doors were turned off, Ee and E3 stated, “Don’t know.” When the Compliance Officer asked who turned off the alerts, E3 stated, “Don’t know.” Speaking to E3 and E4 and referring to the key to the front door, E2 stated, “Don’t leave the key by the door.” 4. The Compliance Officer observed E2 remove the key from the front door and place it in a dish on a stand near the front door. 5. Upon arriving at the facility and entering at approximately 1:30 PM on January 22, 2026, the Compliance Officer again observed the key in the front door and the alert on the front door set to the “Off” position. Upon opening the door, the Compliance Officer heard no alert. The Compliance Officer further observed no monitoring system in place. 6. Upon leaving the facility at approximately 7:30 PM on January 22, 2026, the Compliance Officer observed the key to the front door stuck in the front door lock. 7. In the exit interview, the Compliance Officer reviewed the findings and E2 and E2 reported the key was stuck in the front door lock.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a current service plan which indicated R1 received medication administration. The review revealed a medication order for “Famotidine 20mg Tablet…1 tab Oral Twice a day” and “Sertraline Hydrochloride 50mg Tablet…1 Tablet Oral Daily.” The review revealed no medication order for Olanzapine 7.5 mg. The review revealed a medication administration record (MAR) dated January 2026. The MAR revealed the following: - R1 received Famotidine at 8:00 AM and 8:00 PM on January 1-21, 2026; - R1 received Olanzapine at 8:00 PM on January 1-19, 2026, without an order; and - R1 received Sertraline at 8:00 AM on January 1-21, 2026. 2. The Compliance Officer observed R1’s medication bottles and R1’s medication organizer. The Compliance Officer observed the following: - R1’s Sertraline for Monday, January 19, 2026, still in the medication organizer; - No Famotidine in any of the the evening slots of the medication organizer; and - No Olanzapine. 3. In a series of interviews, when the Compliance Officer asked who filled R1’s medication organizer, E2 stated, “Me.” E2 reported taking over filling the medication organizers from E5 after E5 terminated E5’s employment. E2 stated R2’s bottle of Olanzapine was empty “this Saturday past.” E2 reported caregivers took the medications from the medication organizer, placed the medications in a cup, and administered the medications to the residents from the cup. E2 confirmed R1 had not been receiving R1’s evening dose of Famotidine, and R1 did not receive R1’s Sertraline on January 19, 2026. E2 reported not knowing when R1 last received the Olanzapine. 4. A review of R2’s medical record revealed a current service plan which indicated R2 received medication administration. The review revealed a medication order for “Levothyroxine 75mcg 1-tab po Qd.” The review revealed no medication orders for Clonidine 0.1 mg, Doxazosin Mesylate 1 mg, Furosemide 80mg, Gabapentin 100 mg, Levofloxacin 750 mg, or discontinue orders for Levothyroxine 75 mcg. The review further revealed a MAR dated January 2026. The MAR revealed the following: - R2 received Clonidine 0.1 mg one to three times a day on January 1-5, 9, and 11-19, 2026, without an order; - R2 received Doxazosin mesylate 1 mg once a day on January 1-5, 9, and 11-19, 2026, without an order; - R2 received Furosemide 80 mg once a day on January 1-2, 4-5, 9, and 11-20, 2026, without an order; - R2 received Gabapentin 100 mg twice a day on January 1-2, 4-5, 9, and 11-19, 2026, without an order; - R2 received Levofloxacin 750 mg once on January 5, 2026, without an order; and - R2 did not receive Levothyroxine 75mcg on January

Based on documentation review, observation, interview, and record review, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “MEDICATION SERVICES.” The P&P stated, “All resident medications must be secured in a locked storage area.” 2. The Compliance Officer observed an open metal tin on a counter in the kitchen. Sitting in the open tin, the Compliance Officer observed bottles of ammonium lactate, amoxicillin, Geri-Tussin, and two small containers with handwritten labels made of tape that stated, “LAXATIVE.” 3. In an interview, when the Compliance Officer asked what the laxative was, E3 and E4 reported not knowing, with E3 stating, “We were not in them.” 4. At approximately 1:40 PM on January 21, 2026, the Compliance Officer observed an unlocked refrigerator in the kitchen. Upon opening the refrigerator, the Compliance Officer observed a bottle of Visine eye drops in one of the door compartments, a bottle of Geri Care Artificial Tears on the top shelf, and a medication lock box also on the top shelf. The Compliance Officer observed the number wheel on the lock box was set to the code and the box was not locked. Upon opening the lock box, the Compliance Officer observed a variety of medication inside, including a bottle of bismuth subsalicylate, two bottles of insulin, and 16 insulin pens. 5. In an interview conducted shortly after the aforementioned observation, when the Compliance Officer asked why the medication lock box in the refrigerator was not locked, E4 reported believing E3 had just given a resident insulin. E4 stated E3 “forgot to lock [the box].” 6. A review of R1’s, R3’s, R4’s, R5’s, R6’s, R7’s, R8’s, and R9’s medical records revealed medication administration records (MARs) dated January 2026. Zero of the eight MARs indicated any of the medications inside the lock box were administered at the time the Compliance Officer observed the unlocked lock box. However, R8’s MAR indicated R8 was to receive insulin at 11:00 AM, more than an hour and a half before the Compliance Officer observed the unlocked lock box. 7. The Compliance Officer observed a freestanding cabinet in the office area. The Compliance Officer observed the key in the lock to the cabinet. The Compliance Officer observed E2 arrive at the facility at approximately 1:45 PM on January 21, 2026, and remove the key from the medication cabinet shortly thereafter. 8. In an interview, E2 reported the cabinet was used to store medication. When the Compliance Officer mentioned the key had been left in the lock of the cabinet, E2 confirmed, stating it “was there.” When the Compliance Officer informed E2 the medication lock box in the ref

Based on documentation review, observation, and interview, the manager failed to ensure a food menu was prepared at least one week in advance, conspicuously posted at least one calendar day before the first meal on the food menu was served, and included any food substitution no later than the morning of the day of meal service with a food substitution. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(54)(a-b) states: "'Conspicuously posted' means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. A review of facility documentation revealed a policy and procedure (P&P) titled “FOOD SERVICES.” The P&P stated: “1. A food menu: 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.” The review further revealed a P&P titled “MENU SUBSTITUTIONS.” The P&P stated: “A written, posted menu must be followed, with documentation made of any substitutions to the menu on the written menu…1. When changes are made to the pre-prepared menu by staff, ensure that the substitute items are selected from similar food groups…2. Document the date, original food served, nutritionally equivalent food served, and the reason for the substitution on the menu. Then, initial or sign next to the substitution.” 3. The Compliance Officer observed a food menu posted in the kitchen and not conspicuously posted. The Compliance Officer observed the posted menu was dated January 12-18, 2026, the week prior to the date of the inspection. 4. In an interview, E2 reported the current food menu was not posted. E2 reported E2 still needed to prepare the menu and post it. 5. A review of facility documentation conducted at approximately 1:45 PM on January 21, 2026, revealed the newly prepared food menu dated January 19-25, 2026. The menu included no food substitutions and indicated facility personnel served spaghetti, garlic bread, juice or water, and ice cream for lunch and would be serving fried fish sandwiches, chips, and juice or water for dinner. 6. The Compliance Officer observed what appeared to be chicken thawing in a pot of water on a kitchen counter. 7. In an interview, when the Compliance Officer asked what the residents ate for lunch, E4 stated, “I make some mac and cheese with meatloaf.” When the Compliance Officer asked what the residents would be eating for dinner, E4 stated, “I’m gonna make some chicken with potatoes and salad.” 8. A review of facility documentation conducted at approximately 4:40 PM on January 22, 2026, revealed a posted food menu dated January 19-25, 2026. The menu included no food substitutions and indicated facility personnel serv

Based on documentation review, interview, and record review, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented the items required by this rule. The deficient practice posed a potential risk as an incident was not documented in a timely manner. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “REPORT OF UNUSUAL OCCURRENCE.” The P&P stated: “In the event of a resident accident, incident or injury involving residents and might results in resident requiring medical services, the Report of Unusual Occurrence will be filled out completely to document the incident and address corrective actions to prevent future reoccurrence. Incident Reports must be filled out completely and accurately and must not contain opinions or conclusions. They must consist only of facts, direct observations, and witness statements. The form must be filled out immediately following the incident. The following is a list of common incidents requiring completion of an Incident Report: fall with no apparent injury.” The review further revealed a P&P titled “INCIDENT REPORTS.” The P&P stated: “An incident report will be completed if a resident, staff member, or visitor experiences an accident, emergency, or injury that results in the resident needing medical services, incident that is unusual, improper or harmful. Examples are: Falls…5. Documentation will include the following: a. The date and time of the accident, emergency, or injury. b. A description of the accident, emergency, or injury. C. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver. E. The individuals notified by the caregiver or assistant caregiver; and f. Any action taken to prevent accidents, emergencies, or injury from occurring in the future.” 2. In an interview conducted on January 21, 2026, the Compliance Officer asked if any residents had experienced falls recently. E2 reported no residents had fallen recently. The Compliance Officer requested quality management documentation, including documentation of any recent incidents, including falls. E2 again reported no residents had fallen recently. 3. A review of facility documentation conducted on January 21, 2026, revealed no quality management documentation regarding recent incidents, including falls. 4. In an interview conducted on January 21, 2026, R6 reported R6 fell out of bed late at night on January 19, 2026, or early in the morning on January 20, 2026. R6 reported the caregiver on duty tried to help R6 back into bed but was unable to do so. R6 stated another resident called 911 for R6 “because [the caregiver] couldn’t get me up.” 5. In an interview conducted on January 21, 2026, E3 reported R6 slid out of bed on Monday, January 19, 2026. E3 reported asking R6 if R6 was injured then stated,

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of six employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work... C. Owners 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..." Findings include: 1. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of September 2023. The personnel record revealed a fingerprint clearance card issued October 17, 2020, however, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution. In addition, E3's record did not contain documentation of good faith efforts to verify the current status of a E3's fingerprint clearance card. 2. Review of the Department of Public Safety (DPS) fingerprint clearance card database on September 26, 2023, revealed E3's fingerprint clearance card was valid. 3. In an interview, E1 acknowledged documentation was not available showing E3's work references were obtained and fingerprint clearance card was verified with DPS upon hire at this facility.

Based on record review and interview, the manager failed to ensure a caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of six caregivers. The deficient practice posed a risk if the employees were unable to meet resident's needs. Findings include: 1. Review of E3's personnel record revealed E3 worked as a facility caregiver and had a hire date of September 2023. The personnel record revealed no documentation showing E3 had received orientation specific to the duties to be performed. 2. In an interview, E1 acknowledged documentation was not available showing E3 had received orientation specific to the duties to be performed.

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, before providing assisted living services, for one of six caregivers. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "First Aid and CPR Training" reviewed and signed by E1 August 2023. This policy stated "The hiring person will require that each new employee or volunteer to have First Aid training from a first aid training organization..." 2. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of September 15, 2023. The personnel record revealed no documentation of first aid and CPR training. 3. Review of the September 2023 personnel schedule did not identify E3. In an interview with E1, it was reported E3 "came over last week from other facility owned". E1 reported E3 "covers the evening shift from 7AM-7PM". 4. In an interview, E1 acknowledged documentation was not available showing E3 had documentation of first aid and CPR training.

Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as required information could not be verified for E4, and the Department was provided false and misleading information. Findings include: 1. When the Compliance Officer arrived at the facility, E2, E3, and E4 were the only employees at the facility. 2. The compliance Officer observed E4 administer medication to R1. 3. In an interview, E2 reported E4 worked as a caregiver. 4. In an interview, E2 reported E4 started work at the facility a few weeks ago and is scheduled during the day. 5. Review of the personnel records revealed no record for E4. 6. In an interview, E1 acknowledged a personnel record was not established for E4.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for two of three residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated September 1, 2023. However, this service plan did not include a signature and date from the resident or representative. 2. Review of R2's medical record revealed current written service plans for directed care services dated August 21, 2023. However, the service plan did not include a signature and date from the resident or representative. 3. In an interview, E1 acknowledged R1's and R2's service plans did not include a signature and date from the resident or representative.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed Lorazapam unlocked in the kitchen refrigerator. 2. In an interview, E2 acknowledged medication was stored unlocked.