The Ark of Arcadia Assisted Living LLC

Based on documentation review, observation, and interview, the governing authority failed to ensure that the Department was notified when there was a change in the manager. Findings include: 1. A review of Department documentation revealed email documentation from September 14, 2024, indicating that O1 was the facility's manager as of September 13, 2024. 2. While on-site, the Compliance Officer observed E2’s manager's certificate posted within the facility. [Note: This Compliance Officer had also observed E2's manager's certificate posted during the last inspection conducted on December 9, 2025.] 3. In an interview, E1 reported that E1 hadn't notified the Department of the change in manager. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. Technical assistance was provided on this rule at the compliance inspection conducted on December 9, 2025.

Based on record review, documentation review, and interview, the governing authority failed to ensure the health, safety, or welfare of the resident was not placed at risk of harm. The deficient practice posed a risk to the physical health and safety of the other residents. Findings include: 1. A review of facility documentation pertaining to R1 included a Tempe Police Department "Arrest / Booking" report, which indicated that R1 was arrested on February 8, 2026 on a warrant for being a "Fugitive From Justice" for six various charges. Also included was documentation from Mesa Municipal Court, which indicated that R1 was released on February 9, 2026, on the condition that R1 would appear in court for the various charges on March 4, 2026, and March 17, 2026. 2. A review of R1's medical record revealed a service plan dated February 16, 2026. Aside from SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion), Vascular Dementia, Muscle Weakness, Stimulant Abuse, and Unspecified abnormalities of gait and mobility, the medical diagnosis also included "Psychosis" and "Delusional Disorder," along with Major Depressive Disorder, Anxiety Disorder, and Adjustment Disorder. Further review of R1's medical record revealed that a Primary Care Physician or Medical Practitioner had not completed an assessment to indicate if R1's needs were within the scope of services of the assisted living home. There were also no medication orders for any medication other than the antibiotic (nitrofurantoin) that was prescribed as part of R1's discharge orders from the hospital on February 16, 2026, which had never been filled. 3. A review of Department documentation revealed that the mobile crisis team had determined that R1 had been "living with an untreated UTI" since R1's discharge from the hospital because the facility had yet to obtain the antibiotics ordered for R1 upon R1's release from the hospital. The documentation also indicated that R1 had been previously prescribed Amlodipine, Tamsulosin, and Sertraline, but hadn't had access to these medications "since being in this home." 4. In an interview, E1 stated that R1 had been seen by O2 on February 20, 2026; however, there was no evidence to indicate that R1 was actually seen. The "Consent for Resident's Stay in Facility" had not been completed or signed by O2 and there were no medication orders from O2. 5. In an interview, E3 stated that R1 had expressed having suicidal ideation several days after being admitted into the facility. E3 also stated that R1 appeared to be having withdrawal symptoms but refused to tell E3 what R1 was withdrawing from. When E3 discovered that the lock was missing from the refrigerator, the facility decided to call the crisis team because E3 believed R1 could potentially use the refrigerator lock to put around R1's neck and cause self-harm, due to the shape and strength of the lock. 6. While on-site, the Compliance Officer observed the back gate that led to the alley did not have a lo

Based on observation, documentation review, and interview, the manager failed to ensure that documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. The deficient practice also posed a risk as the Department was provided false or misleading information. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed E3 and E4 working at the facility independently at 9:05 AM. E3 and E4 are both live-in staff. E3 was the lead caregiver and E4 was an assistant caregiver. 2. A review of the facility's employee work schedule revealed a schedule for January 2026. There was no schedule available for February 2026. 3. Further review revealed a "Time of Shift" key in the bottom right corner of the January 2026 schedule that stated the following: "Manager (MWF) - 8am - 3pm; Caregiver (Mon/Fri) - 7am - 7pm; Reliever (Sat/Sun) - 7am-7pm." There is no documentation of a 7:00 PM to 7:00 AM shift on the schedule. 4. A review of the facility's policies and procedures revealed a policy titled "IX. Staffing." The policy stated, "7. A work schedule of all staff members who provide assisted living services to residents...is developed and maintained at the facility...The work schedule must contain facility name, dates, and a key of abbreviation (for names of working staff/volunteers, hours schedule, hours worked, etc)." 5. In an interview, E3 stated E3 had been gone on vacation for approximately a week in January 2026; however, E3 was the only caregiver listed as working on the schedule Monday through Friday for the entire month of January 2026, with no specified shift or hours for each day. E2 was listed as working every Saturday and Sunday, with no specified shift or hours. E3 was asked who covered for E3 when E3 was gone on vacation. E3 responded that E3 didn't know, but suspected that E1 must've scheduled relievers to work. E3 stated E3 didn't know who the relievers were, including the relievers that come on the weekends. E3 was then asked if E2 worked on the weekends as the schedule stated. E3 responded that E2 does not work on the weekends. E3 was asked the last time E3 saw E2. E3 was unable to answer. E3 was asked if E3 knew E2. E3 stated E3 did not know E2. 6. E1 later arrived at the home at approximately 10:25 AM. In an interview, E1 was asked who covered for E3 when E3 was on vacation. E1 stated, "E2." E1 was then specifically asked about the January 2026 schedule, which did not have documentation of E2 covering for E3, and asked to clarify who covered for E3 in January. E1 then stated, "E3 went on a vacation?! I don't think she did." 7. In an interview, R3 was asked if E2 worked at the home on the weekends. R3 responded "no," and that R3 didn't know who E2 was. R3 was asked who worked at the home o

Based on observation, interview, and record review, the manager failed to ensure that all employees had a personnel record as required, for one of three personnel records reviewed. The deficient practice posed a risk as required information could not be verified for E4. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed E3 and E4 working at the facility independently at 9:05 AM. E3 and E4 are both live-in staff. E3 was the lead caregiver and, according to E3, E4 was an assistant caregiver. 2. A review of the facility's employee work schedule revealed a schedule for January 2026. There was no schedule available for February 2026. 3. In an interview, E4 confirmed that E4 was an assistant caregiver. 4. A review of personnel records revealed E4 did not have a personnel record. 5. In an interview, E1 first acknowledged that E4 was an assistant caregiver. However, E1 later said, "E4 is in the process of creating a file and will be hired soon." 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in R9-10-113, for one of four residents reviewed. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of R4's medical record revealed no documentation of a negative TB test available for review at the time of the inspection. In addition, there was no documentation that a TB Risk Assessment/Signs & Symptoms Screening had been completed. Based on R4's date of admission, this documentation was required. 2. A review of the facility's policies and procedures revealed a policy titled "I. Admission A. Resident Acceptance / Residency Agreement." The policy stated, "4. A Manager shall ensure within 12 months prior to or within 7 days of acceptance each resident shall provide evidence of being free from pulmonary tuberculosis...A report of a Negative Mantoux Tuberculin (TB) skin test recorded along with the resident's name, date of injection, date read, the serum lot number, expiration and follow-up date (if applicable)..." Another policy titled "IV. Residency A. Resident Medical Records and Documentation," stated, "3. A Manager shall ensure that resident's medical records...contain...A copy of TB clearance." 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is an uncorrected deficiency from the compliance inspection conducted on December 9, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and the documentation was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for three of four residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a form titled "Consent for Resident's Stay in Facility." The heading of the form indicated that the form was "For PCP/Medical Practitioners and POA." The form had not been completed or signed by the PCP or medical practitioner. In the section that stated, "Please check any that applies:", nothing was checked off, including the statement that indicated "The resident's needs and retention can be met by the assisted living facility within the assisted living facility's scope of services." E1 had printed the nurse practitioner's name in the physician/nurse practitioner's signature line and dated the form. E1 wrote "refused" on the representative/POA signature line. In addition, the form did not include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. 2. A review of R3's medical record revealed a form titled "Consent for Resident's Stay in Facility." The heading of the form indicated that the form was "For PCP/Medical Practitioners and POA." The form had not been completed or signed by the PCP or medical practitioner. In the section that stated, "Please check any that applies:", nothing was checked off, including the statement that indicated "The resident's needs and retention can be met by the assisted living facility within the assisted living facility's scope of services." E1 had printed the nurse practitioner's name in the physician/nurse practitioner's signature line and dated the form. R3 signed on the representative/POA signature line along with a note from E1, which stated, "No POA - referred for Pub Fid." In addition, the form did not include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. 3. A review of R4's medical record revealed a form titled "Consent for Resident's Stay in Facility." The heading of the form indicated that the form was "For PCP/Medical Practitioners and POA." The form had been dated and signed by R2's POA; however, it had not been dated and signed by a PCP or medical practitioner. E1 had printed the nurse practitioner's name in the physician/nurse practitioner's signature line and dated the form. In addition, the form did not include whether t

Based on record review, documentation review, and interview, the manager failed to obtain either the signature of the resident, the resident’s representative, the resident’s legal guardian, or another individual who had been designated by the resident under A.R.S. § 36-3221 to make health care decisions on the resident’s behalf, on the documented residency agreement, before or within five working days after a resident’s acceptance by the assisted living facility, for one of four residents. The deficient practice posed a risk if the resident, the resident's representative, the resident's legal guardian, or another individual designated by the individual under A.R.S. § 36-3221 was not informed of the terms of residency. Findings include: 1. A review of R1's medical record revealed a Residency Agreement. On the line designated "Resident / POA Signature," E1 wrote "refused." 2. A review of the facility's policies and procedures revealed a policy titled "I. Admission A. Resident Acceptance / Residency Agreement." The policy stated, "It is the policy of the assisted living facility to have the resident or resident representative/legal guardian to sign the residency agreement on the day of the resident's acceptance...2. Acceptance of Residency shall contain:...The original copy of the residency agreement signed and dated...[by] the resident or legal guardian..." 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. Technical assistance was provided on this rule at the compliance inspection conducted on December 9, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident had a service plan that was completed and implemented no later than 14 calendar days after the resident’s date of acceptance, that included services pertaining to medication administration, and that was signed and dated by the resident or resident’s representative, the manager, and a nurse or medical practitioner, for one of four residents reviewed. The deficient practice posed a risk as there was no completed service plan to direct services to be provided to a resident. Findings include: 1. A review of R4's medical record revealed that a service plan had been initiated. The service plan indicated that R4 received directed care services. However, the service plan was missing the last page that included the medication administration section and the section designated for signatures of the "Service Plan Group Members," and therefore, was not complete. There was no other service plan available for review at the time of the inspection. 2. A review of the facility's policies and procedures revealed a policy titled "III. Services B. Service Plan." The policy stated, "6. The Management will ensure each resident's service plan is completed no later than 14 days after the resident's date of acceptance..." 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is an uncorrected deficiency from the compliance inspection conducted on December 9, 2025.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that was reviewed and updated at least once every three months for a resident receiving directed care services, for three of three applicable residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a service plan dated September 4, 2025. The service plan indicated that R2 received directed care services. There was no other updated service plan available for review at the time of the inspection. 2. A review of R3's medical record revealed a service plan dated September 2, 2025. The service plan indicated that R3 received directed care services. There was no other updated service plan available for review at the time of the inspection. 3. A review of R4's medical record revealed a service plan dated November 4, 2025. The service plan indicated that R4 received directed care services. The service plan was missing the last page that included the medication administration section and the section designated for signatures of the "Service Plan Group Members," therefore, the service plan was not complete. There was no other updated service plan available for review at the time of the inspection. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. Technical assistance was provided on this rule at the compliance inspection conducted on December 9, 2025.

Based on record review, interview, observation, and documentation review, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner, for two of four residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan dated February 16, 2026. The service plan indicated R1 received medication administration. On the signature page, E1 printed O2's (Physician's Assistant) name on the line designated for the "Nurse Signature;" E2's (manager) name on the line designated for "Facility Representative;" and "refused" on the line designated for "Resident/Representative." The rule required the service plan to be signed by each of the aforementioned individuals. 2. A review of R4's medical record revealed a service plan dated November 4, 2025. The service plan was missing the last page that included the medication administration section and the section designated for signatures of the "Service Plan Group Members." 3. In an interview, E3 stated that R4 received medication administration. 4. While on-site, the Compliance Officer observed that R4's medications were managed by the facility. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 6. Technical assistance was provided on this rule at the compliance inspection conducted on December 9, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided in the resident’s medical record for four of four residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan or as being needed or provided. Findings include: 1. A review of facility documentation revealed a binder titled "Activities of Daily Living - ADL." A review of the binder revealed there were no current ADL sheets for the month of February 2026 for R1, R2, R3, or R4. There were also no ADL sheets for January 2026 or December 2025. Further review revealed the only ADL's available for review for R2 and R3 were from October and November 2025; and the only ADL sheet available for review for R4 was from November 2025. 2. A review of R1's, R2's, R3's, and R4's medical records revealed no additional ADL's available for review. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. Technical assistance was provided on this rule at the compliance inspection conducted on December 9, 2025.

Based on documentation review, record review and interview, the manager failed to ensure that a resident’s medical record contained documentation of medication administered to the resident that included the date and time of administration and the name and signature of the individual administering the medication, for four of four residents reviewed. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. A review of facility documentation revealed a binder titled "MAR - Medication Administration Records." A review of the binder revealed there were no current MAR sheets for the month of February 2026 for R1, R2, R3, or R4. Further review revealed R2 had a fully completed MAR for December 2025, but the MAR for January 2026 only documented medication administration through January 20, 2026, and the rest was blank. R3's December 2025 and January 2026 MAR's were blank. R4 had a fully completed MAR for December 2025, but the MAR for January 2026 only documented medication administration through January 27, 2026, and the rest was blank. 2. A review of R1's, R2's, R3's, and R4's medical records revealed no additional MAR's available for review. 3. A review of the facility's policies and procedures revealed a policy titled "VI. Medications Services C. Medication Administration Record (MAR)." The policy stated, "The Manager shall ensure the personnel follows established procedures when providing residents assistance with medication administration...8. A medication administered to a resident...B. Is administered in compliance with a medication order...[and] E. Is documented in the resident's MAR." 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that the outside area was secure and that the back door alerted staff of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed ambulatory residents. The Compliance Officer also observed that the alert on the back door was not turned on and the door was not secured. The Compliance Officer observed at least one resident going in and out of the door various times and staying outside for long periods of time unsupervised. 2. While on-site in the back yard, the Compliance Officer observed the back gate that led to the alley did not have a lock on it, nor was there a working latch on the gate. There was one cinderblock on the ground up against the bottom of the gate, and one cinderblock on the ground on the opposite side of the gate. 3. A review of R1's, R2's, R3's, and R4's medical records revealed that all of the residents received directed care services. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. Technical assistance was provided on this rule at the compliance inspection conducted on December 9, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for two of four residents reviewed. The deficient practice posed a risk if the resident experiences a change in condition due to improper administration of medication. Findings include: 1. A review of Department documentation revealed information that R1 was prescribed an antibiotic (nitrofurantoin), which was to be picked up on February 16, 2026, "from R1's home pharmacy to treat a UTI." The information continued to state that on February 22, 2026, "the assisted living called crisis due to R1 stating he was experiencing suicidal ideation." Upon the mobile crisis unit's assessment of R1, they learned that R1 had never obtained R1's aforementioned antibiotics and had been living with an untreated UTI since R1's discharge from the hospital. Per the crisis team's report, R1 was also supposed to be taking Amlodipine, Tamsulosin, and Sertraline, however, "R1 has not had access to meds since being in this home." 2. A review of R1's medical record revealed "Discharge Orders" with "Medication Instructions" from O2 (attending physician) at Abrazo West Campus. R1 had been prescribed nitrofurantoin 100 MG oral capsule. R1 was to take the nitrofurantoin every 12 hours for seven (7) days. The instructions stated, "Pickup at Fry's Pharmacy...4440 E Main St, Mesa, AZ...(480)218-8573." Further review of R1's medical record revealed no medication administration record (MAR) to indicate R1 had ever been administered the medication. 3. In an interview, E1 confirmed that the prescription for R1 for nitrofurantoin had never been picked up from the pharmacy, and E3 confirmed that the medication had not been administered to R1. 4. A review of R3's medical record revealed a signed medication order dated December 30, 2025, to start Ranolazine 500 MG BID. The order also stated to "Hold Carvedilol 3.125 MG BID if SBP < 110" and to "Continue Isosorbide 5 MG BID. Hold if SBP < 90." 5. A review of the facility's binder titled "MAR - Medication Administration Records" revealed there was no current MAR sheets for the month of February 2026 for R3. R3 had a MAR for December 2025 and January 2026; however, there was no documentation of any medications being administered. In addition, on the MAR for January 2026, the Ranolazine 500 MG BID had not been added. Both the Carvedilol 3.125 MG BID and Isosorbide 5 MG BID were listed on the MAR, but the Carvedilol did not include the instructions to "Hold if SBP < 110" and the Isosorbide did not include the instructions to "Hold if SBP < 90." 6. A review of the facility's policies and procedures revealed a policy titled "VI Medications Services B. Medical Practitioner Order." The policy stated, "The manager or caregiver designated by a manager should enter the new order on the resident's medication record. In the next available space on the resident's

Based on observation, interview, and documentation review, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers and physical harm to residents. Findings include: 1. While on-site, the Compliance Officer observed ambulatory residents. The Compliance Officer also observed that the alert on the back door was not turned on and the door was not secured. The Compliance Officer observed at least one resident going in and out of the door various times and staying outside for long periods of time unsupervised. 2. While on-site in the back yard, the Compliance Officer observed that there were two ladders laying on the ground with other various old lawn equipment. There was an unsecure shed with the door open, and inside were various items piled on top of each other (metal poles, wood, Glidden paint, a large box, a metal bed frame, a weed whacker, etc). The door couldn't be opened past approximately 7-8 inches because the miscellaneous items were stacked up high and leaning against the door from the inside. There was also an elevated toilet seat assistive device along the side wall of the house. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. Technical assistance was provided on this rule at the compliance inspection conducted on December 9, 2025.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. While on-site, the Compliance Officer observed the cabinet under the kitchen sink was not locked or secured. Inside the cabinet were various items, including a 75-ounce container of Kroger brand dishwasher detergent. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis (TB) infection control activities that included annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a risk to the physical health and safety of the residents if the annual facility risk assessment had not been completed. Findings include: 1. A review of facility documentation revealed there was no documentation of an annual facility risk assessment to determine the facility's risk of exposure to infectious TB. 2. In an interview, E1 reported that E1 was unaware of the requirement to conduct an annual TB facility risk assessment. E1 acknowledged that the facility had not been conducting annual facility risk assessments to determine the facility's risk of exposure to infections TB.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for three of three applicable personnel reviewed. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411.C.1. states, "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." A.R.S. § 36-411.C.4. states, "Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to, on or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459...." 2. A review of E1's, E2's, and E3's personnel records revealed no documentation of an APS Registry Check. 3. A review of E3's personnel record revealed no 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 the assisted living home. 4. In an interview, E1 acknowledged that the governing authority failed to ensure compliance with A.R.S. § 36-411 for E1, E2, and E3.

Based on record review, documentation review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid (FA) training and cardiopulmonary resuscitation (CPR) training certification specific to adults for two of two applicable personnel reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "IX. Staffing A. 9. "At least one staff member who is trained in CPR and 1st Aid shall be within the facility at all times... C. Cardiopulmonary Resuscitation." The policy stated, "All staff must be trained in CPR before starting their job. The Manager shall ensure personnel have current cardiopulmonary resuscitation training documentation specific to adults upon hiring that includes demonstration, and that the certificate is still valid. This facility will only accept CPR and first aid training from one of the nationally recognized organizations: American Red Cross, American Heart Association, EMS Safety or National Safety Council First Aid, CPR & AED course...This facility uses Certified Adult CPR and First Aid Class Instructors not an online training program." 2. A review of E2's personnel record revealed a CPR/FA certificate that had been completed through American Heart Association, which expired in October 2025. On October 6, 2025, E2 took an online course through NationalCPRFoundation; however, E2 failed to participate in an in-person CPR training, which included a demonstration of E2's ability to perform CPR, and this CPR/FA training did not conform to the facility's P&Ps. Therefore, E2 has not had a valid CPR/FA certification since November 1, 2025. 3. A review of E3's personnel record revealed a current and valid CPR/FA certificate that had been completed through EMS Safety; however, the training was completed on August 25, 2025, and E3's date of hire was May 1, 2025. There was no other documentation of CPR/FA training prior to August 25, 2025. 4. In an interview, E3 stated E3 had worked at the home full-time since E3 started employment in May 2025, and that E3 was the only caregiver working on E3's assigned shifts. Therefore, E3 worked without a valid CPR/FA certification from May 1, 2025, until August 25, 2025. 5. A review of facility documentation revealed a posted employee work schedule for November 2025. E2 was the only caregiver scheduled to work on November 1, 2, 8, 9, 15, 16, 22, 23, and 30, 2025. Previous months' schedules and a December 2025 schedule were not available for review at the time of the inspection. 6. In an interview, E1 acknowledged that E2 did not have a current and valid CPR/FA certification, and that E3 did not have documentation of valid CPR/FA training until August 25, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in R9-10-113, for two of four residents reviewed. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of R2's medical record revealed no documentation of a negative TB test available for review at the time of the inspection. In addition, there was no documentation that a TB Risk Assessment/Signs & Symptoms Screening had been completed. Based on R2's date of admission, this documentation was required. 2. A review of R3's medical record revealed documentation that a TB Risk Assessment/Signs & Symptoms Screening had been completed; however, there was no documentation of a negative TB test available for review at the time of the inspection. Based on R3's date of admission, this documentation was required. 3. A review of the facility's policies and procedures revealed a policy titled "I. Admission A. Resident Acceptance / Residency Agreement." The policy stated, "4. A Manager shall ensure within 12 months prior to or within 7 days of acceptance each resident shall provide evidence of being free from pulmonary tuberculosis...A report of a Negative Mantoux Tuberculin (TB) skin test recorded along with the resident's name, date of injection, date read, the serum lot number, expiration and follow-up date (if applicable)..." Another policy titled "IV. Residency A. Resident Medical Records and Documentation," stated, "3. A Manager shall ensure that resident's medical records...contain...A copy of TB clearance." 4. In an interview, E1 acknowledged that the required aforementioned TB documentation for R2 and R3 was not available for review at the time of the inspection.

Based on record review, documentation review, and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility, and if an individual was expected to receive supervisory care services, personal care services, or directed care services, the documentation was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for one of four residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical record revealed a form titled "Consent for Resident's Stay in Facility." The heading of the form indicated the form was "For PCP/Medical Practitioners and POA." The form had been dated and signed by R2's POA; however, it had not been dated and signed by a PCP or medical practitioner. 2. A review of the facility's policies and procedures revealed a policy titled "I. Admission A. Resident Acceptance / Residency Agreement." The policy stated, "7. The Facility, authorized to provide assisted living services dependent upon criteria specified in Arizona Assisted Living Facility Regulations...[which] will include...the resident's Primary Care Provider who has examined the resident within 30 days...upon acceptance into the assisted living facility, signs and dates a statement authorizing residency at the assisted living facility." 3. In an interview, E1 explained that R2 had been evaluated by a doctor; however, since R2 was still pending fiduciary, the doctor chose not to sign off on the form. E1 acknowledged that R2's "Consent for Resident's Stay in the Facility" form had not been signed by a PCP or medical practitioner as required by rule.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, that was completed no later than 14 calendar days after the resident’s date of acceptance, for two of four residents reviewed. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed there had been no service plan established, documented, and implemented. Based on R2's date of admission, a completed service plan was required. 2. A review of R3's medical record revealed there had been no service plan established, documented, and implemented. Based on R3's date of admission, a completed service plan was required. 3. A review of the facility's policies and procedures revealed a policy titled "III. Services B. Service Plan." The policy stated, "6. The Management will ensure each resident's service plan is completed no later than 14 days after the resident's date of acceptance..." 4. In an interview, E1 acknowledged that R2 and R3 did not have service plans available for review at the time of the inspection, and that based on R2's and R3's dates of admission, service plans were required.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, which included the amount, type, and frequency of skin maintenance being provided to the resident, for one of two applicable residents reviewed. The deficient practice posed a risk if a resident's service plan did not include the specific services to be provided. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated June 20, 2025. Under the section titled "Skin care," the service plan stated, "Hydrate skin with lotion" and "Monitor skin integrity/Check pressure areas." However, the frequency of skin care was not noted. R1 had another service plan dated September 4, 2025, which indicated R1's skin was "Intact;" however, the following section titled "Skin care" was left blank. 2. In an interview, E1 acknowledged R1's service plans were missing the necessary requirements pertaining to skin maintenance.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, which included the amount, type, and frequency of skin maintenance being provided to the resident, for one of two applicable residents reviewed. The deficient practice posed a risk if a resident's service plan did not include the specific services to be provided. Findings include: 1. A review of R4's medical record revealed a service plan for directed care services dated July 2, 2025. Under the section titled "Skin condition," the service plan indicated R4 had a "Wound - gluteal (left)." However, there was no other documentation to indicate how to care for the wound. In addition, the following section, titled "Skin care," was left blank. R4 had another service plan dated September 2, 2025, which indicated "Fragile skin/bruising," and to "Hydrate skin with lotion." However, the frequency of skin care was not noted. 2. In an interview, E1 acknowledged R4's service plans were missing the necessary requirements pertaining to skin maintenance.