The Enclave at Anthem Senior Living

Based on documentation review and interview, the assisted living center failed to provide a written document which covered A.R.S § 36-420.04.A.1-9, when the assisted living center contacted an emergency responder on behalf of the resident, for one of one resident sampled. Findings include: 1 . A review of R1's medical record revealed an incident where R1 was sent to the hospital by the facility on October 16, 2025. However, documentation of a written document presented to emergency medical services (EMS) that included all items covered under A.R.S § 36-420.04.A.1-9 was not available for review. 2 . In an exit interview with E1 and E2, the finding was discussed and no additional information was provided.

Based on record review and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to health and safety. Findings include: 1. Review of R1’s medical record revealed a note dated February 18, 2026. This note indicated R1's POA was upset about a man going into R1's apartment. E1 reported the "man" was an independent living resident who came to the Assisted Living dining room for meals and activities. The note further reported “went to speak with the resident...reported O1 walked R1 back to the apartment from the dining room and O1 offered to open the door..R1 reported O1 asked what R1 was doing and R1 answered just watching the Olympics...R1 stated there was a "nurse" in the apartment taking vitals signs." 2. In an interview with E2, the Compliance Officer asked who the "nurse" reference in the note was. E2 stated, "Some nurse comes in to see R1 and takes vitals. The family has hired the nurse, and we don't know what company or what all they do." 3. In an interview with R1 and R1's POA, it was revealed that R1 was transported to the Hospital in October 2025 for difficulty breathing and then later transferred to a rehabilitation facility. R1's POA reported R1 coming back to the facility at the end of November 2025 and was told by the Rehabilitation facility that Medicare would cover for a nurse to check on R1 routinely with no cost to the facility or for the family. R1's POA provided a folder that was near R1's nightstand that contained the name of the company, which was Meridian Health Care Providers, Inc., that provides some oversight, along with staff names and numbers on the front of the folder. The folder contained several documents and a start date of service of December 2025. 4. In an interview with R1, R1 reported not inviting the "man" into the apartment and was a little nervous as jewelry was in the bathroom. R1 reported the "man" did not touch but did make inappropriate gestures and grunts. 5. In an interview with O2, O2 reported that when they arrived at R1's apartment, the door was locked, which was not common. O2 reported "a man" opened the door. O2 indicated upon entry into the apartment, O2 noticed R1 was in the recliner. When asked who "the man" was, R1 indicated "he followed me in and locked the door." O2 reported "the man" was asked to leave, and when O2 walked "the man" out of the apartment, a family member saw "the man" and stated, "we have been looking all over for about an hour". 6. In an exit interview conducted on March 6, 2026, with E1 and E2, the findings were reviewed, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure a resident’s medical record contained the name, address, and contact individual, including contact information, of the home health agency or hospice service agency and any information provided by the home health agency or hospice service agency. Findings include: 1. Based on observation, the Compliance Officer observed a folder that was near R1's nightstand that contained the name of the company of Meridian Health Care Providers, Inc. There was a label on the front cover that identified the Administrator, Director of Clinical Services, Nurse, and Physical Therapist. The paperwork inside the folder showed the service start date in December 2025. 2. A review of R1's medical record contained a service plan dated January 2026 for personal care services. However, the service plan did not identify any of the above-mentioned information, nor did any documents in the resident record. 3. In an interview with E2, E2 reported knowing of a nurse who comes in routinely to check R1's vital signs but stated "We don't know the name of the company or what all they do." 4. In an exit interview conducted on March 6, 2026, with E1 and E2, the findings were reviewed, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to establish, document, and implement a policy and procedure to protect the health and safety of a resident that cover methods by which an assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide which is a health and safety risk. Findings include: 1. The compliance officer observed residents residing at the facility. 2. The compliance officer requested and was not provided with the facility's policy and procedure that covered the methods by which the facility was aware of the general whereabouts of a resident. 3. In an interview, E2 and O1 acknowledged there was no policy and procedure available that covered the whereabouts of all the assisted living residents at the facility. Technical assistance was provided during the compliance inspection conducted on August 30, 2022.

Based on observation, record review, and interview, the manager failed to ensure a written service plan included how a medication would be stored and controlled in a resident's unit, for three of three sampled residents who were storing medications in their unit, which posed a health and safety risk. Findings include: 1. In interview, E2 reported that R2, R3, and R5 were allowed to manage their own medications. 2. Reviewed R2's current service plan that was dated July 27, 2023. Reviewed R3's current service plan that was dated June 6, 2023. Reviewed R5's current service plan that was dated August 6, 2023. Their service plans failed to state how the resident's medications would be stored and controlled in each unit. All three sampled residents' service plans stated the residents required personal care services. 3. In an interview, E2 acknowledged the sampled residents were allowed to self-administer their own medications, however, their service plans did not include how these medications would be stored and controlled in each of their units.

Based on record review and interview, the manager failed to ensure that for one of three sampled residents, who were receiving directed care services, the written service plan included cognitive stimulation and activities to maximize functioning. Findings include: 1. Review of R8's current service plan that was dated July 31, 2023 stated the resident required directed care services. The service plan did not include cognitive stimulation and activities to maximize functioning. 2. In an interview, E11 acknowledged this sampled resident who was receiving directed care services the current written service plan did not include cognitive stimulation and activities to maximize functioning.

Based on observation and interview, the manager failed to ensure that garbage and refuse are stored in covered containers. Findings include: 1. During a facility tour, E2 and the compliance officer observed in the facility's central kitchen there was a large uncovered gray trash bin nearly full of trash setting next to the prep food counter. This trash container was not in use at the time of the observation. 2. In the memory care's prep kitchen, E2 and the compliance officer observed a large uncovered gray trash bin half-full of trash setting next to the prep food counter. This trash container was not in use at the time of the observation. 3. In an interview, E2 acknowledged the uncovered trash at the facility.

Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in closed containers away from food storage and the kitchen, which posed a health risk. Findings include: 1. During a facility tour, E2 and the compliance officer observed in the facility's central kitchen there was stored an open uncovered large bag on a frame that was full of soiled linen sitting in the back part of the kitchen. At the time of the observation this container was not in use. 2. In an interview, E2 acknowledged the soiled linen in the kitchen that was not being stored in a closed container as required.

Based on documentation review and interview, the manager failed to ensure that on the day that a resident used the swimming pool, an employee tested the swimming pool's water quality at least once for compliance with chemical disinfection standards. Findings include: 1. During an interview, E2 and E10 indicated that the facility pool was regularly used by residents at least two times per week. 2. The compliance officer requested and was not provided documentation indicating that on the day that a resident used the swimming pool, an employee tested the swimming pool's water quality at least once for compliance with chemical disinfection standards. 3. During an interview, E10 acknowledged the required documentation was not available for review.

Based on observation and interview, the manager failed to ensure a swimming pool gate was locked when not in use. Findings include: 1. During a facility tour, E2 and the compliance officer observed the facility's swimming pool gate was wide open. The pool gate was propped open with the base of an umbrella stand. The pool was not in use. There was no one seen in this area where the pool was located. 2. In an interview, E2 acknowledged the swimming pool gate was not kept locked when the pool was not in use.