Tucson Assisted Living Retreat

Based on documentation review, record review, and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to immediately report the suspected abuse, neglect, or exploitation of the resident, according to A.R.S. § 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. A review of personnel records revealed a corrective action note in E2’s personnel record dated February 4, 2026. The personnel action stated, “R1 express to management that R1 is afraid of E2, especially during bed changes. That R1 head is being hit against the wall.” The document further stated, “E2 stated that R1 is valid and R1 has accidentally hit R2 head on the wall during brief change.” 2. A review of facility documentation revealed a report was made to Adult Protective Services on February 13, after another allegation was made regarding E2, and E2 was terminated. 3. In an interview, E1 acknowledged a report was not made regarding the allegations until February 13, 2026. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a caregiver’s skills and knowledge were verified and documented before the caregiver provided physical health services for one of four personnel records reviewed. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E2’s personnel record revealed a document titled “Tucson Assisted Living Retreat Employee Skills & Knowledge Record.” However, the document was not completed. The document included the employee's name and date of hire; however, documentation of E2’s skills and knowledge verification was not completed. 2. A review of the facility’s policy and procedures manual revealed a policy titled “Staffing and Record Keeping," revised May of 2025. The policy stated, “5. … A checklist of each caregiver’s knowledge, skills, and abilities is completed and verified by the Manager before the employee provides any health-related services.” 3. A review of facility documentation revealed an incident report dated February 14, 2026, which included evidence of E2 providing services to residents. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat citation from the on-site compliance inspection and complaint investigation conducted on November 21, 2024.

Based on record review, document review, and interview, the manager failed to ensure an employee who was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis(TB) as specified in R9-10-113, on or before the date the individual began providing services at the assisted living facility, for one of four personnel records reviewed. Findings Include: 1. A review of E2 personnel record revealed evidence of documentation of two negative TB skin tests, prior to E2 providing services. However, the record included no evidence of documentation of a baseline screening and risk assessment conducted by an occupational health reviewer. 2. A review of the facility’s policies and procedures manual revealed a policy titled, “Tuberculosis Infection Control”. The policy stated, “… 2. The Manager shall ensure that the facility complies with the following requirements: … b. on or before the date an employee begins providing services at the facility, the individual must provide evidence of freedom from infectious tuberculosis”. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, document review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident’s date of occupancy, and as specified in R9-10-113, for four of five resident records reviewed. Findings include: 1. A review of R2’s, R3’s, R4’s, and R5’s medical records revealed evidence of documentation of negative TB skin tests, within seven calendar days after the resident’s date of occupancy. However, the records included no evidence of documentation of baseline screenings and risk assessments conducted by an occupational health reviewer. 2. A review of the facility’s policies and procedures manual revealed a policy titled, “Tuberculosis Infection Control”. The policy stated, “… 2. The Manager shall ensure that the facility complies with the following requirements: a. on or before the date a resident is accepted into the facility, the resident must provide evidence of freedom from infectious tuberculosis.” 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, interview, and documentation review, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for four of five resident records reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R1's medical record revealed signed medication orders dated February 20, 2026, for Atorvastatin, Clopidogrel, Donepezil, Furosemide, Gabapentin, Polyethylene Glycol, Senna, Tamsulosin, Tramadol, and Trazadone. 2. A review of R1’s Medication Administration Record (MAR) dated February 2026 revealed medication notes at the end of the MAR. The notes stated, “Medication Given On Time, but Charted Late” for the following medications and dates: -Atorvastatin on February 1, 5, 12, 14, 17, 18, and 19, 2026; -Clopidogrel on February 1, 8, 10, and 17, 2026; -Donepezil on February 1, 8, 10, and 17, 2026; -Furosemide on February 1, 8, 10, and 17, 2026; -Gabapentin on February 1, 2, 3, 8, 10, 16, 17, and 18, 2026; -Polyethylene Glycol on February 1, 8, 10, and 17, 2026; -Senna on February 1, 2, 8, 10, 16, 17, and 18, 2026; -Tamsulosin on February 1, 8, 10, and 17, 2026; -Tramadol on February 1, 2, 3, 8, 10, 16, 17, and 18, 2026; and -Trazodone on February 18, 2026. 3. A review of R2's medical record revealed signed medication orders dated February 3, 2026, for Acetaminophen, Docusate Sodium, Doxycycline, Eliquis, Furosemide, Levothyroxine, Nystatin, Potassium, and Senna. 4. A review of R2’s MAR dated February 2026 revealed medication notes at the end of the MAR. The notes stated, “Medication Given On Time, but Charted Late” for the following medications and dates: -Acetaminophen on February 1, 2, 8, 9, 10, 17, 18, and 19, 2026; -Ammonium Lactate 12% lotion on February 1, 8, 17, and 19, 2026; -Docusate Sodium on February 1, 8, 10, 17, and 19, 2026; -Eliquis on February 1, 2, 8, 10, 16, 17, 18, and 19, 2026; -Furosemide on February 1, 8, 10, 17, and 19, 2026; -Levothyroxine on February 7 and 11, 2026; -Nystatin on February 1, 8, 17, and 19, 2026; -Potassium on February 1, 8, 10, 17, and 19, 2026; and -Senna on February 1, 2, 8, and 10, 2026. 5. A review of R3's medical record revealed signed medication orders dated February 2, 2026, for Aspirin, Atorvastatin, Divalproex Sodium, Losartan Potassium, Metoprolol, and Tamsulosin. 6. A review of R3’s MAR dated February 2026 revealed medication notes at the end of the MAR. The notes stated, “Medication Given On Time, but Charted Late” for the following medications and dates: -Aspirin on February 1, 7, 8, 10, 13, 14, 16, 17, and 18, 2026; -Atorvastatin on February 1, 3, 12, 13, 14, and 19, 2026; -Divalproex Sodium on February 1, 2, 3, 7, 8, 10, 13, 14, 16, 17, and 18, 2026; -Losartan Potassium on February 1, 7, 8, 10, 13, 14, 16, 17, and 18, 2026; -Metoprolol on February 1, 7, 8, 10, 13, 14, 16, 17, and 18, 2026; and -Tamsulosin on F

Based on document review and interview a manager failed to provide written notification to the Department of a resident’s: Elopement, within 24 hours of the elopement being discovered. Findings include: 1. A review of facility documentation revealed an incident report documenting an elopement by R2 on August 18, 2025, at approximately 9:30 am. 2. A review of Department documentation revealed notification was made to the Department by E1 on August 20, 202,5 at 3:30 pm. 3. In an interview, E1 reported the delay in reporting was due to E1 being out of the office.

Based on record review, and interview, the manager failed to ensure a resident had a written service plan which accurately included the level of service the resident was expected to receive, for two of three resident records reviewed. Findings include: A.R.S. § 36-401.48 "Supervisory care services" means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in self-administering prescribed medications. A.R.S. § 36-401.39 "Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. A.R.S. § 36-401.16 "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. A review of R1's medical record revealed a service plan, dated July 14, 2024, for supervisory care services. However, the service plan included directed care services and had not been updated. 2. In an interview, E1 agreed R1 was receiving directed care and the service plan was incorrect. 3. A review of R2's medical record revealed a service plan, dated July 26, 2024, for personal care services. However, the service plan included directed care services. 4. In an interview, E1 agreed R2 was receiving directed care services and the service plan was incorrect. 5. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated at least once every 12 months for a resident receiving supervisory care services, for one of three resident records reviewed. Findings include: 1. A review of R1's medical record revealed a service plan for supervisory care services dated July 14, 2024. A service plan update was due on or before July 2025. 2. A review of the updated service plan dated July 14, 2025, revealed it was signed only by the manager and the nurse. The document was not signed by the resident or the resident’s representative. 3. In an interview, E1 acknowledged R1's service plan was not reviewed and updated at least once every twelve months.

Based on record review, and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for one of three resident records reviewed. Findings include: 1. A review of R2's medical record revealed a service plan, dated July 26, 2024, for personal care services. A service plan update was due on or before January 2025. 2. The updated service plan provided was signed by the manager on September 1, 2025. The update did not include signatures of the nurse or the resident or resident’s representative. 3. In an interview, E1 acknowledged R2's service plan was not reviewed and updated at least once every six months.

Based on record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provides physical health services, for three of three caregivers personnel records reviewed. The deficient practice posed a risk if the employees did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of E3's, E4's, and E5's personnel records revealed E3, E4, and E5 were hired as caregivers. 2. A review of E3's, E4's, and E5's personnel record revealed a document titled "TUCSON ASSISTED LIVING RETREAT SKILLS & KNOWLEDGE RECORD". The document required the caregiver and manager or designee to initial each task to indicate completion. There was no documentation to indicate E3's, E4's, and E5's skills and knowledge were verified before E3, E4, and E5 provided physical health services. 3. In an interview, E1 acknowledged E3's, E4's, and E5's skills and knowledge were not verified and documented before E3, E4, and E5 provided physical health services.

Based on record review, and interview, the manager failed to ensure a personnel record contained documentation indicating a caregiver received orientation before providing assisted living services to a resident, for three of four personnel records reviewed. Findings include: 1. A review of E3's, E4's, and E5's personnel records revealed no documentation to indicate E3, E4, and E5 received orientation prior to providing physical health services. 2. A review of the facility records revealed E3 currently worked as a caregiver in the facility, E4 was employed with the facility as a caregiver for over three months, and E5 worked as a caregiver in the facility for eleven months. 3. In an interview, E1 acknowledged E3's, E4's, and E5's personnel record did not include documentation of orientation before E3, E4, and E5 provided physical health services.

Based on record review and interview, the manager failed to ensure a resident had a written service plan when initially developed and when updated, that was signed and dated by the manager, for one of three residents' records reviewed. The deficient practice posed a risk if the service plan was not developed and updated to articulate decisions and agreements. Findings include: 1. A review of R2's medical record revealed a service plan dated June 24, 2024 for personal care level services. The service plan was signed by E1 and appeared to be electronic, though did not include signature authentication. 2. A review of E1's personnel record revealed E1 was not employed by the facility at that time. 3. In an interview E1 acknowledged E1 was not employed by the facility at that time and denied signing the document. 4. In an interview, E1 acknowledged the reviewed residents' service plan did not include the manager's dated signature.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled 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 general or specific whereabouts of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officer observed no alert on the door exiting a resident's room, leading to the secured grounds of the facility. This was observed in three different resident rooms. 3. In an interview E1 reported some of the alerts were missing or broken. E1 further reported maintenance was waiting for the devices to arrive and is scheduled to install the devices in two days. 4. During an environmental inspection of the facility, the Compliance Officer observed a door located in a resident hallway, leading to the secured facility grounds. The door was equipped with a door alarm; however, the door was left open and the alarm only sounds once when the door is opened. 5. In an interview, E1 acknowledged a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility. E1 reported they did not have any residents that may wander and the units would be installed on November 23, 2024.

Based on documentation review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future. The deficient practice posed a health and safety risk to residents. Findings include: 1. A review of documentation provided by E1 revealed the following: - R5 had an incident resulting in the resident needing medical services on May 28, 2023. The documents did not include "any action taken to prevent the incident from occurring in the future". 2. During an interview, E1, and E3 acknowledged that R5's incident report did not include documentation showing any action taken to prevent the incident from occurring in the future.

Based on documentation review and interview, the manager failed to ensure a dog residing at the facility was vaccinated against rabies. The deficiency practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Finding include: 1. When the Compliance Officer entered the facility a big dog greeted the Compliance Officer at the door. 2. The Compliance Officer requested and was not provided with documentation of a current rabies vaccination for D1. 3. In an interview, E1 acknowledged current documention of rabies vaccination for D1 was unavailable for review.