Villa Hermosa

Based on record review, documentation review, and interview, the manager failed to ensure that a personnel record for each employee included initial training in fall prevention and fall recovery for four of nine personnel records reviewed. Findings Include: 1. A review of E6's, E7's, E9's, and E10's personnel records revealed no documentation of initial fall prevention and fall recovery training. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411, for five of nine personnel records 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(A) and (C) states: “A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.” and; “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. and 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459…” 2. A review of E3's personnel record revealed E3 was in a position that required a fingerprint clearance card. Further review revealed no evidence of a fingerprint clearance card, or an application for a fingerprint clearance card. 3. A review of E3’s, E5’s, E6’s, E7’s, and E8’s personnel records revealed no evidence of documented, good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 4. A review of E3's personnel record revealed E3 was hired after January 1, 2025. The review revealed no documentation the governing authority checked the Adult Protective Services (APS) Registry for E3. 5. A review of the Arizona Department of Economic Security, Adult Protective Services (APS) Registry at https://hsapps.azdhs.gov/ls/sod/SearchAPS.aspx?type=APS revealed E# was not on the APS registry. 6. In an interview

Based on record review and interview, the manager failed to ensure a policy and procedure was implemented to protect the health and safety of a resident that covered cardiopulmonary resuscitation (CPR) training for applicable employees, which included a demonstration of the employee's ability to perform CPR, for two of nine personnel records reviewed. Findings include: 1. A review of E5's personnel record revealed documentation of CPR training issued on March 15, 2024, by "NationalCPRFoundation", which did not include a demonstration of E5’s ability to perform CPR. 2. A review of E10's personnel record revealed documentation of CPR training issued on December 21, 2023, by "American Healthcare Academy", an online-only CPR training program, which did not include a demonstration of E10’s ability to perform CPR. 3. In an exit interview, the findings were reviewed with E1 and E2 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 six of nine personnel records reviewed. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E3’s, E5’s, E6’s, E7’s, E8’s, and E10’s personnel records revealed no documentation of verification of a caregiver’s skills and knowledge prior to providing services to the residents. 2. A review of R3’s medical record revealed documentation of services provided for the month of September 2025. The document revealed E3, E5, E6, E7, E8, and E10 provided services to R3 in September 2025. 3. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided. This is a repeat deficiency from the on-site complaint investigation conducted on January 9, 2024.

Based on record review and interview, the manager failed to ensure that a caregiver received orientation that was specific to the duties to be performed by the caregiver before they provided assisted living services to a resident for four of nine personnel records reviewed. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E3’s, E5’s, E6’s, and E10’s personnel records revealed there was no documented orientation prior to E3, E5, E6, and E10 providing services to the residents. 2. A review of the R3’s medical record revealed documentation of services provided for the month of September 2025. The document revealed E3, E5, E6, and E10 provided services to R3 in September 2025. 3. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.

Based on 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 three of nine personnel records reviewed. 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 E4's personnel record revealed E4 worked as a caregiver and was hired in June 2025. However, documentation of E4’s first aid training was not available for review. 2. A review of E7's personnel record revealed E7 worked as a caregiver and was hired in November 2024. However, documentation of E7’s first aid training was not available for review. 3. A review of E8's personnel record revealed E8 worked as a caregiver and was hired in October 2024. However, documentation of E8’s first aid and CPR training was not available for review. 4. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.

Based on documentation review and interview, the governing authority failed to notify the Department according to Arizona Revised Statutes (A.R.S.) \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings include: 1. A review of Department documentation revealed E13 was no longer the licensed manager effective February 28, 2023. 2. In an interview, E1 reported E3 became the manager on December 23, 2023. 3. A review of Department documentation revealed no evidence to indicate the governing authority notified the Department when there was a change in the manager. 4. During the on-site inspection, E1 provided evidence of an email notifying the Department of the change in manager. The email was sent by the governing authority to the Department on January 9, 2024, the day of the inspection. 5. In an interview, E1 acknowledged the governing authority did not notify the Department of a change in the facility's manager in December of 2023.

Based on record review, documentation review observation, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA) for one of ten personnel records sampled. The deficient practice posed a risk if E4 was not able to meet the needs of residents. Findings include: 1. A review of E4's personnel record revealed a caregiver certification issued December 2, 2004, with student ID: 5422 from the Care Search Caregiver Education. This certificate was for "Certified Caregiver at the Supervisory Care Level". The caregiver's name was E4's name handwritten and the school's information stated: "Care Search Training, 1051 N. Constitution Dr.; Tucson Arizona 85748; ADHS Accr......". The rest of this information was missing. A black line was drawn through the middle of the certificate and "Copy Not Original" was written across the document. 2. A review of E4's personnel record revealed a caregiver certification issued December 6, 2004, with student ID: 5422 from the Care Search Caregiver Education. This certificate was for "Certified Caregiver at the Personal Care Level". The caregiver's name was E4's name handwritten and the school's information stated: "Care Search Training, 1051 N. Constitution Dr.; Tucson Arizona 85748; ADHS Accr......". The rest of this information was missing. A black line was drawn through the middle of the certificate and "Copy Not Original" was written across the document. 3. A review of E4's personnel record revealed a caregiver certification issued December 2, 2004, with student ID: 5422 from the Care Search Caregiver Education. This certificate was for "Certified Caregiver at the Directed Care Level". The caregiver's name was E4's name handwritten and the school's information stated: "Care Search Training, 1051 N. Constitution Dr.; Tucson Arizona 85748; ADHS Accreditation #ALTP0019......". The rest of this information was missing. A black line was drawn through the middle of the certificate and "Copy Not Original" was written across the document. 4. The Compliance Officer observed the student's name had been altered on all three certificates. After reviewing the database provided by O1, who was the owner and teacher of Care Search, revealed E4's name was not associated with the student ID number 5422. This number was issued to O2. 5. Further review of Care Search Caregiver Education's student roster revealed no evidence E4 completed caregiver training with Care Search Caregiver Education. 7. A review of the NCIA's verification of the caregiver training portal, revealed no evidence E4 completed caregiver training after August 3, 2013. 8. In an interview, E1 reported being unaware E4's caregiver certificates were invalid, and acknowledged the caregiver certificate appears to have been altered from the original document. E1 acknowled

Based on documentation review, and interview the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, for one of ten personnel records sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. The Compliance Officer requested the skills and knowledge checklist list for the following caregivers E1, E4, E5, E6, E7, E8, E9, E10, E11, and E12. 2. A review of E12's personnel record revealed no evidence of verified and documented skills and knowledge. 3. In an interview, E1 acknowledged E12's personnel record did not include verified and documented skills and knowledge. E1 further reported the document was in progress , though not complete when it was misplaced. E1 reported E12 would begin retraining in order to have E12's skills and knowledge verified and documented.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which, when initially developed and when updated, was signed and dated by the resident or resident's representative, the manager, or the nurse or medical practitioner who reviewed the service plan, for three of ten resident records reviewed. Findings include: 1. A review of R1's medical record revealed an initial service plan, for personal care level of services and medication administration, dated December 27, 2023. The service plan did not include the required signature of the resident or the resident's representative. 2. A review of R5's medical record revealed an updated service plan, for personal care level of services, dated August 16, 2023. The service plan did not include the required signature of the manager. 3. A review of R8's medical record revealed an updated service plan, for personal care level of services, dated August 13, 2023. The service plan did not include the required signature of the manager. 4. In an interview, E1 acknowledged the service plans for R1, R5, and R8 were not signed as required by the resident or resident's representative, or the manager.

Based on record review, documentation review, and interview, the manager failed to ensure service plans for residents receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, offering sufficient fluids to maintain hydration, and incontinence care that ensures that a resident maintains the highest practicable level of independence, for five of ten resident records sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated December 27, 2023, for personal care services. However, the service plan did not include the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and - Offering sufficient fluids to maintain hydration. 2. A review of R3's medical record revealed a service plan, dated November 29, 2023, for personal care services, However, the service plan did not include the following: - Offering sufficient fluids to maintain hydration. 3. A review of R6's medical record revealed a service plan, dated August 13, 2023, for personal care services, However, the service plan did not include the following: - Offering sufficient fluids to maintain hydration. 4. A review of R8's medical record revealed a service plan, dated August 13, 2023, for personal care services, However, the service plan did not include the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and - Offering sufficient fluids to maintain hydration. 5. A review of R9's medical record revealed a service plan, dated November 13, 2023, for personal care services. However, the service plan did not include the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 6. In an interview, E1 acknowledged the service plans for R1, R3, R6, R8, and R9 did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; offering sufficient fluids to maintain hydration; and/or incontinence care that ensures that a resident maintains the highest practicable level of independence.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents. Findings include: 1. During an inspection of a resident room number 1206, the Compliance Officer observed the hot water temperature in the bathroom sink registered at 125.3\'ba F on the Compliance Officer's department-issued thermometer. 2. In an interview, E1 acknowledged the water temperatures were not within the 95\'ba F and 120\'ba F range.