Eden Assisted Living Home.

“Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for three of three personnel sampled. The deficient practice posed a health and safety risk for residents.  Findings include:  1. A review of the facility's policies and procedures revealed a policy titled "Policy on: A.R.S 36-420.01: Health Care Institutions; Fall Prevention and Fall Recovery; Training Programs (Ref: SB1373)." The policy stated, "A. All staff will have an initial training that will be included during orientation. ... C. After orientation, all staff will be required to have an ongoing training that will cover fall prevention and fall recovery at least once every 12 months." 2. A review of E1’s personnel record revealed documentation of a completed training regarding fall prevention and fall recovery on April 22, 2022. However, documentation of additional training was not available for review.  3. A review of E2’s personnel record revealed documentation of a completed training regarding fall prevention and fall recovery on September 23, 2022. However, documentation of additional training was not available for review.  4. A review of E3's personnel record did not include documentation of completed fall prevention and fall recovery training. Given E3's date of hire, this documentation was required. 5. In an interview, E1 acknowledged the facility failed to administer a training program for all staff regarding fall prevention and fall recovery that included initial and continued competency training.”

“Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure an annual assessment of the health care institution's risk of exposure to infectious tuberculosis (TB) was completed and training and education related to recognizing the signs and symptoms of TB was provided annually to individuals employed by the health care institution, for three of three personnel sampled. The deficient practice posed a potential illness risk to residents.  Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Tuberculosis Screening Policy." The policy stated, "4. Annual assessment of the HCI's risk of exposure to infectious TB... 5. Annual training and education related [sic] recognizing the signs and symptoms of TB will be provided annually to all staff and will be mandatory in-service training requirement." 2. While on-site for the compliance inspection, the Compliance Officers requested the facility's TB program documents at approximately 10:15 AM. However, documentation of the facility's risk assessment was not available for review. 3. A review of E1's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Based on E1's date of hire, this documentation was required. 4. A review of E2's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Based on E2's date of hire, this documentation was required. 5. A review of E3's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Based on E3's date of hire, this documentation was required. 6. In an interview, E1 reported the facility was unaware of the TB requirements per R9-10-113. E1 acknowledged the facility failed to conduct an annual assessment of the health care institution's risk of exposure to infectious TB. E1 also acknowledged training and education related to recognizing the signs and symptoms of TB was not provided initially and annually to individuals employed by the health care institution.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for three of three personnel sampled. The deficient practice posed a risk if E1, E2, and E3 were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states, "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. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee." 2. A review of E1's personnel record did not include documentation of verification that E1 is not on the adult protective services registry. 3. A review of the E2's personnel record revealed documentation of a valid fingerprint clearance card (FPCC). However, the status of E2's FPCC was not verified as required. 4. A review of E2's personnel record did not include documentation of verification that E2 is not on the adult protective services registry. 5. A review of E3's personnel record did not include documentation of the facility's good faith effort to contact E3's previous employers. 6. A review of E3's personnel record did not include documentation of verification that E3 is not on the adult protective services registry. 7. In an interview, E1 acknowledged the facility did not ensure compliance with A.R.S. § 36-411.”

“Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include:  1. A review of the facility's policy and procedure manual revealed a review date of October 1, 2021.  2. In an interview, E1 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed.”

“Based on record review and interview, the manager failed to ensure that before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility that included the manager's signature and date signed.     Findings include:     1. A review of R1’s medical record revealed a Residency Agreement signed by the governing authority.  However, the Residency Agreement was not signed by the manager.     2. In an interview, E1 and E2 acknowledged that the Residency Agreement for R1 was not signed by the manager.”

“Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program that included a method to identify, document, and evaluate incidents, a method to collect data to evaluate services provided to residents, a method to evaluate the data collected to identify a concern about the delivery of services related to resident care, a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care, and the frequency of submitting a documented report required in subsection (2) to the governing authority. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management Policy and Procedure." The policy stated, "A method to evaluate the data collected to identify a concern about the delivery of services related to resident care: Maintain a line graph for each of the above to identify trends form [sic] month to month. Monthly meetings between the licensee or representative, the manager, any designees, service plan nurse, caregivers, and others needed, to discuss each month's findings and any identified trends. ... The frequency of submitting a documented report a. An Assurance checklist will be performed by manager/caregiver/designee on a regular basis for at least once every 3 month [sic]. b. A Quarterly report will be compiled for residents having falls, medication errors, calling 911, weight loss, pressure sores, and residents admitted with C-Diff or MRSA.... d. The report and the supporting documentation for the report are maintained for 12 months after the date the report is submitted to the governing authority." 2. While on-site for the compliance inspection, the Compliance Officers requested the facility's quality management documentation at approximately 10:15 AM. However, documentation of the documented reports required per the facility's policies and procedures was not available for review. 3. In an interview, E2 reported the facility had not completed the reports required per the facility's policies and procedures. E1 acknowledged the facility failed to implement a quality management program that meets all requirements per R9-10-804.a-e.”

“Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for two of three personnel records sampled. 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 E2's personnel record revealed CPR and first aid training with an expiration date of September 14, 2023. 2. Further review of E2's personnel record revealed CPR and first aid training completed on March 30, 2024. However, documentation of E2's completed CPR and first aid training valid between September 14, 2023, and March 20, 2024, was not available. 3. A review of E3's personnel record did not include documentation of completed CPR and first aid training. 4. In an interview, E2 reported E3 had completed CPR and first aid training; however, documentation was not available for review. E2 reported that E2 worked at the facility between September 14, 2023, and March 20, 2024. E1 acknowledged E2 and E3 did not provide current documentation of first aid and CPR training specific to adults.”

“Based on observation, documentation review, record review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided health services, for two of two personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include; 1. While on-site for the compliance inspection, the Compliance Officers observed E2 and E3 at the facility, providing services to residents. 2. A review of the facility's policies and procedures revealed a form titled "Caregiver Skills and Knowledge Documentation." The form outlined all required caregiver skills to be verified before the caregiver or assistant caregiver provided physical health services. 3. A review of E2's personnel record revealed a blank Caregiver Skills and Knowledge Documentation form. However, the form was not completed. 4. A review of E3's personnel record did not include documentation of the verification of E3's skills and knowledge. 5. In an interview, E2 reported E3 had just started working at the facility. E1 acknowledged verification of skills and knowledge was not documented in E2's and E3's personnel records before E2 and E3 provided health services.”

“Based on observation, documentation 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 and assistance caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers observed E2 and E3 at the facility, providing services to residents. 2. A review of the facility's posted personnel schedule revealed a schedule for January 2025. However, documentation of a current personnel schedule was not available for review. 3. In an interview, E1 reported E2 worked as a live-in caregiver. E1 acknowledged the employee work schedule did not include documentation of the caregivers who worked each day and the hours worked by each.”

“Based on documentation review, observation, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A 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, provides volunteer services for the health care institution, or is admitted to 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. While on-site for the compliance inspection, the Compliance Officers observed E3 at the facility, providing services to residents. 4. A review of E3's personnel record did not include documentation of E3's freedom from infectious TB. Based on E3’s date of hire, this documentation was required. 5. In an interview, E1 acknowledged E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113.”

“Based on observation, 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 providing assisted services to a resident, for two of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer observed E2 and E3 at the facility, interacting with residents. 2. A review of E2's personnel record revealed an orientation form. However, the form was not completed. 3. A review of E3's personnel record did not include documentation of E3's completed orientation. 4. In an interview, E1 acknowledged E2 and E3 did not receive orientation that was specific to the duties to be performed by E2 and E3 before providing assisted services to a resident.”

“Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included the requisite components for one of three personnel sampled. The deficient practice posed a risk as the required information could not be verified for E3. Findings include:  1. A review of the facility's policies and procedures revealed a policy titled "Applicant and Employee Requirement Policy and Procedure." The policy reported all requirements per R9-10-806.C.1-a-c would be maintained in personnel files. 2. While on-site for the compliance inspection, the Compliance Officers requested all personnel records. However, a personnel record for E3 was unavailable for Compliance Officer review.  3. In an interview, E2 reported E3 did not have a personnel record maintained on the facility premises. E1 acknowledged the personnel file for E3 did not include the requisite components.”

“Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in Arizona Administrative Code (A.A.C.) R9-10-113, before or within seven days after the resident's date of occupancy, for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents.   Findings include:      1. R9-10-113.A 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, provides volunteer services for the health care institution, or is admitted to 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. A review of R1’s medical record revealed a TB test document that was less than 12 months old; however, the test was not completed within seven days of R1's date of occupancy. 3. In an interview, E1 and E2 acknowledged that the manager failed to ensure there was a TB test completed before or within seven days after the resident's date of occupancy.”

“Based on record 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 an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers requested R1's medical record with all required documents at 10:15 AM. However, the medical record provided did not include documentation signed by a medical practitioner that included whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints.  2. In an interview, E1 and E2 acknowledged that R1's medical record did not contain documentation signed by a medical practitioner that included whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints at the time of acceptance or within 90 days before R1 was accepted into the facility.”

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record for two of two residents reviewed. The deficient practice posed a health and safety risk.   Findings include: 1. A review of R1's medical record revealed a current written service plan for directed care services from February 2025. The service plan stated the following services were needed: ·        Shower and Partial showers ·        Shampoo ·        Shave ·        Oral Care daily ·        Change undergarments – AM, PM, and HS ·        Medication Administration However, there was no documentation of services provided from May 1, 2025, to May 5, 2025. 2. A review of R2's medical record revealed a current written service plan for directed care services from April 2025. The service plan stated the following services were needed: ·        Shower ·        Shampoo ·        Oral Care – Daily ·        Change undergarments – AM, PM, and HS ·        Medication Administration However, there was no documentation of services provided from May 1, 2025, to May 5, 2025.     3. During an interview, E2 acknowledged R1's and R2's medical records did not include documentation of the services provided.”

“Based on documentation review and interview, the manager failed to ensure that a calendar of planned activities was not prepared at least one week in advance for the date the activity was provided. Findings include:     1. During an environmental inspection of the facility, the Compliance Officers observed a posted activity calendar for February 2025. However, documentation of additional activity calendars was not available for review.     2. In an interview, E2 acknowledged that a calendar of planned activities was not prepared at least once week in advance of the date the activity was provided.”

“Based on observation and interview, the manager failed to ensure that a resident was not subjected to restraint. The deficient practice posed a risk of injury and violated a resident's rights.  Findings include:  1. During an environmental tour of the facility, the Compliance Officers observed R4’s bed was equipped with half-bedrails on both sides of the bed.  2. In an interview, E2 reported that R4 was unable to lower the half rails. E2 also reported the bedrails were used to keep R4 from getting out of bed independently. 3. In an interview, E2 acknowledged that R4 was subjected to restraint.”

“Based on observation, record review, and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk to the physical health and safety of a resident.     Findings include:     1. During the environmental inspection of the facility, the Compliance Officers observed R3 in R3's room with no means to alert employees of R3's needs or emergencies. E2 reported the resident was bed-bound.     2. A review of R3’s medical record revealed that R3 required directed care services.     3. In an interview, E2 acknowledged that there was no bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies available in a bedroom being used by a resident receiving directed care services.”

“Based on observation and interview, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area that 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. During the environmental tour of the facility, the Compliance Officers observed the front door of the facility had a control to alert employees of a resident’s egress from the facility.  However, the control was turned off. 2. The Compliance Officers observed a door labeled “Employees only” that led to the laundry room. There was no lock on the door to the laundry room. There was an alert on the door to the laundry room that had been removed. From the laundry room, there was a door to the garage that was not secured or controlled to alert employees of a resident’s egress. 3. The Compliance Officers observed a door in a resident room that led to the backyard. However, this door was not secured to alert employees to the egress of the resident. There was part of an alarm on the door; however, it was not functioning. 4. The Compliance Officers observed a resident room that had a door leading to a small courtyard in the front of the house, which did not have an alarm or control to alert employees of a resident’s egress. 5. The Compliance Officers observed a door leading to the back yard from the kitchen, which had an alarm to alert employees to the egress of a resident. However, the alarm was turned off. 6. In an interview, E2 acknowledged that the manager failed to ensure that all means of exiting the facility had a means to alert employees to the egress of a resident.”

“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 two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1 . A review of R1's medical record revealed a medication list dated August 12, 2024. The medication list included the following: ·        Coumadin 5 mg (milligrams), 1 tablet Monday, Wednesday, and Friday ·        Coumadin 5 mg, ½ tablet Tuesday, Thursday, Saturday, and Sunday ·        Bumex 1 mg, 1 tablet twice a day ·        Donepezil Hydrochloride 5 mg, 1 tablet at night ·        Lorazepam 2 mg, 1 mg every 4 hours for agitation ·        Tamsulosin Hydrochloride 0.4 mg, 1 capsule at bedtime   However, a review of R1's Medication Administration Record (MAR) sheet for May 2025 revealed the above medications were not documented as administered from May 1, 2025, to May 5, 2025. 2 . A review of R2's medical record revealed a medication list dated March 7, 2025. The medication list included the following: ·        Aspirin 81 mg, 1 tablet every day ·        Venlafaxine HCL 37.5 mg, 1 tablet every day ·        Carbidopa – Levodopa 25-100 mg, 1 tablet five times a day ·        Seroquel 50 mg, 1.5 tablets twice a day ·        Amantadine HCL 100 mg, 1 tablet every 12 hours ·        MiraLAX 17 grams/scoop, 1 time a day ·        Refresh Tears 0.5 %, 2 drops twice a day ·        Trazadone HCL 150 mg, 1 tablet daily However, a review of R2’s Medication Administration Record (MAR) sheet for May 2025 revealed the above medications were not documented as administered from May 1, 2025, to May 5, 2025. 3. In an interview, E1 and E2 acknowledged medication administration was not documented as provided from May 1, 2025 to May 5, 2025 for R1 and R2. This is a repeat citation from the compliance inspection completed on July 28, 2023.”

“Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During the environmental inspection, the Compliance Officers observed a lock box in the refrigerator for medications. However, the Compliance Officer was able to open the lock box without the combination code. 2. During the environmental inspection, the Compliance Officers observed an open cabinet in the kitchen that contained medications. The cabinet door had a magnetic lock; however, the cabinet door was unlocked. The magnetic device to open the cabinet door was kept on the side of the refrigerator and accessible to residents. 3. In an interview, E1 and E2 acknowledged that medications stored in the refrigerator and in the kitchen cabinet were not secured and were accessible to residents.”

“Based on observation and interview, the manager failed to ensure that a food menu was prepared at least one week in advance. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed that the food menu posted was dated January 2025. However, there were no other menus for review.  2. In an interview, E1 and E2 reported the facility’s food menu was based on resident preferences. However, E1 acknowledged that a food menu was not prepared at least one week in advance.”

“Based on observation and interview, the manager failed to ensure food that required refrigeration was maintained at 41° or below. The deficient practice posed a risk for potential foodborne illnesses. Findings include: 1. During the environmental inspection, the Compliance Officers observed a refrigerator in the kitchen. The refrigerator contained foods that required refrigeration, such as butter, milk, and other perishable foods. However, the thermometer on the refrigerator‘s shelf read 50°F. 2. In an interview, E1 and E2 acknowledged that foods requiring refrigeration had not been maintained at 41°F or below.”

“Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include:  1. A review of the facility's policies and procedures revealed the facility's disaster plan; however, no documentation of a review was available. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.”

“Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers requested the facility's disaster drill documentation for review at approximately 10:15 AM. However, there was no documentation of disaster drills conducted available for review. 2. In an interview, E2 reported the facility had not conducted a disaster drill within the last 12 months. E1 acknowledged that a disaster drill for employees was not conducted on each shift at least once every three months and documented.”

“Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers requested the facility's evacuation drill documentation at approximately 10:15 AM. However, there was no documentation of evacuation drills conducted available for review. 2. In an interview, E2 reported the facility had not conducted an evacuation drill within the past 12 months. E1 acknowledged that an evacuation drill for employees and residents was not conducted at least once every six months.”

“Based on documentation review, observation, and interview, the manager failed to ensure that a smoke detector was tested once a month. The deficient practice posed a health and safety risk to the residents.   Findings include: 1. A review of the facility's smoke detector testing documentation revealed a test completed on October 15, 2022. However, documentation of additional tests was not available. 2. In an interview, E1 acknowledged the facility's smoke detectors were not tested at least once a month and documented.”

“Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice poses a health and safety risk to residents. Findings include: 1. During the environmental inspection of the backyard, the Compliance Officers observed a hacksaw placed on a ladder. The ladder was next to an exit door off of a resident’s room. 2. During the environmental inspection of the facility, the Compliance Officers observed a rusted nail on the ground in the backyard. 3. In an interview, E2 acknowledged that the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and inaccessible to residents. Findings include: 1. During the environmental inspection, the Compliance Officers observed a cupboard in the kitchen that was unlocked and contained: ·        Palmolive Liquid dish soap ·        Febreze air freshener ·        Unlabeled bottle of liquid product ·        Remeady – Spray cleaner 2. During the environmental inspection, the Compliance Officers observed two buckets of powder laundry soap stored in the facility's unlocked laundry room. 3. In an interview, E2 acknowledged there were poisonous or toxic materials stored by the assisted living facility that were not in a locked or secure area and inaccessible to residents.”

“Based on observation and interview the manager failed to ensure that combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in the original labeled containers or safety containers in a locked area inaccessible to residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed a propane tank and two small propane bottles in the backyard, unsecured and accessible to residents. 2. In an interview, E2 acknowledged that the combustible or flammable materials stored by the facility were not in a locked area and inaccessible to residents.”

“Based on observation, documentation review, and interview the manager failed to ensure that pets or animals were licensed with local ordinances and vaccinated against rabies. The deficient practice posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers observed a dog at the facility, known by the residents by name. 2. The Compliance Officers requested the dog's vaccination and licensing records at approximately 10:15 AM. However, the required documentation was not available for review. 3. In an interview, E2 reported the dog was just visiting the facility. E1 acknowledged the pet at the facility was not licensed consistent with local ordinances and was not vaccinated against rabies.”