Hilda's Haven Alf #3.

“Based on documentation review and interview, the governing authority failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk if the effectiveness of the quality management program was not measured.  Findings include: 1. A review of the facility’s quality management documentation revealed the documentation evaluating the effectiveness of the quality management program every 12 months was not available for review.  2. Upon documentation review of the facility’s policies and procedures, the section titled “Quality Management Program including Incident Reports” stated, “The facility governing authority reviews and evaluates the effectiveness of the quality management program at least once every 12 months.” 3. In an interview, E1 and E3 reported the facility completed the monthly quality management reports, but not the annual review. 4. In an exit interview, the findings were discussed with E1 and E3, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a resident had a service plan established that included the amount, type, and frequency of assisted living services and ancillary services being provided to the resident for one of the two residents reviewed. The deficient practice posed a risk if a resident’s service plan did not include the services to be provided. Findings include: 1. A record review of R1’s current service plan, dated March 18, 2026, revealed the service labeled “Monitor skin integrity/Check pressure areas” did not have a frequency detailed.  2. A record review of R1’s activities of daily living (ADL) form, dated May 2026, revealed the following services had been provided to R1: “Comb Hair”; “Sponge bath”; and “Dressing.” 3. A record review of R1’s current service plan, dated March 18, 2026, revealed the following services had not been listed or marked in the service plan with an amount, type, or frequency: “Comb Hair”; “Sponge bath”; and “Dressing.” 4. In an exit interview, the findings were discussed with E1 and E3, and no additional information was provided.”

“Based on observation, department documentation review, documentation review, and interview, the manager failed to ensure there was a means of exiting a facility for a resident that provided access to a secure, outside area that allowed residents to be at least 30 feet (ft) away and monitored or alerted employees to 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 inspection of the facility, the Compliance Officers observed a door leading to the secure backyard area for one resident's room did not alarm when opened.  2. During the environmental inspection of the facility, the Compliance Officers observed the main backdoor leading to the secure backyard area of the facility did not alarm when opened. 3. During the environmental inspection of the facility, the Compliance Officers observed E2 turning the door alarms on and off. 4. During the department documentation review of the facility, the Compliance Officers confirmed the facility was licensed to provide directed care services. 5. Upon documentation review of the facility’s policies and procedures, the section titled “Environmental and Physical Plant Safety” stated, “Exit doors, and windows to the outside that a wandering resident may use, will be alarmed, to alert employees in the event such a resident may wander.” 6. In an interview, E3 and E2 reported the facility turned off the alarms. E1 and E3 acknowledged the door alarms must remain on at all times. 7. In an exit interview, the findings were reviewed with E1 and E3, and no additional information was provided.”

“Based on observation, record review, documentation review, and interview, the manager failed to ensure that if pets or animals were allowed in the assisted living facility, pets or animals were licensed consistent with local ordinances for the one pet record reviewed. The deficient practice posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed that R2 had a pet dog in the room. 2. A review of the facility pet records revealed that there was no documentation of a Maricopa license for the dog available for review. 3. Upon documentation review of the facility’s policies and procedures, the section titled “Environmental and Physical Plant Safety” stated, “Pets or animals are controlled to prevent endangering the residents and to maintain sanitation, are licensed with local ordinances, and cats and dogs are vaccinated against rabies.” 4. A review of Maricopa County's licensing website revealed the following statement: "All dogs in Unincorporated Maricopa County, Apache Junction, Avondale, Buckeye, Carefree, Cave Creek, Chandler, El Mirage, Fountain Hills, Gila Bend, Gilbert, City of Glendale, Goodyear, Guadalupe, Litchfield Park, Mesa, Paradise Valley, Peoria, Phoenix, Queen Creek, Scottsdale, Surprise, Tempe, Tolleson, Wickenburg, Youngtown must be licensed and vaccinated against rabies." 5. In an interview, R2 reported that R2 was the owner of the dog. 6. In an exit interview, the findings were reviewed with E1 and E3, and no additional information was provided.”

“Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed a document labeled "Fall prevention and recovery training programs." The program stated "All employees will have an initial training on fall prevention and recovery. After initial training, all employees will be required to attend continuing competency training on fall prevention and recovery at least every 12 months. Completion of the training shall be documented and included in the employee files." 2. A review of E1's personnel record revealed documented fall prevention and recovery training dated May 2022. However, E1's personnel record did not include a current annual training for fall prevention and recovery as required per the documented program. 3. In an interview, E3 acknowledged the facility's fall prevention and fall recovery program was not administered according to the documented program requirements.”

“Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of facility documentation revealed a policy and procedure manual labeled "Hilda's Haven of Coronado Ranch LLC DBA: Hilda's Haven ALF #3 Policy and Procedures." The documentation indicated the most recent review date was March 22, 2020. 2. In an interview, E3 acknowledged the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed.”