May's Haven, LLC.

“Based on documentation review and interview, the assisted living home failed to maintain a copy of the document provided to the emergency responder as prescribed in A.R.S. § 36-420.04.A.1-9, for one of four residents reviewed. The deficient practice posed a risk as the designated standards were not followed and the department was unable to ensure compliance with the applicable statute. Findings include: 1. A review of R1's medical record revealed a prepared EMS packet of paper in the front sleeve of the binder. The paperwork contained the required pre-filled standardized form and all necessary attachments. The packet also included recent hospital discharge information for both October 14, 2025, and October 20, 2025. However, there were no copies of the specific EMS forms that were provided to EMS at the time of the incident/transport for October 14, 2025, and October 20, 2025, available for review. 2. Further review of R1's medical record revealed progress notes with detailed information regarding the need to call for an EMS response for R1 on both October 14, 2025, and October 20, 2025, which resulted in R1 being transported to the hospital. 3. In an interview, E3 acknowledged E3 failed to make a copy of the EMS form provided to emergency responders for R1 on October 14, 2025, and October 20, 2025. E3 explained the EMS responders were moving quickly and E3 didn't have time to make a copy. E3 was able to show another incident where R1 had gone out to the hospital and E3 did ensure to keep a copy of the form. 4. In an interview, E1 acknowledged copies of the EMS form provided to emergency responders for R1 on October 14, 2025, and October 20, 2025 were not available for review at the time of the inspection.”

“Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis (TB) infection control activities that included annually assessing the health care institution's risk of exposure to infectious TB. Findings include: 1. A review of facility documentation revealed there was no documentation of an annual facility risk assessment to determine the facility's risk of exposure to infectious TB. 2. A review of the facility's policies and procedures revealed a policy titled "Tuberculosis ("TB") Testing." The policy talked about annually assessing individuals' symptoms via a Symptom Screen form; however, it did not include the requirement of annually assessing the facility as a whole. 3. In an interview, E1 reported that E1 believed E1 was following the requirements by completing annual symptom screenings on all staff and residents and explained how E1 believed this practice would have served as an annual assessment of the facility's risk of TB. E1 acknowledged E1 was unaware of the requirement to conduct an annual TB facility risk assessment as intended in R9-10-113.2.d.”

“Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included compliance with the requirements in A.R.S. § 36-411.C.2 and with policies and procedures, for four out of four personnel reviewed. The deficient practice posed a risk as required information had not be verified. Findings include: 1. A.R.S. § 36-411.C.2 states, "Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to...Verify the current status of a person's fingerprint clearance card." 2. A review of E1's, E2's, E3's, and E4's personnel records revealed that all four personnel began employment in 2013. Further review revealed that all four personnel had copies of current fingerprint clearance cards available for review in their respective records; however, the only documentation of verification of those fingerprint clearance cards was the verification that was done at the time of hire in 2013. 3. A review of the facility's policies and procedures revealed a policy titled "Fingerprint." The policy stated, "Manager shall verify the validity of the fingerprint clearance card at least once a year if the employee is continuing employment with the facility."  4. In an interview, E1 acknowledged the aforementioned fingerprint clearance cards had not been verified annually as required by the facility's policies and procedures.”