Willow Canyon LLC.

“Based on observation, documentation review, record review, and interview, the manager failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(A) for one of four sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population.     Findings include:     1. During the environmental inspection of the facility, the Compliance Officer observed E2, E3, and E4 working at the facility at the time of inspection. E2, E3, and E4 identified themselves as caregivers. E1 was not at the facility at the time of inspection.     2. A.R.S. § 36-411(A) 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work."     3. A review of facility documentation revealed staff schedules for the previous 12 months. The schedules revealed E3 was scheduled for multiple shifts at the facility each month between July 16, 2025, and April 23, 2026.     4. A review of E3's personnel record revealed a fingerprint clearance card that expired on July 16, 2025. E3 had no current, valid fingerprint clearance card from July 16, 2025, to the time of inspection.     5. A review of the Department of Public Safety website revealed E3’s fingerprint clearance card had expired on July 16, 2025.     6. In an interview, E2 reported that the facility went to a 3rd party fingerprinting company and did not complete the process for the fingerprinting for E3.      7. In an interview, E3 acknowledged E3's fingerprint clearance card had expired. 8. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of four sampled employees. 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 the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel.   3. A review of E1’s personnel record revealed E1 was hired in 2024. The review revealed a negative TST dated as read on May 15, 2025. However, a second TST was not available for review.   4. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 5. This is a repeat deficiency from the inspection conducted on April 15, 2025.”

“Based on observation and interview, the manager failed to ensure that medications stored by the facility were stored in a locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a health and safety risk for medications to be stored inappropriately.     Findings Included:     1. During an environmental inspection with E2, the Compliance Officer observed medication in the kitchen refrigerator in a self-contained unit used only for medication storage; however, the self-contained unit used only for medication storage was not locked. The medications were:   2 Bottles of “Lorazepam 2MG/mL 0.25 mL oral” 2 Bottles Morphine Sulf 20MG/mL 1 Bottles Morphine Sulf 10MG/mL 1 Bottle Morphine 100MG/54mL 0.25 mL (5.MG) per syringe     2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents.      Findings include:     1. During an environmental inspection of the facility, the Compliance Officer observed a water temperature of 148.4º F in a resident room and 156.7º F in the common restroom.     2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for five of five employees reviewed. The deficient practice posed a TB exposure risk to residents and the Department was unable to determine substantial compliance as the documentation was not provided during the inspection. 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 E2's, E3's, E4's, E5's, and E6's personnel record revealed two Mantoux skin tests dated within 12 months of each other as required for employees. However, a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. 3. In an interview, E2 acknowledged E2, E3, E4, E5, and E6 did not provide documentation of freedom from infectious TB as specified in R9-10-113.”

“Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1), for five of six employees sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence to show E1, E2, E3, E4, and E5 were fit to work at the assisted living facility. Findings include: 1. A.R.S. \'a7 36-411(C)(1) states: "1. Owners shall make 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, nursing care institution or home health agency." 2. A review of E1's, E2's, E3's, E4's, and E5's personnel records revealed no documentation of evidence to indicate a good faith effort to contact previous employers was made to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 3. In an interview, E2 acknowledged E1's, E2's, E3's, E4's, and E5's personnel records did not include the documentation required in A.R.S. \'a7 36-411(C)(1). E3 acknowledged the reference checks were not done.”

“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 days before the individual was accepted by an assisted living facility, and, if the individual was requesting or was expecting to receive supervisory care services, personal care services, or directed care services, included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician's assistant, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed there was no documentation indicating whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E2 acknowledged R1's medical record did not contain documentation that was dated within 90 days before the individual was accepted by the assisted living facility and was signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant. After a review of R1's medical record, E2 stated, "To be honest, we don't have it."”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk of a medication error if medication administered to a resident was not documented. Findings include: 1. A review of R2's medical record revealed a service plan dated January 15, 2024. The service plan revealed R2 received medication administration. 2. A review of R2's medication administration record (MAR) revealed R2 received medication administration of the following medications with PM administration: -Sulfasalazine 500 mg, two tablets at 5:00 PM; -Naproxen Sodium 220 mg, one tablet at 5:00 PM -Haloperidol 0.5 milligrams (mg), one tablet at 12:00 PM and 8:00 PM; and -Atorvastatin 20 mg, one tablet at 8:00 PM; 3. A review of R2's medication organizer revealed individual compartments for Morning, Noon, Evening, and Bedtime medications. The Compliance Officer observed five tablets in the evening compartment and confirmed they were the medications scheduled for administration at 5:00 PM and 8:00 PM. The bedtime compartment was empty. 4. In an interview, E2 reported all evening and bedtime medications were administered at 8:00 PM, not separately at 5:00 PM and 8:00 PM as documented on the MAR. E2 acknowledged the time of medication administration of the aforementioned medications was not being accurately documented.”

“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. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. Upon entry into the facility, the Compliance Officer observed a medication cart with the locking mechanism out, indicating the medication cart was unlocked. The keys were also hanging in the lock. 2. During a review of R2's medications, the Compliance Officer observed E4 take a lockbox out of the refrigerator. There was a small padlock on the lockbox. However, the padlock was not locked and the Compliance Officer observed medication was stored inside. 3. In an interview, E2 acknowledged the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.”

“Based on observation, documentation review, and interview, the manager failed to ensure a smoke detector was tested at least once a month. The deficient practice posed a health and safety risk if the smoke detectors did not work properly during an emergency. Findings include: 1. During a tour of the facility, the Compliance Officer observed there was no fire alarm system installed at the facility. 2. In an interview, the Compliance Officer requested monthly smoke detector testing documentation. A review of facility records revealed smoke detector testing documentation was not available for review. 3. In an interview, E2 acknowledged E2 did not have smoke detector testing documentation. E2 stated, "I believe they work."”

“Based on documentation review and interview, the governing authority failed to designate, in writing, an acting manager, if the manager was expected not to be present or was not present on the assisted living facility's premises for more than 30 calendar days. The deficient practice posed a risk to the health and safety of the residents as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. A review of Department documentation revealed the Compliance Officer was on-site at AL10614 for a compliance inspection on June 27, 2023. 2. While on-site on June 27, 2023, the Compliance Officer observed E5's manager's certificate hanging on the facility's wall. The Compliance Officer communicated to E3 and E4 that the Department had not received notification of E5's appointment as manager of the facility. 3. Upon hearing the aforementioned information from the Compliance Officer, E4 emailed the Department and reported that E5 was the facility's manager, effective April 1, 2023. 4. In an email to the Department received on or around November 28, 2023, E5 reported E5 had been out of the country since June 23, 2023. E5 included documentation of E5's flight information showing that E5 left the country for the Philippines on June 23, 2023 with a return date of December 22, 2023. 5. In an on-site complaint investigation conducted December 1, 2023, the Compliance Officer observed E1's manager's certificate hanging on the facility's wall. The Compliance Officer communicated to E2 and E3 that the Department had not received notification of E1's appointment as manager of the facility. 6. In an interview, the Compliance Officer asked who managed the facility while E5 was out of the country. E2 and E3 believed E5 to be the manager. E2 and E3 reported not being aware that if the manager was expected not to be present or was not present on the assisted living facility's premises for more than 30 calendar days, an acting manager must be appointed.”

“Based on observation, documentation review and interview, the governing authority failed to notify the Department according to 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. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. In an on-site complaint investigation, the Compliance Officer observed E1's manager's certificate conspicuously posted in the facility. 2. A review of Department documentation revealed an email dated June 27, 2023 from E4. The email indicated O1 was the facility's manager effective April 1, 2023. However, there was no documentation to indicate E1 was the new manager. 3. In an interview, E2 and E3 reported E1's date of hire as the manager of the facility was November 15, 2023. E2 and E3 reported to believe E1 notified the Department of the facility's change of manager, but E2 and E3 were not sure. This is a repeat deficiency from the compliance inspection conducted June 27, 2023.”