The Peaks, a Senior Living Community.

“Based on record review and interview, the manager failed to ensure that if a manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation had occurred on the premises the manager documented the immediate action to stop the suspected abuse, neglect, or exploitation and report the suspected abuse, neglect, or exploitation to a peace officer or to the adult protective services (APS) central intake unit. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: A.R.S. § 46-454. states, "Duty to report abuse, neglect and exploitation of vulnerable adults; duty to make medical records available; violation; classification A. A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online. B. If an individual listed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law, the individual is deemed to have complied with the requirements of subsection A of this section by reporting or causing a report to be made to the health care institution in accordance with the health care institution's procedures."  1. A review of R1’s and R2’s medical records revealed a document titled, “Resident Incident Report”. The document stated, “Resident stated that [R2’s] roommate punched [R2] in the face (on the right of the cheek) when [R2] was coming out of the bathroom. Resident stated the room was dark and [R2] was not able to see if [R2’s] roommate’s hand was in a fist, but [R2] states it felt like [R2] was punched with a fist.” The document indicated the incident occurred May 9, 2026 and the manager on duty was notified on the date of the incident. The document did not report that a peace officer was called. The document reported APS was notified May 12, 2026.  2. In an interview, E3 acknowledged APS was not notified immediately .  3. In an exit interview, the findings were reviewed with E1 and E3 and no additional information was provided.  This is a repeated violation from the on-site compliance and complaint inspection completed on April 2, 2026.”

“Based on record review, documentation review, and interview, the manager failed to ensure that an individual authorized to administer opioids identified the resident's need for an opioid before administering the opioid and monitored the resident's response to the opioid for residents who did not have an active malignancy or an end-of-life condition. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R8’s medical record revealed a signed service plan dated March 2, 2026. The service plan revealed R8 received medication administration. The service plan did not indicate that R8 was receiving end of life care or had an active malignancy.  2. A review of R8’s medical record revealed a medication order with a start date of October 2025 for Hydrocodon-Aceta 5-325 MG.  3. A review of R8’s medical record revealed a medication administration record (MAR) for Hydrocodon-Aceta 5-325 MG. Hydrocodon-Aceta 5-325 MG was administered on the following days: October 9, 2025 to October 13, 2025 October 15, 2025 to October 18, 2025 October 22, 2025 to October 25, 2025 October 27, 2025 to October 29, 2025 November 19, 2025 to November 21, 2025 February 6, 2026 March 11, 2026 March 13, 2026 The section for “Reason Given” had “Pain” listed for the above dates. The section for “Result” had “effective” or “somewhat effective” listed for the above dates. However there is no pain level recorded.  4. A review of the facility policies and procedures revealed a policy titled, “Narcotic Policy” which stated, “3. For residents who can express pain level: the licensed nurse/ trained caregivers will use the NRS tool: verbal pain rating scale. 4. For Residents who are nonverbal or cannot express pain level, the licensed nurse/ trained caregivers will use the Wong-Baker faces tool to determine pain level. 7. Licensed nurse/ trained caregiver will reassess resident pain level after administration and document if medication is effective or non-effective.” 5. In an interview, E8 reported there were no pain levels recorded.  6. In an exit interview, the findings were reviewed with E1, E8, and E9 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that if a manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation had occurred on the premises the manager documented the immediate action to stop the suspected abuse, neglect, or exploitation and report the suspected abuse, neglect, or exploitation to a peace officer or to the adult protective services central intake unit. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: A.R.S. § 46-454. states, "Duty to report abuse, neglect and exploitation of vulnerable adults; duty to make medical records available; violation; classification A. A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online. B. If an individual listed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law, the individual is deemed to have complied with the requirements of subsection A of this section by reporting or causing a report to be made to the health care institution in accordance with the health care institution's procedures."  1. A review of R7’s medical records revealed a couple of documents titled, “Resident Incident Report”. An incident report dated April 1, 2026 revealed, “[R7] was sitting in a chair that another resident grabbed the arm of and [R7] pouched [the other resident] in the hand that was holding the chair.” A further review of the incident report did not indicate that adult protective services (APS) or a peace officer was contacted. Another incident report dated November 7, 2025 revealed, "Resident [R10] sat down in the lounge area and then resident [R7] lifted [R7’s] left arm and striked resident [R10] on [R10’s] face. Resident [R10] didn’t show any emotion when striked.” A further review of the incident report did not indicate that APS or a peace officer was contacted.  2. In an exit interview, the findings were reviewed with E1, E8, and E9 and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to verify and document a caregiver's skills and knowledge before the caregiver provided physical health services, for four of seven personnel members sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy titled, “Staff skills, Knowledge, and competency verification,” which stated, "Prior to independent assignment staff must: 1. Complete orientation training. 2. Demonstrate skills through: -return demonstration -skills checklists -written or verbal testing,” 2. A review of E2’s personnel record revealed E2’s schedule. The schedule revealed E2 worked September 13, 2024, September 14, 2024, and September 15, 2024.  3. A review of E2’s personnel record revealed E2’s "Relias Transcript” which revealed E2’s “Arizona Med Aid Skills Checklist” was completed August 8, 2025 and “Arizona Caregiver Skills checklist” was completed August 27, 2025. 4. A review of E4’s personnel record revealed E4’s schedule. The schedule revealed E4 worked December 22, 2025, December 23, 2025, December 25, 2025, December 26, 2025, December 30, 2025, and December 31, 2025. 5. A review of E4’s personnel record revealed E4’s "Relias Transcript” which revealed E4’s “Arizona Caregiver Skills checklist” was completed January 2, 2026.  6. A review of E6’s personnel record revealed E6’s schedule. The schedule revealed E6 worked January 23, 2026, January 26, 2026, January 28, 2026, January 29, 2026, February 2, 2026, February 3, 2026, February 5, 2026, February 6, 2026, February 7, 2026, February 9, 2026, February 12, 2026, February 13, 2026, February 15, 2026, and February 16, 2026. 7. A review of E6’s personnel record revealed E6’s "Relias Transcript” which revealed E6’s “Arizona Caregiver Skills checklist” was completed February 19, 2026.  8. A review of E7’s personnel record revealed E7’s schedule for March 23, 2023 to April 23, 2023. The schedule revealed E7 did not work March 23, 2023, March 26, 2023, April 1, 2023, April 8, 2023, April 14, 2023, April 15, 2023, April 21, 2023, and April 22, 2023. E7 worked the days that were not listed from March 23, 2023 to April 23, 2023. 9. A review of E7’s personnel record revealed E7’s "Relias Transcript” which revealed E7’s “Arizona Med Aid Skills Checklist” was completed May 2, 2025 and “Arizona Caregiver Skills checklist” was completed May 5, 2025. 10. In an interview, E8 reported when the schedule mentioned “ORIENT” and “INSRV-ED” that means the employee was being orientated to the facility or doing Relias training respectively. The dates mentioned above did not have “ORIENT” and “INSRV-ED” on the schedules for E2, E4, E6, and E7. 11. In an exit interview, the findings were reviewed with E1, E8, and E9 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed a half door in the memory care unit’s kitchenette area. The Compliance Officer was able to reach over the door and open the half door. The following chemicals were found in unlocked cabinets: A bottle of Desolve Odorless Drain Line Control  A spray bottle of Grease Express Fast Foam Degreaser A bottle of windex  The Compliance Officer observed under the unlocked kitchenette sink a one gallon bottle of Sysco Classic Germiciadal Ultra bleach.  2. In an interview, E8 reported the chemicals listed above were not supposed to be in the kitchenette area.  3. In an exit interview, the findings were reviewed with E1, E8, and E9 and no additional information was provided. 4. Per facility staff, a lock was added to the cabinets during the inspection.”

“C. If an assisted living facility provides assistance in the self-administration of medication, a manager shall ensure that: 4. Assistance in the self-administration of medication provided to a resident: a. Is in compliance with an order, and”

“Based on record review and interview, the manager failed to ensure that assistance in the self-administration of medication provided to a resident was in compliance with an order. Findings include: 1. The record for R1 contained a physician's order for Eliquis 5mg tab, take 1 tab by mouth, twice daily. 2. Record review further indicated that the medication was to be discontinued on December 7, 2024. 3. The medication administration record (MAR) for R1 indicated that the medication had continued to be administered until December 10, 2024 at 8am. 4. During an interview, E1 stated, "There was a miscommunication. We discontinued the medication as soon as we realized the error."”

“Based on record review and interview, the manager failed to ensure that a sample resident record contained a service plan that included the level of service the resident was expected to receive. Findings include: 1. The record for R3 contained a service plan dated November 4, 2023 that did not include the level of service the resident received. 2. During an interview, E1 acknowledged the resident record did not contain the required information.”

“Based on record review and interview, the manager failed to ensure that a sample resident record contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services. Findings include: 1. The record for R3 contained service plan reviews reflecting the following dates of completion: November 4, 2023 and August 28, 2024. 2. During an interview, E1 acknowledged the service plan documentation did not reflect that the plans were reviewed and updated at least once every six months.”

“Based on record review and interview the manager failed to ensure for a sample service plan, the service plan that when updated, was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan. Findings include: 1. Review of the record for R3 (receiving medication administration), revealed that the service plan dated August 28, 2024 was not signed and dated by the resident or their representative, the manager or the nurse or medical practitioner who reviewed the service plan. 2. During an interview E1 acknowledged the required documentation was not available for review.”

“Based on record review and interview, the manager failed to ensure that two of two sample resident records, had service plans that were reviewed and updated at least once every three months for a resident receiving directed care services. Findings include: 1. The record for R1 contained a service plan that was last updated on January 18, 2024. 2. The record for R2 contained a service plan that was last updated on February 19, 2024. 3. During an interview, E1 acknowledged that service plan documentation did not reflect that updates were conducted at least once every three months.”

“Based on record review, facility documentation review and interview, the Manager failed to ensure that a resident was treated with dignity, respect and consideration. Findings include: 1. Review of the record for R1 revealed an incident report dated April 2, 2024 that indicated witnesses had observed E2 "yelling" at R1 and telling R1 that "You are being mean to staff and need to stop". Additionally, witnesses claimed that E2 was observed "using frequent profanity" when referring to residents. 2. Review of facility documentation revealed that the internal investigation conclusion was that E2 "should be terminated from employment at The Peaks as to not put residents at risk of emotional abuse." E2 was terminated on April 10, 2024. 3. During an interview, E1 acknowledged E2 failed to treat R1 with dignity, respect and consideration.”

“Based on record review and interview, the manager failed to ensure that for three of three sample resident records, a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for each resident. Findings include: 1. The record for R1 did not contain the completed emergency responder patient information documentation. 2. The record for R2 did not contain the completed emergency responder patient information documentation. 3. The record for R3 did not contain the completed emergency responder patient information documentation. 4. During an interview, E1 acknowledged that the required documentation was not available for review.”

“Based on observation and interview, the manager failed to ensure that the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection can be found, was conspicuously posted. Findings include: 1. Observation of the locked memory unit failed to reveal a posting indicating the location at which a copy of the most recent Department inspection report can be found. 2. During an interview E5 acknowledged the required documentation was not conspicuously posted. This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.”

“Based on record review and interview, the manager failed to ensure that one of four sample personnel records contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. Findings include: 1. The personnel record for E2 (Manager Designee, hired July 10, 2023) contained documentation indicating that only one TB test was administered; however, this TB test was not done within the 12 month period prior to the date of hire. 2. During an interview, E1 acknowledged that the employee worked more than 8 hours per week and the documentation did not reflect that the employee's record contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.”

“Based on record review and interview, the manager failed to ensure for one of four records that before providing personal care services or directed care services to a resident, a caregiver provides documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults. Findings include: 1. The record for E3 (hired February 24, 2023), revealed documentation of CPR and First Aid certifications that expired on December 8, 2023. 2. During an interview, E1 acknowledged that the required documentation was not available for review. This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.”

“Based on record review and interview, the manager failed to ensure that one of three sample resident records contained evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident's date of occupancy as specified in R9-10-113. Findings include: 1. The record for R2 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required. 2. During an interview, E1 acknowledged that the record did not contain evidence of freedom from TB.”

“Based on record review, observation and interview, the manager failed to ensure that two of two sample service plans for residents who were storing medication in their bedrooms, included how the medication would be stored and controlled. Findings include: 1. During an interview, E1 indicated that R2 self-administered their own medications and stored the medications in their room. 2. The record for R2 contained a service plan dated August 10, 2023 that did not include how the resident's medication would be stored and controlled. 3. During an interview, E1 indicated that R3 self-administered their own medications and stored the medications in their room. 4. The record for R3 contained a service plan dated December 21, 2023 that did not include how the resident's medication would be stored and controlled. 5. During an interview, E1, acknowledged the service plans did not indicate how the resident's medication would be stored and controlled in their rooms. This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.”

“Based on record review and interview, the manager failed to ensure that two of two sample resident records contained documentation of notification to the resident of the availability of vaccinations for influenza and pneumonia. Findings include: 1. The record belonging to R1 contained no documentation indicating that the resident had been notified of the availability of pneumonia vaccination, and the last documentation indicating that the resident was last notified of the availability of the influenza vaccination was dated October 8, 2022. No additional documentation indicating when the resident had been offered, refused or received either vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required. 2. The record belonging to R3 contained documentation indicating that the resident was last notified of the availability of the influenza vaccination on November 2, 2022. No additional documentation indicating when the resident had been offered, refused or received the vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required. 3. During an interview, E1 acknowledged that the required documentation was not available for review.”

“Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The toxicology guide available for use by personnel members was the Poisoning and Drug Handbook, 6th. edition. 2. The Internet web site for the toxicology guide revealed that a more current edition was available for distribution. 3. During an interview, E1 acknowledged that a current toxicology reference guide was not available for use by personnel members. This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.”

“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. Findings include: 1. Twelve months of facility disaster drill documentation was requested. Review of the disaster drill documentation provided revealed that disaster drills were conducted for each shift on the following dates: March 11, 2023, and May, 2023. No other disaster drill documentation was available for review. 2. During an interview, E1 acknowledged the requested documentation was not available for review. This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.”

“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. Findings include: 1. Twelve months of facility employee and resident evacuation drill documentation was requested. Review of the evacuation drill documentation provided revealed that an evacuation drill was conducted for employees on November 9, 2023. No other evacuation drill documentation was available for review. 2. During an interview, E1 acknowledged the requested documentation was not available for review.”

“Based on observation and interview, the manager failed to ensure that oxygen cylinders were secured. Findings include: 1. Two large oxygen cylinders were observed sitting upright and unsecured on R4's closet floor. 2. During an interview, E5 acknowledged the oxygen cylinders were not secured. This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.”

“Based on documentation review and interview, the chief administrative officer failed to ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review. Technical assistance was provided on this Rule during the compliance inspection conducted on February 23, 2023.”