The Manors at Glencroft.

“Based on documentation review, 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 the report of 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: 1. A.R.S. § 46-454. stated, "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."  2. In an interview, E3 reported R1 hit R4, on the back during an activity due to agitation with the noises made by R4. 3. A review of the facility's records revealed documentation of an incident that occurred on March 31, 2026. This documentation stated, "What Happened: The activity staff has informed this staff of an event happening during the dining experience activity. The residents were brought over to participate in the dining experience activity. There was a group of four residents sitting at the table and they started to drum on the table. [R1] became upset with this and said, "stop that". One of the three had stopped drumming on the table but [R1] was still upset at the other two. [R1] had hit the one who stopped on back with an open hand to his upper back. The activity had removed [R1] to a different table. Once the residents were back in the building this is when this writer was told about the event. All parties was notified of the event." According to this report, the facility took immediate action by separating R1 and R4, however, E1 reported that they did not report this incident to a peace officer or Adult Protective Services. 4. A review of the facility's documentation revealed an incident report concerning an incident involving R1 punching an unknown caregiver in the chest on April 14, 2026. In this report, there was no documentation of immediate action to stop the suspected abuse. 5. In an interview, E3 reported that R1 had been having an ongoing behavioral issue with many verbal outbursts and displays of agitation. 6. In an exit interview, the findings were reviewed with E1 and no additional information was provided.  7. This is a repeat deficiency from the inspection conducted on April 15, 2025.”

“Based on record review, documentation review and interview, the manager failed to ensure that the medication administered to a resident was documented in the resident's medical record in compliance with the medication order. Findings include: 1. A review of R5's medical record revealed a document titled "Physician's Orders", which included various medications, one of which was MIDODRINE HCL 5 MG TABLET TAKE 1 TABLET BY MOUTH EVERY 8 HOURS FOR SBP<110 (HOLD FOR SBP>131). 2. A review of R5's medication administration record for January 2026 revealed Midodrine was listed under the exceptions notes as "Med Unavailable - Notify Coordinator" on the following dates: January 21, 2026 - 2:00 pm and 8:00 pm January 22, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 23, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 24, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 25, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 26, 2026 - 8:00 am and 8:00 pm January 27, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 28, 2026 - 8:00 am and 2:00 pm January 29, 2026 - 8:00 am and 2:00 pm January 30, 2026 - 8:00 am, 2:00 pm, and 8:00 pm 3. Further review revealed Midodrine was administered on the following dates: January 26, 2026 - 2:00 pm January 28, 2026 - 8:00 pm January 29, 2026 - 8:00 pm 5. In an interview, E1 reported that the medication administration record showed the wrong documentation for Midodrine. The medication would not have been available. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454 and document the actions taken by the manager to prevent the suspected abuse from occurring in the future. The deficient practice posed a risk to the physical health and safety of a resident.   Findings include:   1. A.R.S. § 46-454(A) states: "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 vulnerable 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...The reports required by this subsection shall be made immediately by telephone or online."   2. Arizona Administrative Code (A.A.C.) R9-10-101(111) states, "'Immediate' means without delay."   3. A review of facility documentation revealed an incident report regarding an altercation between R1 and R2 dated March 21, 2025. The report stated “this writer was assisting another resident with … ADLs when I heard a resident yelling not twice. went to see what was happening since resident was safe on the seat. this writer saw ... (R2) … and (R1) in the hallway… (R2) … was walking towards the living room area one slightly further away. (R1) grabbed the closes … (R2) elbow saying, “I was talking to (R2)”… (another resident) told (R1) to let go and shook off (R1) hand. this writer was trying to get (R1) attention while walking towards all three. once there this writer had stepped in between the (R2) … and (R1). this writer had the (R2) … walk away. at this time this writer convinces the (R1) to go into … room. once there was able to get (R1) to sit in … recliner with cat and tv on. once (R3) was calm enough this writer stepped out of (R3) room.” However, Adult Protective Services (APS) was only notified on March 24, 2025 at 3:14 PM. In addition, the incident report did not include documentation for any action taken to prevent the incident from occurring in the future.   4. In an interview, E1 reported that there were several incidents with R1 that weekend and acknowledged the altercation between R1 and R2 was not reported to APS immediately and the incident report did not include documentation of any action taken to prevent the incident from occurring in the future.”

“Based on record review and interview, for one of two employees reviewed, the governing authority failed to ensure an employee submitted a completed application to the department of public safety, with twenty days of working, and failed to ensure an employee who was denied a fingerprint clearance card, was not allowed to continue employment without having submitted a good cause exception. The deficient practice posed a risk to a resident who was financially exploited by an employee who had a documented history of repeated criminal offenses, and was allowed to continue to work unsupervised, with residents without having submitted a good cause exception after being denied a fingerprint clearance card. A.R.S. \'a7 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions 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. E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked. Findings include: 1. In record review, the personnel record for E3 (hired August 22, 2023, as a housekeeper), did not include documentation the employee submitted a completed application for fingerprint clearance within twenty days after the date E3 began working at the facility. 2. In record review, E3's record included documentation of a "Notice of Denial," from the Arizona Board of Fingerprinting, dated November 16, 2023, and stamped as "Received December 20, 2023." The Notice of Denial letter listed extensive and repeated offenses and criminal history information, including, but not limited to: "Possession, Use or Sale of Narcotic Drugs... Dangerous Drugs... Felony Sale, Distribute, Transport, Offer to Sell, Transport, Distribute or Conspire to Sell... Dangerous or Narcotic Drug... Forgery... Criminal Impersonation... Shoplifting..." 3. In record review, E3's record included a documentation package for a good cause exception, with a copy of a certified mail receipt, dated February 15, 2024, and addressed to the Arizona Board of Fingerprinting. 4. During an interview, E1 reported the facility's Human Resources department was notified by an employee that R1 reported [R1] purchased breakfast and lunch for E3, and bought E3 a car for $1000.00. E1 reported the allegation of potential exploitation of R1, as required, and conducted an investigation. 5. In documentation review, the facility's investigation of the allegation revealed a total of $840.50 of purchases made by R1, for meals from the facility's dining room, which were charged to R1's account, and were picked up by E3. The charges were incurred from December 1, 2023, through March 1, 2024. The documentation revealed E3 was terminated from employment on March 1, 2024. 6. During an interview, E2 reported E3 submitted a fingerprint clearance card application to DPS; however, E2 was unable to locate the documentation of the fingerprint clearance card application. E2 acknowledged E3 was denied a fingerprint clearance card, and was allowed to continue working as a housekeeper at the facility, unsupervised and provided direct supportive services, without having applied for a good cause exception (until February 15, 2024) after being denied a FP clearance card, on November 16, 2023. E1 and E2 reported E3 worked day shifts Monday - Friday from 7:00am - 3:30pm. 7. During an interview, the findings were reviewed with E1 and E2, who acknowledged E3's personnel record did not include documentation an application for a fingerprint clearance card was submitted to DPS, as required, and that E3 continued working at the facility without having applied for a good cause exception.”