Starlight Care Seniors, LLC.

“Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program that, at a minimum, included the frequency of submitting a documented report to the governing authority. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management Program Including Incident Reports" reviewed and signed by E1 in 2025. This policy stated, "In order to provide quality and safe services to the facility residents, the manager shall ensure that: 1. Facility personnel will document and evaluate incidents at the facility to ensure quality services are provided. 2. A copy of each filled out form regarding the incident, accident, emergency, unusual occurrence, or event that puts the resident in danger, including incidents regarding opioid-related adverse reactions or other negative outcomes a resident experiences, or opioid-related deaths, will be placed in the QOS Folder and the Quality of Service Monthly Recording Form. Information collected is to be used to accurately report and evaluate services provided to residents as per procedure below. 3. Facility may use a survey tool (Quality of Service Monthly Recording Form) to help in identifying and collecting information. Data and reports collected are used to identify a concern..." However, no documentation of any quality management program was available for review. 2. In an interview, E1 reported that the quality management program was implemented; however, it was unavailable to locate at the time of inspection. 3. In an exit interview, findings were discussed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure the quality management report required in R9-10-804(2) and the supporting documentation for the report was maintained for at least 12 months after the date the report was submitted to the governing authority. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. R9-10-804.2.a-b states: A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes: a. An identification of each concern about the delivery of services related to resident care, and b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care; and 2. A review of the facility's policies and procedures revealed a policy titled "Quality Management Program Including Incident Reports," reviewed and signed by E1 in 2025. This policy stated, "5. Documentation of all reports made in regards to the resident care will be submitted to the governing authority... The facility governing authority reviews and evaluates the effectiveness of the quality management program at least once every 12 months." 3. The Compliance Officer requested to review the facility's quality management report and supporting documentation for the report as required in subsection (2). However, a quality management report was not available for review. 4. In an interview, E1 reported that the quality management program was implemented; however, it was unavailable to locate at the time of inspection. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review, observation and interview, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication that was administered, for two of two residents sampled. The deficient practice posed a health and safety risk.   Findings include:   1. A review of R1's medical record revealed a current written service plan that included personal care services and medication administration.   2. A review of R1's medical record revealed an August 2025 and September 2025 electronic medication administration record (eMAR). The eMAR included the following medication, which was administered to R1 from August 2025 to present; -Diclofenac 1% Gel – Otc Apply 2 Grams Topically To Affected Area(S) 4 Times Daily – 8:00 Am, 12:00 Pm, 5:00 Pm, 8:00 Pm -Nitrofurantoin Mono-Mcr 100 Mg Take 1 Capsule By Mouth Twice Daily – 8:00 Am, 5:00 Pm -Tamsulosin Hcl 0.4 Mg Capsule Take 1 Capsule By Mouth Once Daily – 8:00 Am -Diclofenac Sod Ec 75 Mg Tab Take 1 Tablet By Mouth Twice Daily – 8:00 Am, 5:00 Pm   3. A review of R1's medical record revealed no documentation of a signed medication order or verbal medication order for the above-mentioned medication. However, a review of the medication recap revealed the following active medications for R1: -Acetaminophen 325 mg Tablet (Tylenol 325 mg Tablet) Take 2 tablets by mouth every 4 hours as needed for pain or fever Start Date: 10/01/2024 – No End Date -Diclofenac 1% Gel – OTC Apply 2 grams topically to affected area(s) 4 times daily Start Date: 10/01/2024 – No End Date -Diclofenac Sod EC 75 mg Tab Take 1 tablet by mouth twice daily Start Dates: 10/01/2024 – No End Date -Nitrofurantoin Mono-Mcr 100 mg Take 1 capsule by mouth twice daily Start Dates: 09/10/2025 – No End Date -Sennoside S 8.6 mg–50 mg Take 2 tablets by mouth every evening as needed Start Dates: 10/01/2024 – No End Date -Tamsulosin HCl 0.4 mg Capsule Take 1 capsule by mouth once daily Start Dates: 05/04/2025 – No End Date     4. During an observation, the physical medications for R1 from Saliba's Pharmacy were observed to be available.   5. A review of R2's medical record revealed a current written service plan that included directed care services and medication administration. 6. A review of R2's medical record revealed an August 2025 and September 2025 eMAR. The eMAR included the following medication, which was administered to R2 from August 2025 to present; - Atorvastatin 40 mg tablet – Take 1 tablet by mouth at bedtime – 8:00 PM -Memantine HCL 5 mg tablet – Take 1 tablet by mouth every 12 hours for dementia – 8:00 AM, 8:00 PM -Acidophilus-Pectin Capsule (Acidophilus Capsule) – Take 1 capsule by mouth once daily – 8:00 AM -Eliquis 2.5 mg tablet – Take 1 tablet by mouth twice daily – 8:00 AM, 5:00 PM -Donepezil HCL 5 mg tablet – Take 1 tablet by mouth at bedtime – 8:00 PM -Fluoxetine HCL 20 mg cap – Take 1 capsule by mouth once daily in the morning – 8:00 AM -Bupropion HCL 75 mg tablet – Take 1 tablet by mouth once daily in the morning – 8:00 AM -Gabapentin 100 mg capsule – Take 1 capsule by mouth 3 times daily at 8:00 AM, 1:00 PM, and 8:00 PM – 8:00 AM, 1:00 PM, 8:00 PM -Bupropion HCL 100 mg tablet – Take 1 tablet by mouth once daily in the morning – 8:00 AM -Lisinopril 2.5 mg tab – Take 1 tab by mouth once daily; hold for SBP less than 110 – 8:00 AM  -Mirtazapine 15 MG Tablet – Take 1 Tablet by Mounth at Bedtime – 8:00 PM   7. A review of R2's medical record revealed no documentation of a signed medication order or verbal medication order for the above-mentioned medication. However, a review of the medication recap revealed the following active medications for R2: -Atorvastatin 40 mg Tablet – Take 1 tablet by mouth at bedtime Start Dates: 06/01/2025 – No End Date -Bisacodyl 10 mg Suppository (Dulcolax 10 mg Suppository) – Unwrap and insert 1 suppository rectally daily as needed for bowel care if Milk of Magnesia ineffective Start Dates: 10/18/2024 – No End Date -Bupropion HCL 100 mg Tablet – Take 1 tablet by mouth once daily in the morning Start Dates: 08/05/2025 – No End Date -Eliquis 2.5 mg Tablet – Take 1 tablet by mouth twice daily Start Dates: 04/29/2025 – No End Date -Fluoxetine HCL 20 mg Capsule – Take 1 capsule by mouth once daily in the morning Start Dates: 05/10/2025 – No End Date -Gabapentin 100 mg Capsule – Take 1 capsule by mouth 3 times daily at 8 am, 1 pm, and 8 pm Start Dates: 06/04/2025 – No End Date -Lisinopril 2.5 mg Tablet – Take 1 tablet by mouth once daily; hold for SBP less than 110 Start Dates: 08/05/2025 – No End Date -Memantine HCL 5 mg Tablet – Take 1 tablet by mouth every 12 hours for dementia Start Dates: 10/18/2024 – No End Date -Mirtazapine 15 mg Tablet – Take 1 tablet by mouth at bedtime Start Dates: 09/04/2025 – No End Date 8. During an observation, the physical medications for R2 from Saliba's Pharmacy were observed to be available.   9. In an interview, E1 reported that all signed orders were sent by the doctor to the pharmacy, and the pharmacy provided the medications and updated the eMAR. Therefore, the facility did not maintain signed medication orders. E1 acknowledged that R1's and R2's medical records did not contain a medication order from a medical practitioner for each medication administered.   10. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.   Findings include: 1. A review of R1's medical record revealed a current service plan that included personal care services and medication administration.   2. A review of R1's medical record revealed an August 2025 and September 2025 electronic medication administration record (eMAR). The eMAR included the following medication, which was administered to R1 from August 2025 to present; -Diclofenac 1% Gel – Otc Apply 2 Grams Topically To Affected Area(S) 4 Times Daily – 8:00 Am, 12:00 Pm, 5:00 Pm, 8:00 Pm -Nitrofurantoin Mono-Mcr 100 Mg Take 1 Capsule By Mouth Twice Daily – 8:00 Am, 5:00 Pm -Tamsulosin Hcl 0.4 Mg Capsule Take 1 Capsule By Mouth Once Daily – 8:00 Am -Diclofenac Sod Ec 75 Mg Tab Take 1 Tablet By Mouth Twice Daily – 8:00 Am, 5:00 Pm   3. A review of R1's medical record revealed no documentation of a signed medication order or verbal medication order for the above-mentioned medication. However, a review of the medication recap revealed the following active medications for R1: -Diclofenac 1% Gel – OTC Apply 2 grams topically to affected area(s) 4 times daily Start Date: 10/01/2024 – No End Date -Diclofenac Sod EC 75 mg Tab Take 1 tablet by mouth twice daily Start Dates: 10/01/2024 – No End Date -Nitrofurantoin Mono-Mcr 100 mg Take 1 capsule by mouth twice daily Start Dates: 09/10/2025 – No End Date -Tamsulosin HCl 0.4 mg Capsule Take 1 capsule by mouth once daily Start Dates: 05/04/2025 – No End Date     4. During an observation, the physical medications for R1 from Saliba's Pharmacy were observed to be available.   5. A review of R2's medical record revealed a current service plan that included directed care services and medication administration. 6. A review of R2's medical record revealed an August 2025 and September 2025 eMAR. The eMAR included the following medication, which was administered to R2 from August 2025 to present; - Atorvastatin 40 mg tablet – Take 1 tablet by mouth at bedtime – 8:00 PM -Memantine HCL 5 mg tablet – Take 1 tablet by mouth every 12 hours for dementia – 8:00 AM, 8:00 PM -Acidophilus-Pectin Capsule (Acidophilus Capsule) – Take 1 capsule by mouth once daily – 8:00 AM -Eliquis 2.5 mg tablet – Take 1 tablet by mouth twice daily – 8:00 AM, 5:00 PM -Donepezil HCL 5 mg tablet – Take 1 tablet by mouth at bedtime – 8:00 PM -Fluoxetine HCL 20 mg cap – Take 1 capsule by mouth once daily in the morning – 8:00 AM -Bupropion HCL 75 mg tablet – Take 1 tablet by mouth once daily in the morning – 8:00 AM -Gabapentin 100 mg capsule – Take 1 capsule by mouth 3 times daily at 8:00 AM, 1:00 PM, and 8:00 PM – 8:00 AM, 1:00 PM, 8:00 PM -Bupropion HCL 100 mg tablet – Take 1 tablet by mouth once daily in the morning – 8:00 AM -Lisinopril 2.5 mg tab – Take 1 tab by mouth once daily; hold for SBP less than 110 – 8:00 AM -Mirtazapine 15 MG Tablet – Take 1 Tablet by Mounth at Bedtime – 8:00 PM     7. A review of R2's medical record revealed no documentation of a signed medication order or verbal medication order for the above-mentioned medication. However, a review of the medication recap revealed the following active medications for R2: -Atorvastatin 40 mg Tablet – Take 1 tablet by mouth at bedtime Start Dates: 06/01/2025 – No End Date -Bisacodyl 10 mg Suppository (Dulcolax 10 mg Suppository) – Unwrap and insert 1 suppository rectally daily as needed for bowel care if Milk of Magnesia ineffective Start Dates: 10/18/2024 – No End Date -Bupropion HCL 100 mg Tablet – Take 1 tablet by mouth once daily in the morning Start Dates: 08/05/2025 – No End Date -Eliquis 2.5 mg Tablet – Take 1 tablet by mouth twice daily Start Dates: 04/29/2025 – No End Date -Fluoxetine HCL 20 mg Capsule – Take 1 capsule by mouth once daily in the morning Start Dates: 05/10/2025 – No End Date -Gabapentin 100 mg Capsule – Take 1 capsule by mouth 3 times daily at 8 am, 1 pm, and 8 pm Start Dates: 06/04/2025 – No End Date -Lisinopril 2.5 mg Tablet – Take 1 tablet by mouth once daily; hold for SBP less than 110 Start Dates: 08/05/2025 – No End Date -Memantine HCL 5 mg Tablet – Take 1 tablet by mouth every 12 hours for dementia Start Dates: 10/18/2024 – No End Date -Mirtazapine 15 mg Tablet – Take 1 tablet by mouth at bedtime Start Dates: 09/04/2025 – No End Date   8. During an observation, the physical medications for R2 from Saliba's Pharmacy were observed to be available. 9. In an interview, E1 reported that all signed orders were sent by the doctor to the pharmacy, and the pharmacy provided the medications and updated the eMAR. Therefore, the facility did not maintain signed medication orders. E1 acknowledged R1's and R2's medication was not administered in compliance with an available medication order.  10. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was accurately documented in the resident's medical record for two of two residents sampled. The deficient practice posed a risk as the medical record inaccurately indicated a medication was administered, and the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a current written service plan that included personal care services and medication administration. 2. A review of R1's medical record revealed no documentation of a signed medication order for the medication below. However, a review of the medication recap revealed the following active medications for R1: -Diclofenac 1% Gel – OTC Apply 2 grams topically to affected area(s) 4 times daily Start Date: 10/01/2024 – No End Date -Diclofenac Sod EC 75 mg Tab Take 1 tablet by mouth twice daily Start Dates: 10/01/2024 – No End Date -Nitrofurantoin Mono-Mcr 100 mg Take 1 capsule by mouth twice daily Start Dates: 09/10/2025 – No End Date -Sennoside S 8.6 mg–50 mg Take 2 tablets by mouth every evening as needed Start Dates: 10/01/2024 – No End Date -Tamsulosin HCl 0.4 mg Capsule Take 1 capsule by mouth once daily Start Dates: 05/04/2025 – No End Date 3. A review of R1's medical record revealed an August 2025 electronic medication administration record (eMAR). The eMAR had not documented the following medications for August 2025 as administered: -Diclofenac 1% Gel – Otc Apply 2 Grams Topically To Affected Area(S) 4 Times Daily 8:00 AM – August 4th, 7th , 9th , 11th –17th , 19th –21st , 24th , 27th –29th , and 31st. 12:00 PM – August 1st – 31st.  5:00 PM – August 1st – 4th, 6th – 31st.   8:00 PM – August 1st – 31st.  -Tamsulosin Hcl 0.4 Mg Capsule Take 1 Capsule By Mouth Once Daily  8:00 AM – August 26th 4. In an interview, E1 and E3 reported that the above-mentioned medications were administered; however, the administrations were not properly documented. 5. A review of R1's medical record revealed an August 2025 eMAR. The eMAR had documented the following medications for August 2025 as administered; -Nitrofurantoin Mono-Mcr 100 Mg – Take 1 capsule by mouth twice daily for 10 days – Times: 8:00 AM, 5:00 PM with a Start Date: 10/01/2024. However, this medication was prescribed for only 10 days and was administered on August 8th. During an observation of R1's medications, Nitrofurantoin Mono-MCR 100 mg was not observed. - Doxycycline Mono 100 Mg Cap Take 1 – Capsule By Mouth 2 Times A Day For 14 Days. Times: 8:00 Am, 5:00 Pm – Start Dates: 02/11/2025. However, this medication was prescribed for only 14 days and was administered on August 1st, 8th, and 26th. During an observation of R1's medications, Doxycycline Mono 100 Mg Cap was not observed. 6. In an interview, E1 reported that the above-mentioned medications had been discontinued and were not administered; however, they were documented in the eMAR as having been administered by error.     7. A review of R2's medical record revealed a current service plan that included directed care services and medication administration. 8. A review of R2's medical record revealed no documentation of a signed medication order for the medication below. However, a review of the medication recap revealed the following active medications for R2: -Atorvastatin 40 mg Tablet – Take 1 tablet by mouth at bedtime Start Dates: 06/01/2025 – No End Date -Bupropion HCL 100 mg Tablet – Take 1 tablet by mouth once daily in the morning Start Dates: 08/05/2025 – No End Date -Eliquis 2.5 mg Tablet – Take 1 tablet by mouth twice daily Start Dates: 04/29/2025 – No End Date -Fluoxetine HCL 20 mg Capsule – Take 1 capsule by mouth once daily in the morning Start Dates: 05/10/2025 – No End Date -Gabapentin 100 mg Capsule – Take 1 capsule by mouth 3 times daily at 8 am, 1 pm, and 8 pm Start Dates: 06/04/2025 – No End Date -Memantine HCL 5 mg Tablet – Take 1 tablet by mouth every 12 hours for dementia Start Dates: 10/18/2024 – No End Date 9. A review of R2's medical record revealed an August and September 2025 eMAR. The eMAR had not documented the following medications for August and September 2025 as administered; - Atorvastatin 40 mg tablet – Take 1 tablet by mouth at bedtime 8:00 PM – August 1st – 31st, September 1st to present. -Memantine HCL 5 mg tablet – Take 1 tablet by mouth every 12 hours for dementia 8:00 AM – August 4th 8:00 PM – August 1st – 31st. -Eliquis 2.5 mg tablet – Take 1 tablet by mouth twice daily 8:00 AM – August 4th. -Donepezil HCL 5 mg tablet – Take 1 tablet by mouth at bedtime 8:00 PM – August 1st – 31st. -Fluoxetine HCL 20 mg cap – Take 1 capsule by mouth once daily in the morning 8:00 AM – August 4th -Gabapentin 100 mg capsule – Take 1 capsule by mouth 3 times daily at 8:00 AM – August 4th 1:00 PM – August 3rd, 5th, 17th, 22nd – 24th, 27th and 31st, September 7th. 8:00 PM – August 1st – 31st, September 1st to present. -Bupropion HCL 100 mg tablet – Take 1 tablet by mouth once daily in the morning 8:00 AM – August 25th.   10. In an interview, E1 and E3 reported that the above-mentioned medications were administered to R2; however, the administrations were not properly documented.     11. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“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. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include:   1. A review of the facility's personnel schedule revealed there were two shifts: Day and Night. 2. A review of the facility's disaster drills revealed documentation of a disaster drill conducted on the following dates and times: -January 01, 2025 at 9:00 AM -January 01, 2025 at 6:00 PM -April 01, 2025, at 9:00 AM -April 01, 2025, at 6:00 PM However, no documentation was provided to demonstrate that a drill was conducted between April 2025 to present. 3. In an interview, E1 acknowledged that a disaster drill for employees was not conducted on each shift at least once every three months.  4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. This is a repeat deficiency from the compliance inspection conducted on May 18, 2022.”

“36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.”

“E. A manager shall ensure that, unless otherwise stated: 1. Documentation required by this Article is provided to the Department within two hours after a Department request; and”

“F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or”

“A. A manager shall ensure that: 1. A food menu: c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served,”

“A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;”

“Based on observation, interview and documentation review, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas and the Department was provided false and misleading documentation. Findings include: 1. The Compliance Officer observed three oxygen containers stored upright in R1's bedroom closet. One oxygen container was on a two-wheel vertical medical cylinder cart, however, two oxygen containers were not secured. 2. In an interview, E1 acknowledged there were unsecured oxygen containers in R1's bedroom closet. E1 reported E1 had attempted to have the oxygen containers returned to the home health company but had been unsuccessful. E1 acknowledged E1 submitted a plan of correction to the Department, stating the oxygen containers had been secured and acknowledged this was false information. 3. A review of facility documentation revealed a Plan of Correction (POC) received by the Licensee on September 19, 2023. The POC stated "The Manager secured both oxygen containers that were located in a resident's bedroom and are now safely stored in and [sic] upright position and secured, away from flammables and open flames. The Manager retrained and instructed all facility personnel to check and ensure that all oxygen containers are secured in an upright position." 4. Based on photographic evidence, obtained on August 22, 2023 and December 4, 2023, the oxygen containers were not secured and were in the same location. 5. Based on photographic evidence, obtained on December 4, 2023, the oxygen containers were not secured as indicated in the aforementioned POC. 6. Based on photographic evidence, provided by E1 on December 4, 2023, E1 attempted to purchase an oxygen cylinder storage rack through an online marketplace (date unknown). However, E1 did not follow-through with the purchase, though the seller contacted E1 three additional times to see if E1 was still interested in the oxygen cylinder storage rack, on October 2, October 4 and October 6, 2023. This deficiency was found to be uncorrected from the compliance inspection conducted on August 22, 2023.”