New Beginnings in Phoenix, LLC.

“Based on documentation review, record review, and interview, the manager of an assisted living home who contacted emergency responders on behalf of a resident failed to provide to the emergency responders a written document that included all information required in A.R.S. § 36-420.04 for one of one applicable residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.   Findings include: 1. A review of facility documentation revealed a progress note dated March 13, 2026. The progress note revealed R1 had been transported to the hospital. 2. A review of R1's medical record revealed no documentation to include all information required in A.R.S. § 36-420.04, including basic information about the resident's physical and mental conditions, as well as dates of recent episodes. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for two of three personnel sampled. 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel. The webpage states, "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing." 3. A review of E2 and E3's personnel records revealed one TB test, risk assessment, and signs and symptoms screening. 4. In an interview, E1 acknowledged that E2 and E3 did not have a second TB test. 5. 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 a resident was treated with dignity, respect, and consideration.       Findings include:       1. A review of facility documentation revealed an incident report, dated September 15, 2023, which documented an argument between E1 and R5. Additionally, the APS worker was on-site on this date and heard E1 say to R5, "You are crazy".      2. In an interview, E1 reported that APS opened an investigation for this. E1 showed the Compliance Officer the letter sent by APS dated September 30, 2024, that stated: "did not substantiate the allegation".       3. In an exit interview, E1 acknowledged saying the aforementioned statement above to R5 and apologized. The findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident's representative was designated for a resident who was unable to direct self-care. The deficient practice posed a risk as no individual was designated to participate in decisions concerning the assisted living services the resident was to receive. Findings include: 1. A.R.S. 36-401: "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need, or making basic care decisions. 2. Review of R4's medical record revealed a service plan dated August 1, 2025, indicating R4 received directed care services. However, no documentation to demonstrate that R4 had a designated representative was available for review. 3. In an interview, E1 acknowledged R4 received directed care services and reported that E1 was told by R4's family member, who admitted R4 to the facility, that they were the representative. 4. In the exit interview, the findings were reviewed with E1, and no further paperwork was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that documentation of medication administration showed the name and signature of the individual administering or providing assistance in the self-administration of medication for one of five residents reviewed.    Findings include:   1.   A review of documentation contained a policy and procedure which stated, "The trained caregiver will sign off the medication for the date and time the medication was given to the resident and the medications taken by initialing the medication administration record."   2.   A review of R1's medical record contained a Medication Administration Record for March 2026. The MAR did not contain caregiver initials documenting the medication was administered for the following medications on March 1, 2026 through March 12, 2026: Valproic Acid 250 mg take one tablet twice a day Memantine 10 mg take one tablet daily Lasix 20 mg take one tablet daily Rosuvastatin 10 mg take one tablet at bedtime Trazodone 100 mg take one tablet at bedtime Metformin 1000 mg take one tablet twice a day Glibizide 5mg take on tablet daily Famotidine 20 mg take one tablet daily Novolo flex pen 5 units with meals   3.   In an interview, E1 reported that the medication was provided to the resident but "forgot" to document on the record.     4.   In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that medication stored by an assisted living facility 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 the physical health and safety of residents with access to the medication. Findings include: 1. The Compliance Officer observed a box with medication that was located on a cabinet in the dining room area. The box was unlocked. Upon opening the box, the Compliance Officer observed a variety of resident medications, including Trazodone, Seroquel, and Lispro. 2. In an interview, E1 reported was recently working with the medication lock box but “didn’t lock it.” 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on December 7, 2023.”

“Based on documentation review and interview, the manager failed to ensure that, if the assisted living facility was authorized to provide directed care services, an elopement drill for employees was conducted every six months on each shift and document the date, time, and description of each drill. Findings include: that 1. A review of the facility's license revealed that the facility was licensed to provide Directed Care services. 2. A documentation review of the facility's disaster plan revealed no documentation of elopement drills. 3. In an interview, E1 acknowledged that the manager failed to ensure an elopement drill for employees was conducted every six months on each shift and to document the date, time, and description of each drill. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on interview and documentation review, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a potential risk of re-injury. Findings include: 1. In an interview, E1 reported R1 had an accident, emergency, or injury that resulted in R1 needing medical services on March 13, 2026. 2. A review of facility documentation revealed a note that R1 was not eating or drinking, and several methods were tried...Hospice was notified and recommended 911 be called. However, the report did not include: -The names of individuals who observed the accident, emergency, or injury; -The actions taken by the caregiver or assistant caregiver; The individuals notified by the caregiver or assistant caregiver; and - Any action taken to prevent the accident, emergency, or injury from occurring in the future. 3. In an interview, E1 reported E1 not documenting the aforementioned information. 4. In the exit interview, the Compliance Officer reviewed the findings with E1, and no additional paperwork was provided.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents.       Findings include:       1. During a tour of the facility, the Compliance Officer observed a metal table on the back patio of the facility. Items sitting on the table included insect spray, glass cleaner, and 3-1 ceramic cleaner.       2. In an interview, E1 acknowledged that cleaners and insecticides were not kept in a secure area, inaccessible to residents.   3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on December 7, 2023.”

“Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of two caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. The Compliance Officer observed E2 working with residents on-site during the inspection. 2. A review of E2's personnel record revealed no documentation of completion of a caregiver training program approved by the Department or the NCIA Board. 3. In an interview, E1 reported E2 was a volunteer caregiver with a certified nursing assistant (CNA) license. 4. A review of the Arizona State Board of Nursing website revealed E2's CNA license was inactive. 5. In an interview, E2 confirmed E2 worked at the facility as a caregiver.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type and frequency of assisted living services to be provided to the resident, for one of two sampled residents. The deficient practice posed a risk if a resident did not receive sufficient services as necessary. Findings include: 1. A review of R1's medical record revealed a service plan dated November 9, 2023 for personal care services. The service plan indicated R1 required assistance with toileting and oral care. However, the service plan did not indicate the amount or frequency at which the services would be provided. 2. In an interview, E1 reviewed R1's service plan and acknowledged R1's service plan did not reflect the amount or frequency of oral care or toileting provided to R1. This is a repeat citation from the previous compliance inspection conducted on November 14, 2022.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for one of two sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated November 9, 2023 for personal care services. The service plan indicated R1 required assistance with toileting and oral care. However, the service plan did not indicate the amount or frequency at which the services would be provided. 2. A review of R1's medical record revealed a document titled "Assisted Living Facility Daily Activity Record (ADL)" dated November-December 2023. However, the ADL document did not reflect R1 was provided oral care or toileting. 3. In an interview, E1 reviewed R1's ADL document and acknowledged the document did not reflect R1 was provided oral care or toileting.”

“Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area inaccessible to residents. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a cabinet in the dining area. The cabinet contained various medications belonging to residents. There was a lock on the cabinet, however the lock was broken, making the medication accessible. 2. In an interview, E1 acknowledged the medication was not stored in a locked location.”

“Based on documentation review and interview, the manager failed to ensure 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 facility documentation revealed the most recent disaster drill was conducted on July 10, 2023. There was no additional documentation indicating a disaster drill was conducted at least once every three months. 2. In an interview, E1 acknowledged a disaster drill was not conducted at least every three months.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer an unlocked cabinet under the kitchen sink. The cabinet contained a can of "WD-40" and a bottle of dish detergent. 2. In an interview, E1 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked area inaccessible to residents.”