A Place of Joy Assisted Living.

“Based on record review, document review and interview, the manager failed to ensure that written notification was provided to the Department of a resident's death. Findings include: 1 . A review of R1's medical record revealed an admission date of July 11, 2023, however there was no documentation available to support notification of R1's passing on August 4, 2025. 2 . In an interview, E2 reported that R1 was not receiving Hospice services or any other end of life services. In an interview, E2 reported that E2 was not aware that the death of a resident was to be reported to the Department. There was no incident report or notifications, for the Compliance Officer to review, at the time of inspection. 3 . A review of facility documents revealed a policy titled, Death Reporting, which states, "The facility manager shall provide written notification to the Department if a resident's death is required to be reported accordingly to A.R.S. 11-593, within one working day after the resident's death. 4. In an exit interview, the findings were shared with E2 and no further information was provided.”

“Based on observation and interview, the manager failed to ensure that a resident was not subjected to a restraint.  The deficient practice posed a risk of injury and violated a resident's rights.  Findings include: 1 . During a tour of the facility, the Compliance Officer observed R2 had a full bed rail attached to the bed. In an interview, R2 reported the R2 was not able to operate the bed rail independently. 2. In an interview, E2 reported that the bed rails were ordered by hospice. 3. In an exit interview, the findings were reviewed with E2 and no further information was provided.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. Findings include: 1 . During a tour of the facility the Compliance Officer observed the door to the laundry room was unlocked. In the laundry room, the Compliance Officer observed two bottles of laundry detergent and a container of fabric softener. 2 . In an interview, E2 acknowledged that the door to the laundry room was left unlocked and accessible to residents at the assisted living facility.”

“Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411. The deficient practice posed a risk if E1 and E2 were a danger to a vulnerable population. Findings include: 1 . A review of E1's and E2's employee records revealed no evidence of a search of the Adult Protective Services (APS) registry. 2 . A search of the APS website was conducted by the Compliance Officer and revealed no record with APS for E1 or E2. 3 . In an interview, E1 acknowledged that there were no APS registry search results available for E1 or E2, for review during the inspection.”

“Based on document review and interview, the manager failed to ensure that there was a plan established, documented, and implemented for an ongoing quality management program. Findings include: 1 . A review of facility documents revealed no Quality Management program that was used to identify, document and evaluate incidents at the facility. 2 . In an interview, E1 acknowledged that the manager failed to ensure there was a Quality management program used to identify, document and evaluate incidents at the facility.”

“Based on record review and interview the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. Findings include: 1 . A review of E2's personnel record revealed that E2's position was manager. 2. A review of E2's employee records revealed a CPR (Cardiopulmonary Resuscitation) card, however, it did not include first aid. 3 . In an interview, E1 acknowledged that the manager failed to ensure that an employee record contained certifications for CPR and First Aid trainings.”

“Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented , and implemented for one of two residents sampled. The deficient practice posed a risk if the resident's representative and other individuals identified were unable to participate in decisions concerning the assisted living services the resident was to receive. Findings include: 1 . A review of R1's record reveal no current service plan for review. 2 . In an interview, E1 acknowledged a documented service plan for R1 was not provided for review.”

“Based on observation and interview, the manager failed to ensure that an exit that provided access to an outside area was monitored or alerted staff of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1 . During a tour of the facility, the Compliance Officer observed the alert on the front door to be in the off position, not alerting employees of the egress of a resident from the facility. 2 . In an interview, E1 acknowledged that the means of alerting employees to the egress of a resident was turned off.”

“Based on document review and interview, the manager failed to ensure that documentation for each evacuation drill included the amount of time taken for employees and resident to evacuate the assisted living facility, an identification of residents needing assistance for evacuation, or identification of residents who were not evacuated. Findings include: 1 . During a review of facility documents, the Compliance Officer observed Evacuation drill forms, however the forms were missing the following information: Amount of time it took to evacuate residents and staff Names of residents evacuated Any residents that were not evacuated and the reason 2 . In an interview, E1 acknowledged that documentation for each evacuation drill did not include the amount of time take for employees and resident to evacuate the assisted living facility, an identification of residents needing assistance for evacuation, or identification of residents who were not evacuated.”