Armada Care Homes.

“Based on record review, documentation review, and interview, the manager failed to ensure that at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home and if the manager or caregiver was not awake during nighttime hours the manager or caregiver could hear and respond to a resident needing assistance. The deficient practice posed a risk to the health and safety of the residents.  Findings include: 1. Record review revealed E2's employment record. E2 was hired on April 11, 2026, as an assistant caregiver. 2. Review of the Mesa Police Report stated, "On 04-11-2026, at approximately 1919 hours...I was dispatched for a call for service...regarding a welfare check...Call comments stated the reporting party's elderly friend lives at the above address and...no staff had been at the facility for several hours...Prior to arrival on scene, using my department issued cellphone, I contacted the owner of the home, identified as [E5]. [E5] stated that everything should be fine at the care home and one staff member is present, but [E5] could not remember the staff member's name or phone number. [E5] stated [E5] was outside however, and would answer the door. Upon arrival at the facility, Officers knocked and yelled for several minutes with no answer from the door and no obvious movement inside. A miscommunication determined [E5] was actually driving to the facility and not inside the facility. Upon learning this information, [E5] gave Officers verbal consent to enter the facility. With the front door unlocked, I entered the facility and made several more announcements. I heard a faint yelling of help coming from a room deeper inside the house. Upon conducting room checks, I contacted several patients and residents, identified as [R1], [R2], [R4], and [R5]. Additionally, upon conducting an additional room and opening the door, I observed another subject, identified as [E2] (verified through AZ MVD Photo), sitting up on an empty patient bed with no shoes on and medical gloves on. Upon immediate contact, I observed [E2's] eyes to be bloodshot and watery. [E2] immediately identified [E2] as a staff member. I immediately asked [E2] to step out to the main room. [E2] immediately began reaching for [E2's] wallet and identification. It took several attempts even with hand signals to get [E2] to exit the room and walk out to the main room. Upon [E2] getting up from the bed, [E2] nearly fell over and had to grab onto the end of the bed to steady [E2]. Upon trying to walk down the hallway, [E2] could barely walk straight and [E2] fell against the hallway wall. [E2] continued stumbling down the hallway using the wall to support [E2] and had to be directed to sit down. I immediately recognized these behaviors to be congruent with impairment consistent with alcoholic beverages." Further review of the Mesa Police Report revealed the only personnel members listed in the report were E2 and E5, indicating E2 and E5 were the only personnel members on-site at some point during the incident. 3. Documentation review revealed the facility's policy and procedures on "Checking On A Resident During Nighttime". The policy stated, "To ensure the safety of our residents and to properly provide services in the facility, the manager or at least one caregiver will be at the facility whenever there is a resident present on the premises. Day and night supervision will be provided per the procedures below. 1. Regardless if the facility has staff that is awake for nighttime hours, the manager or caregiver on duty will provide services as outlined in the Service Plan, and per doctor's orders. Assistance will be provided on an as needed basis. 2. If the manager or caregiver is not awake during nighttime hours, the manager or caregiver must be able to hear and respond to a resident needing assistance." 4. In an interview, E5 reported that another caregiver was on site but in the shower during the incident. 5. In an exit interview, findings were reviewed with E1 and E5 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for one of the five reviewed caregivers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include:   1. A review of E3's personnel record revealed E3 was hired in September 2025 as a caregiver.  Review of E3's personnel record revealed no documented verification of E3's skills and knowledge.   2. A documentation review of the 2024 Policy and Procedures revealed a policy titled "Skills and Knowledge Policy and Procedures." The document states: "VERIFICATION PROCESS: Skills and knowledge will be verified by Manager/Designee on date of hire through practical assessment and demonstrate their understanding by checking, sign and dated the caregiver skills and knowledge documentation before they are permitted to provide services to the residents. The signed document will be included in the employee's file.   REGULAR AUDITS: Caregiver skills and knowledge documentation is completed accurately and thoroughly before the employee provides services to residents. Any lapses on verification process must be address promptly and perform a regular performance review to implement continuous education as part of the in service or refresher course training" 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on observation, a record review, documentation review, and interview, the manager failed to ensure that one of the five caregivers reviewed received orientation specific to the duties to be performed before providing assisted living services to a resident. The deficient practice posed a risk if the employees were unable to meet residents' needs. Findings include: 1. The Compliance Officer observed E3 with three residents upon entry. During the investigation, E3 answered the call lights, and E3 prepared lunch for three residents. 2. A review of E3’s personnel record revealed no documentation showing E3 received orientation.   3. A review of the September 2025 personnel schedule revealed E3 was not listed on the schedule.    4. In an interview, E2 reported that E2 was unaware that E3 was left off the schedule. E2 reported that orientation was not completed for this facility, but it was done at the other facility from which E3 transferred.   5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on record review, interview, and documentation review, the manager failed to ensure a personnel record for each caregiver included documentation of cardiopulmonary resuscitation (CPR) training, which included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of five employees reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.   Findings include: 1. A review of E2's personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on September 9, 2025. There was no other current documentation of CPR training available for review that included a demonstration of E2's ability to perform CPR. 2. In an email exchange, a representative from NationalCPRFoundation stated, "Our courses are online only."   3. A documentation review revealed the employee's work schedule, dated August and September 2025, showed E2 had worked every day on the day shift. 4. In an interview, E2 reported that E2 was unaware that online classes were not acceptable. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of the three personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include:  1. A.R.S. § 36-411.C states, "Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution ..." 2. Review of E3's personnel file revealed no documentation of good faith efforts to contact previous employers.  3. In an interview, E1 acknowledged E3's personnel record contained no documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution.”

“Based on the record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of three caregivers reviewed. The deficient practice posed a potential risk of TB exposure to residents.   Findings include:   1. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test healthcare personnel upon hire (pre-placement), two-step testing should be used."   2. A review of E3's personnel record revealed documentation of a negative TB skin test dated June 8, 2025. However, there was no documentation of a second TB skin test.   3. In an interview, E1 acknowledged E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility.”

“Based on document review, record review, and interview, the manager failed to ensure a written service plan include the correct level of service the resident received for one of two residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A.R.S. § 36-401.38 defines "Supervisory care services" to mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis, and assistance in the self-administration of prescribed medications. 2. A.R.S. § 36-401.38 defines "Personal care services" to mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. 3. R9-10-101.135 defines "Medication administration" means restricting a patient's access to the patient's medication and providing the medication to the patient or applying the medication to the patient's body, as ordered by a medical practitioner. 4. Review of R1’s record revealed a written service plan with no date on it. Indicating R1 received supervisory care services. This service plan stated, "R1 will be receiving medication administration from the facility. 5. During an interview, E1 reported that R1 received medication administration from the facility and received directed care services. E1 acknowledged R1's service plan did not include the correct level of service the resident was receiving.”

“Based on observation and interview, the manager failed to ensure there was a current toxicology reference guide that was available for use by personnel members. This posed a health and safety risk to the resident if the caregiver was unable to reference a toxic material. Findings include: 1. The Compliance Officer requested the current toxicology reference guide. However, the toxicology reference guide was not provided to the department for review.  2. In an interview, E1 acknowledged that the facility did not have a toxicology reference guide available for use by personnel members.”

“Based on observation and interview, the manager failed to ensure that toxic materials stored by the assisted living facility 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. During an environmental tour of the facility, the Compliance Officer observed the following materials stored in the facility's unlocked cabinet under the sink: -  All-purpose powder comet bleach; -  Windex Glass Cleaner; - Lysol Disinfectant wipes; and - Gain ultra clean dish soap.     2. In an interview, E1 reported that the facility locked the cabinet under the sink to prevent access; however, the cabinet was accessible at the time of inspection. E1 acknowledged that poisonous or toxic materials stored by the facility were not maintained in a locked area and inaccessible to residents.”