Seven Haven LLC.

“Based on record review, documentation review, and interview, the assisted living home failed to administer Fall Prevention and Fall Recovery training as required by A.R.S. § 36-420.01.A and the facility's policies and procedures, for four of four personnel reviewed. The deficient practice posed a risk to the physical health and safety of a resident. 1. A review of E1's personnel record revealed that E1 had last completed Fall Prevention/Fall Recovery training on January 6, 2025. There was no other documentation available for review to indicate that E1 had current training. 2. A review of E2's personnel record revealed that E2 had last completed Fall Prevention/Fall Recovery training on January 8, 2025. There was no other documentation available for review to indicate that E2 had current training. 3. A review of E3's personnel record revealed that E3 had last completed Fall Prevention/Fall Recovery training on January 9, 2025. There was no other documentation available for review to indicate that E3 had current training. 4. A review of E4's personnel record revealed that E4 had last completed Fall Prevention/Fall Recovery training on January 8, 2025. There was no other documentation available for review to indicate that E4 had current training. 5. A review of the facility's policies and procedures revealed a policy titled "Fall Prevention and Recovery." The policy stated, "The training program requires initial training and continued competency review on an annual basis...6. Once a year, the caregivers will go through a refresher course on fall prevention and fall recovery." 6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on record review, documentation review, and interview, the manager failed to ensure that the assisted living home established, documented, and implemented tuberculosis (TB) infection control activities that included annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution, for three of four personnel reviewed; and failed to annually assess the assisted living home's risk of exposure to infectious TB. The deficient practices posed a risk to the physical health and safety of the residents. Findings include: 1. A review of E1's personnel record revealed documentation that indicated that E1 had last completed training and education related to recognizing the signs and symptoms of TB on January 8, 2025. There was no other documentation available for review to indicate that E1 had current training. 2. A review of E3's personnel record revealed documentation that indicated that E3 had last completed training and education related to recognizing the signs and symptoms of TB on January 10, 2025. There was no other documentation available for review to indicate that E3 had current training. 3. A review of E4's personnel record revealed documentation that indicated that E4 had last completed training and education related to recognizing the signs and symptoms of TB on January 6, 2025. There was no other documentation available for review to indicate that E4 had current training. 4. A review of facility documentation revealed there was no documentation of a completed annual facility risk assessment to determine the home's risk of exposure to infectious TB, as required. 5. A review of the facility's policies and procedures revealed an information packet titled "Recommendations for Preventing Transmission of M. tuberculosis in Health Care Settings." Included with the packet was "Appendix B. Tuberculosis (TB) Risk Assessment Worksheet." However, the worksheet had not been completed. 6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed two different binders with two sets of policies and procedures. One of the binders contained a set of policies and procedures with a 1998 copyright. The other binder contained a set of policies and procedures that were last revised in August 2013. Several of the policies were outdated as they referred to Article 7, the behavioral health rule set, and neither of the binders had updated policies and procedures to reflect current rules. However, both of the binders included documentation indicating they were last reviewed and signed by E1 on August 30, 2022. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy, and as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents.   Findings include:   1. A review of R1's medical record revealed a completed TB Screening and Risk Assessment; however, there was no documentation of evidence of freedom from infectious TB. Based on R1's date of admission, this documentation was required.   2. Further review of R1's medical record revealed a "Hospital Visit Summary Form" dated July 24, 2025, which included a TB Screening and Risk assessment (that listed the same questions as the facility's aforementioned TB Screening and Risk Assessment). At the bottom of the list of questions, it stated "TB Status - Negative by Screening." 3. A review of the facility's policies and procedures revealed a policy titled "Tuberculosis (TB) Testing." The policy stated, "1...the manager or manager's designee shall obtain... a. On or before the date the individual...is admitted to the facility (resident)...i. Documentation of a negative Mantoux skin test administered within six months before the date...the resident is admitted to the facility..." 4. In a exit interview, the findings were reviewed with E2, and no additional information was provided.”

“A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and”

“D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 10. The manager's signature and date signed.”

“B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility,”

“Based on documentation review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services for one of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of E2's personnel record revealed E2's role as a caregiver, however, documentation verifying E2's skills and knowledge was not available. 2. In an interview E2 acknowledged that the manager failed to ensure that a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services.”

“Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility that included the manager's signature and date signed for 1 of 4 residents sampled. Findings include: 1. A review of R1's medical record revealed a residency agreement signed by R1's representative on October 9, 2024. However, the residency agreement was not signed or dated by the manager. 2. In an interview, E2 acknowledged that the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility that included the manager's signature and date signed.”

“Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility for 3 of 4 residents sampled. Findings include: 1. A review of R1's medical record revealed a document titled "Emergency Orientation Reviewed & *Signed within 24 hours after resident moves in*," however, this document was not dated within twenty four hours after the resident's acceptance by the assisted living facility. 2. A review of R3's medical record revealed a document titled "Emergency Orientation Reviewed & *Signed within 24 hours after resident moves in*," however, this document was not dated within twenty four hours after the resident's acceptance by the assisted living facility. 3. A review of R4's medical record revealed a document titled "Emergency Orientation Reviewed & *Signed within 24 hours after resident moves in*," however, this document was not dated within twenty four hours after the resident's acceptance by the assisted living facility. 4. In an interview, E2 acknowledged the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within twenty four hours after the resident's acceptance by the assisted living facility.”

“Based on documentation review, interview, and record review, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings include: 1. A review of Department documentation revealed the facility provided notification that E3's final day as the manager of the AL7214 was August 31, 2022. 2. In an interview, E1 reported E2 was the facility's manager. 3. A review of E2's personnel record revealed E2's effective date as the facility's manager was September 22, 2022. 4. In an interview, E1 reported to have notified the Nursing Care Institution (NCIA) Board of the facility's change in manager. E1 was unaware of the need to notify the Department.”