Ambiance Assisted Living.

“Based on record review and interview, the manager failed to provide the emergency responder a written document that included all required documentation for one of three residents sampled. Findings include: 1. A review of R2's medical record revealed an incident report dated June 15, 2025. The report revealed that R2 had an accident, emergency, or injury, the facility contacted an emergency responder, and R2 was taken to the hospital. However, the documented information provided to the emergency responder did not include the following: -The name, address, and telephone number of the resident's current pharmacy; -The point-of-contact information for the assisted living home, including the cell phone number and email address; and -A copy of R2's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living home to plan for R2's discharge.  2. In an interview, E1 reported not being aware of the specifics of this regulation. E1 acknowledged there was no further paperwork available for review.”

“Based on observation, record review, and interview, the governing authority designated in writing a manager who has a certificate issued under A.R.S. § 36-446.04(C) or A.R.S. § 36-446.06. Findings include: 1. During the facility tour, the compliance officer observed a manager's certificate posted in the facility with O1's name and expiration date of June 30, 2021. 2. A review of the facility’s documentation revealed that there was no manager's delegation of authority available for review. 3. A review of personnel records revealed there was no personnel file for the current manager of the facility. 4. In an interview, E2 reported O1 no longer being the manager for the facility, and O2 has been the new manager for approximately two months. 5. In an interview, E2 reported that there was no personnel record available for review for O2, a current certified manager, and there was no documentation that designated a manager in writing. 6. A review of Department records indicated that the governing authority notified the Department that O2 was the manager on July 3, 2025. 7. The Compliance Officer spoke with a representative at the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board) who reported not having O1 identified as a manager at this facility. In further review, a review of the NCIA Board database did not contain information that O2 was a certified manager.”

“Based on record review and interviews, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training for one of three sampled employees. 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 the personnel file for E2 revealed that E2 is a caregiver. E2's Cardiopulmonary resuscitation (CPR) and First Aid (FA) certification expired June 30, 2025.   2. In an interview, E2 checked and verified that the employee did not have a current CPR/FA certification.   3. In an interview, E2 acknowledged that E2 did not have a current CPR/FA certification in the personnel record as required.”

“Based on observation, record review, and interview, the manager failed to ensure that an employee had a personnel record. Findings include: 1. During the facility tour, the compliance officer observed a manager's certificate posted in the facility with O1's name and expiration date of June 30, 2021. 2. A review of the facility’s documentation revealed that there was no manager's delegation of authority available for review. 3. A review of personnel records revealed there was no personnel file for the current manager of the facility. 4. In an interview, E2 reported O1 no longer being the manager for the facility, and O2 is the new manager. 5. In an interview, E2 reported that there was no personnel record available for review for O2, a current certified manager, and there was no documentation that designated a manager in writing.”

“Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees 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. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed five ambulatory residents. 3. At the beginning of the inspection, the Compliance Officer observed two residents using the sliding glass doors in the kitchen to access the backyard. However, the door was unsecured and the chime was not functioning. 4. During the environmental tour, the Compliance Officer found that the kitchen sliding door chime leading to the backyard was operational, however, it was barely audible to the Compliance Officer. E4 had to turn up the volume to make it audible. 5. During the environmental tour, the Compliance Officer observed the sliding glass door leading from the master bedroom to the backyard. This bedroom housed two ambulatory residents. The door was unsecured, and the door chime was not functioning. 6. In an interview, E1 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.”

“Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a risk of a potential explosion or leak of a compressed gas. Findings include: 1. During the environmental tour, the Compliance Officer observed five oxygen containers in a resident room closet. Two of the containers were stored upright, but not secured. 2. In an interview, E4 acknowledged the oxygen containers were not secured in an upright position.”