Family Matters Care.

“Based on record review and interview, the manager failed to develop and administer a training program for all staff regarding fall prevention and fall recovery, for one of three personnel sampled. Findings include: 1 . A review of facility documentation revealed documentation of a training program regarding fall prevention and fall recovery, including initial and continued competency training, was not available for review at the time of inspection. 2 . A review of E3's personnel record revealed documentation of fall prevention and fall recovery training was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided. This is a repeat deficiency from an inspection conducted on February 24, 2025.”

“Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section. Findings include: 1 . A review of R1's and R2's medical records revealed that documentation of a maintained standardized form for the emergency responder was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on record review and interview, the governing authority failed to ensure compliance with A.R.S § 36-411 for three of three employees sampled. Findings include: 1 . A review of E1's and E2's personnel records revealed that documentation of an annual Adult Protective Services (APS) registry check was not available for review at the time of inspection. 2 . A review of E3's (provided direct supportive services) personnel record revealed that documentation of a fingerprint clearance card was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation required by policies and procedures, for one of three employees sampled. Findings include: 1 . A review of facility documentation revealed a policy titled "Orientation, In-Service Trainings for Employees." The policy stated, "Schedule and provide new employee and volunteer orientation sessions as appropriate to ensure the proper orientation of all staff." 2 . A review of E3's personnel record revealed that documentation of a completed orientation was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. Findings include: 1 . A review of R2's medical record revealed a negative TB test. However, documentation of a signs and symptoms screening and risk assessment was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident had a service plan that was established, documented, implemented, and completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. Findings include: 1 . A review of R2's medical record revealed that documentation of a completed service plan was not available for review at the time of inspection. Based on the resident's date of acceptance, this documentation was required.  2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a service plan was reviewed and updated at least once every three months for a resident receiving directed care services. Findings include: 1 . A review of R1's medical record revealed the latest completed service plan dated August 21, 2025. However, documentation of a completed service plan after August 21, 2025 was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two residents sampled. Findings include: 1 . A review of R1's and R2's medical records revealed documentation of an orientation completed was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure there was a means of exiting the facility for a resident that monitors or alerts 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 . During an environmental inspection of the facility, the Compliance Officers observed an alert placed on the door of the facility leading to the garage. However, when the Compliance Officer opened the garage door, the alert was turned off. 2 . During an environmental inspection of the facility, the Compliance Officers observed a sliding glass door leading to the backyard. The door had half of an alert system in place. However, the other half of the alert system was not there, making the alert not able to function. 3 . A review of facility documentation revealed no monitoring system for the garage door or the back door. 4 . In an interview, E1 reported no monitoring system for the garage door or the back door. 5 . In an exit interview, the findings were discussed with E1 and no additional information was provided. This is a repeat deficiency from an inspection conducted on February 24, 2025.”

“Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed medication for E2 sitting on a bathroom counter in a resident room. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a door to a resident room. The door was propped open with a dumbbell, and had no handle. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that a resident's sleeping area was not used as a passageway to another sleeping area. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a bed located in the closet of the master bathroom of a resident's room. 2 . In an interview, E2 reported sleeping in the closet to be closer to a resident who needs more assistance at night. 3 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure the swimming pool was locked when the swimming pool was not in use. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed that the gate latch for the pool was unlocked at the time of the inspection. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided. This is a repeat deficiency from inspections conducted on June 23, 2023, and February 24, 2025.”

“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 which allowed a resident to be 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: A review of the Department's documentation revealed the facility was licensed at the directed care level. During an environmental inspection of the facility, the Compliance Officers observed the garage door did not have a control or alert and was not locked. The garage door led to the outside. In an interview, E1 reported E1 would buy an egress control device or an alarm to put on the garage door. E1 acknowledged the garage door was not controlled and did not alert the employees of the egress of a resident from the facility.”

“Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents, which posed a health and safety risk if a resident inappropriately used the toxic material.   Findings include: During an environmental inspection, the Compliance Officers observed Comet, Drano, and Kroger Charcoal Lighter unlocked in the cabinet under the kitchen sink. The locking device was not activated. During an interview, E2 reported E2 will keep the cleaners in another locked cabinet because E2 prefers to keep the cabinet under the sink unlocked. E1 reported E2 forgot to lock the cabinet under the sink. E1 acknowledged toxic materials were stored unlocked.”

“Based on observation and interview, the manager failed to ensure a swimming pool gate was locked when not in use. Findings include: 1. During an environmental inspection, the Compliance Officers observed the swimming pool was not in use and the gate was unlocked. 2. During an interview, E2 and E3 acknowledged the swimming pool was not in use and was unlocked.”

“Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.   Findings include: A review of facility documentation revealed the facility did not have documentation of a fall prevention and fall recovery training program. In an interview, E1 reported E1 did not know a training program had to be documented for the facility. E1 acknowledged the facility had not developed and implemented a fall prevention and fall recovery training program for all staff.”

“Based on observation, documentation review, record 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 provides physical health services, for two of two caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of E1's and E2's personnel records revealed E1 and E2 were hired as caregivers. 2. A review of E1's and E2's personnel records revealed no documentation to indicate E1's and E2's skills and knowledge were verified before E1 and E2 provided physical health services. 3. In an interview, E1 acknowledged E1's and E2's skills and knowledge were not verified and documented before E1 and E2 provided physical health services.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two residents sampled. The deficient practice posed a risk if residents were unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1's and R2's medical record revealed no documentation to indicate R1 and R2 were oriented to exits from the assisted living facility. 2. In an interview, E1 reported the documentation must have been misplaced, but was unable to locate the documentation during the inspection. E1 acknowledged E1 failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility.”