Quality Senior Home LLC.

“Based on record review and interview, the manager failed to ensure a standardized form for each resident that included the information prescribed in subsection A of this section was completed and maintained for two of two residents sampled. The deficient practice posed a risk as the required patient information was not prepared in case of an emergency.   Findings include:     1. A request for the facility's standardized emergency responder patient information form for R1 and R2 reveals that no standardized emergency responder patient information form was available for review.     2. In an interview, E1 acknowledged that a standardized emergency responder patient information form was not available for review.”

“Based on documentation review and interview, the manager failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided.     Findings include:      1. A request for quality management program documentation revealed that no documentation was available for review.      2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was incomplete documentation identifying the staff present each day to ensure the health and safety of residents.      Findings include:      1. A review of facility documentation revealed a work schedule dated March 2026. A work schedule for April, May, June, July, August, September, October, November, December of 2025, or January, February, and April 2026 was not available. Documentation was not maintained for at least 12 months after the last date on the documentation of the caregivers working each day, including the hours worked by each.      2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for two of two residents reviewed receiving directed care services. The deficient practice posed a health and safety risk to the residents.     Findings include:     1. Review of R1's medical record revealed a service plan for directed care services dated April 1, 2026. This service plan revealed no documentation of R1's weight. In addition, R1's record revealed no documentation of R1's weight or documentation from a medical practitioner stating that weighing R1 was contraindicated.     2. Review of R2's medical record revealed a service plan for directed care services dated March 27, 2026. This service plan revealed no documentation of R2's weight. In addition, R2's record revealed no documentation of R2's weight or documentation from a medical practitioner stating that weighing R2 was contraindicated.     3. In an exit interview, the findings were reviewed with E3, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan.       Findings include:      1. A review of facility documentation revealed no documentation of disaster drills being conducted at least once every three months within the last 12 months.      2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months, and included all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. The deficient practice posed a health and safety risk to residents and employees if the employee were unable to implement the evacuation plan. Findings include: 1. A review of facility documentation revealed no documentation of evacuation drills being conducted at least once every six months within the last 12 months. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.”

“Based on observation, documentation review, and record review, the governing authority failed to notify the Department according to A.R.S. § 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. A.R.S. § 36-425(I) states "A health care institution shall immediately notify the department in writing when there is a change of the chief administrative officer..." 2. During the environmental inspection upon entry into the facility, the Compliance Officer observed no current manager's certificate was hanging on the wall. 3. In an interview, E1 acknowledged the facility did have a manager change, and the Department was not notified of the change. 4. In a telephone interview, E4 reported starting at the facility as the assisted living facility manager on April 1, 2025. E4 reported the Department was not notified of the change. 5. In an interview, E1 acknowledged the Department was not notified of the change of managers.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for two of two employees reviewed. The deficient practice posed a safety risk to residents.   Findings include:   1. ARS § 36-411(C)(3-4) states:   "C. Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to: [...] (3) Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency may not hire the potential employee.   (4) On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency shall take action to terminate the employment of that employee."   2. A review of E2's and E3's personnel records revealed no documentation of good faith efforts to verify that each employee was not on the adult protective services registry pursuant to section 46-459. 3. Department review of the Adult Protective service registry reveled no registry records for E2 or E3.     4. In an interview, E1 acknowledged that good faith efforts to verify that each employee was not on the adult protective services registry were not conducted even after receiving technical assistance.”

“Based on observation, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge are verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services and according to policies and procedures for one of two personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs.  Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3 at the facility. 2. A review of E3's personnel record revealed E3's skills and knowledge were not verified and documented. 3. In an interview, E1 and E2 reported E3 is an assistant caregiver and has been working at the facility since February 20, 2025.”

“Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented that ensure the safety of a resident who may wander.     Findings include:     1. A review of the facility's documentation policies and procedures revealed a policy. The policy stated: POLICY TOPIC: Safety of Wandering Residents RESPONSIBLE PERSON: All Personnel Policy Statement: Residents who wander are at great risk in health and safety areas if they should leave the facility and get lost. The personnel of the facility will make every attempt to keep residents from wandering away from the facility by following the steps outlined in the procedures below. ….5. If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security. a. Alarms that are triggered will be investigated immediately by the caregiver on duty.     2. A review of facility documentation incident reports revealed R2 had wandered away from the facility on April 13, 2025 after leaving through the front door.     3. In an interview, E2 reported the alert to the front door had sounded, however, E2 was the caregiver on duty and did not check to see who had gone out the front door. E2 reported R2 was the one who had left the facility through the front door.     4. In an interview, E1 reported R2 was outside with E1 while cleaning a vehicle out, and when E1 looked up, R2 had left the facility and was unable to locate R2. E1 reported the facility called 911 to report R2 missing. E1 acknowledged the policies were not implemented to ensure the safety of a resident who may wander.”

“A. A manager shall ensure that: 2. An assistant caregiver: b. Interacts with residents under the supervision of a manager or caregiver;”

“C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual's name, date of birth, and contact telephone number; b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties; ii. The individual's education and experience applicable to the individual's job duties; iii. The individual's completed orientation and in-service education required by policies and procedures; iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or policies and procedures; and ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);”

“A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 calendar days after the resident's date of acceptance;”

“A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: iii. At least once every three months for a resident receiving directed care services; and”

“E. A manager shall ensure that: 2. A calendar of planned activities is: b. Posted in a location that is easily seen by residents,”

“A. A manager shall ensure that: 1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1;”

“B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident's medical record.”

“A. A manager shall ensure that: 1. A food menu: a. Is prepared at least one week in advance, b. Includes the foods to be served each day, c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served, d. Includes any food substitution no later than the morning of the day of meal service with a food substitution, and e. Is maintained for at least 60 calendar days after the last day included in the food menu;”

“A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;”

“F. A manager of an assisted living home shall ensure that: 4. Except as provided in subsection (G): a. A smoke detector is: i. Installed in each bedroom, hallway that adjoins a bedroom, storage room, laundry room, attached garage, and room or hallway adjacent to the kitchen, and other places recommended by the manufacturer; ii. Either battery operated or, if hard-wired into the electrical system of the assisted living home, has a back-up battery; iii. In working order; and iv. Tested at least once a month; and”

“A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;”

“Based on observation, record review, and interview, the manager failed to ensure the manager designated, in writing, a caregiver who was present on the facility's premises and accountable for the facility when the manager was not present. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. When the Compliance Officer arrived at the facility, the manager was not present. E3 was the only caregiver at the facility. 2. A review of E3's personnel record revealed no documentation to indicate E3 was designated to be accountable for the facility when the manager was not present. 3. In an interview, E2 acknowledged the manager failed to designate, in writing, a caregiver who was present on the facility's premises and accountable for the facility when the manager was not present.”

“Based on documentation review, 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 sampled personnel members. The deficient practice posed a risk if the employee was unable to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy titled "Employment and Volunteers Qualifications." The policy stated "Employment requirements: Employee orientation within 10 days of employment, before providing any assisted living services to the residents." 2. A review of E3's personnel record revealed documentation of completed orientation was not available for review. 3. In an interview, E2 acknowledged E3's personnel record did not include documentation of E3's completed orientation required by policies and procedures.”

“Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to indicate whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of four sampled residents. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed documentation stating whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints. However, the documentation was dated four days after R1's admission date. 2. In an interview, E2 acknowledged the documentation for R1 was not completed before or at the time of R1's acceptance.”

“Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of four sampled residents. Findings include: 1. A review of R1's medical record revealed a residency agreement. However, this residency agreement did not include the signature of the manager and date signed. 2. In an interview, E1 acknowledged R1's residency agreement did not include the signature of the manager and date signed.”

“Based on record review and interview, the manager failed to ensure a documented residency agreement included the signature of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, and date signed, for two of four sampled residents. The deficient practice posed a risk if a resident did not consent to the terms of residency. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(214) states "Signature" means: "a. A handwritten or stamped representation of an individual's name or a symbol intended to represent an individual's name, or b. An electronic signature." 2. A review of R1's medical record revealed a residency agreement. However, this residency agreement did not include the signature of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, and date signed. 3. A review of R4's medical record revealed a residency agreement. However, the document stated "Refused to sign" in the resident's or resident's representative signature line. 4. During an interview, E2 acknowledged R1's and R4's residency agreements did not include required signatures.”

“Based on documentation review and interview, the manager failed to ensure a resident was not subjected to misappropriation of personal and private property by the assisted living facility's manager, caregivers, assistant caregivers, employees, or volunteers. The deficient practice posed a risk of exploitation of a resident. Findings include: 1. A review of Department documentation revealed a report from another state agency. The documentation stated E2 admitted to having used R5's "UHC Card" to pay for the facility's electric bill on October 21, 2023, November 31, 2023, and February 1, 2024. 2. In an interview, E2 reported the aforementioned dates were correct, and reported R5 had given E2 permission to use the "UHC Card" to pay for the electric bill in lieu of payments for rent. However, documentation of this agreement between R5 and E2 was dated February 25, 2024. E2 disagreed with the Compliance Officer that using R5's funds was a misappropriation of R5's personal or private property.”

“Based on observation and interview, the manager failed to ensure a food menu was prepared at least one week in advance, conspicuously posted at least one calendar day before the first meal on the food menu was served, and included any food subsitution no later than the morning of the day of meal service with a food subsitution. The deficient practice posed a risk of not meeting a resident's dietary needs. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a document titled "Weekly Menu" for the dates of April 1-7, 2024. However, documentation of a "Weekly Menu" for the dates of April 8-14, 2024 was not available for review. 2. In an interview, E3 reported E3 tried to serve food items close to what was listed on the menu, but didn't always serve exactly what was listed on the menu. When the Compliance Officer asked what was for lunch on the date of inspection, E3 pointed to April 4, 2024 on the menu and stated "Turkey sandwich." The items listed with the turkey sandwich were a baked potato, pie, and tea or juice. However, the Compliance Officer observed E3 making chicken salad sandwiches with a brownie and banana slices at approximately 12:30 PM. When a resident asked what was for lunch, E3 stated "Chicken salad sandwiches and a brownie." 3. In an interview, E2 acknowledged a food menu for the week of April 8-14, 2024 was not prepared at least one week in advance, conspicuously posted at least on calender day before the first meal on the food menu is served, and included any food subsitution no later than the morning of the day of meal service with a food subsitution.”

“Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed baseboards throughout the facility peeling away from the wall, or sticking out around corners, posing tripping hazards to residents. The Compliance Officer also observed bulk trash on the side of the house along the walkway, including windowpanes with glass, a freezer unit full of green-tinted water, a toilet with a broken tank, and a pile of both rusted and clean nails. 2. In an interview, E2 acknowledged the premises was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.”

“Based on observation and interview, the manager failed to ensure a resident's sleeping area has sufficient light for reading. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R2's bedroom had no light activated by the light switches on the wall. On the ceiling where a light or ceiling fan might be, there was exposed wiring. No other working electrical light source was present in R2's bedroom at the time of the inspection. 2. In an interview, E2 reported E2 was going to install a ceiling fan in R2's bedroom. However, E2 had not had the chance to install the ceiling fan yet. E2 acknowledged R2's sleeping area did not have sufficient light for reading at the time of the inspection.”