West Wing Loving Care LLC.

“Based on documentation review, record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of four personnel sampled. The deficient practice posed a risk if E4 was a danger to a vulnerable population. Findings include: 1 . A.R.S. § 36-411.C states: "4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459...[and] 5. Beginning March 31, 2025, annually reverify 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 facility documentation revealed E4 was scheduled to work at the facility during February of 2026. 3 . A review of Department documentation revealed E4 was added to the Adult Protective Services (APS) registry on January 29, 2026. 4 . A review of E4's personnel record revealed documentation of an APS registry check was not available for review at the time of inspection. E4 was no longer working at the facility at the time of inspection. 5 . In an interview, the findings were discussed with E3 and no additional information was provided.”

“Based on documentation review, record review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility’s premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1 . A review of facility documentation revealed a "Delegation of Manager's Authority." However, the documentation was signed by E4, who is not the current facility manager. 2 . A review of E3's personnel record revealed documentation of an updated "Delegation of Manager's Authority" was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E3 and no additional information was provided. ”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented according to policies and procedures, for one of three caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1 . A review of facility documentation revealed an employee work schedule for April 2026. The employee schedule included E2 was scheduled to work multiple days during the month. 2 . A review of facility documentation revealed a policy titled "Employees and Volunteers Qualification." The policy stated, "The hiring individual will check and document qualification, skills and knowledge for each employee and volunteer to ensure the meet criteria....Documentation of such check is going to be kept in the employees' record upon hiring ("Employee Orientation" and "Employee Qualification and Skills.")" 3 . A review of E2's personnel record revealed that documentation of "Employee Qualification and Skills" was not available for review at the time of inspection. 4 . In an exit interview, the findings were discussed with E3, 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 no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1 . A review of facility documentation revealed a document titled "Employee Work Schedule" for April 2026. E2 was scheduled to work eight days in April. 2 . In an interview, E3 reported E2 had not actually worked at the facility on the days the "Employee Work Schedule" listed E2 was expected to work. 3 . In an exit interview, the findings were discussed with E3 and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that, before providing assisted living services to a resident, a caregiver received orientation that was specific to the duties to be performed by the caregiver, for one of three caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1 . A review of facility documentation revealed an employee work schedule for April 2026. The employee schedule included E2 was scheduled to work multiple days during the month. 2 . A review of E2's personnel record revealed that documentation of "Employee Orientation" was not available for review at the time of inspection. 3 . In an interview, E3 reported E2 had worked at the facility several times when E3 had been unavailable to work. 4 . In an exit interview, the findings were discussed with E3, and no additional information was provided.”

“Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults, for one of three personnel sampled. 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 documentation of current CPR training. However, the CPR training was from the National CPR Foundation. 2 . A review of the National CPR Foundation website revealed a frequently asked questions (FAQ) section. One of the questions in the FAQ states, "Do you offer hands-on training?" The answer posted was "No, we do not offer hands-on training." 3 . In an exit interview, the findings were discussed with E3, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a personnel record for each employee included the individual's starting date of employment, for one of three personnel sampled. The deficient practice posed a risk as required information could not be verified for E2. Findings include: 1 . A review of E2's personnel record did not include a starting date of employment. 2 . In an exit interview, the findings were discussed with E3, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility which included if the individual was expected to receive supervisory care services, personal care services, or directed care services, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of five residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1 . A review of R4's medical record revealed documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility which included if the individual was expected to receive supervisory care services, personal care services, or directed care services, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E3, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, and when initially developed, was signed and dated by the resident or resident's representative and the manager, for one of five residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1 . A review of R5's medical record revealed a service plan dated March 27, 2026. However, the service plan was not signed by the manager or the resident representative. 2 . In an exit interview, the findings were discussed with E3, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for five of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. 1 . A review of R1's, R2's, R3's and R5's medical records revealed documentation of service plans which reported the residents needed assistance with bathing twice a week, dressing daily, and toileting assistance every 2 hours. However, documentation of activities of daily living (ADL) sheets for May 2026 for R1, R2, R3, and R5 were not available for review at the time of inspection. 2 . A review of R4's medical record revealed documentation of a service plan which reported the resident needed assistance with bathing three times a week, dressing daily, and toileting assistance every 2 hours. However, documentation of an ADL sheet for May 2026 for R4 was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E3 and no additional information was provided. This is a repeat deficiency from a compliance inspection conducted on June 23, 2023.”

“Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for five of five residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1 . In an interview, E3 reported the residents received medication administration. 2 . A review of R1's medical record revealed a signed medication order list for the following: -Gabapentin 100 milligrams (MG), 2 capsules three times a day; -Sertraline 25 MG, 1/2 tablet daily; -Trazodone 50 MG, 1 tablet daily; and -Senna 8.6 MG, 2 tablets daily. However, a review of R1's medical record revealed that documentation of a Medication Administration Record (MAR) sheet for May 2026 was not available for review at the time of inspection. 3 . A review of R2's medical record revealed a signed medication order list for the following: -Clopidogrel 75 MG, 1 tablet daily; and -Amlodipine 5 MG, 1 tablet daily. However, a review of R2's medical record revealed that documentation of a MAR sheet for May 2026 was not available for review at the time of inspection. 4 . A review of R3's medical record revealed a signed medication order list for the following: -Buspirone 10 MG, 1 tablet twice daily; -Donepezil HCL 10 MG, 1 tablet daily; -Levothyroxine 50 MG, 1 tablet daily; -Losartan 25 MG, 1 tablet daily; -Sertraline HCL 100 MG, 1 tablet daily; and -Trazodone 100 MG, 1 and 1/2 tablets daily. However, a review of R3's medical record revealed that documentation of a MAR sheet for May 2026 was not available for review at the time of inspection. 5 . A review of R4's medical record revealed a signed medication order list for the following: -Carbidopa-levodopa 25-250 MG, 1 tablet daily; -Amantadine 100 MG, 1 tablet three times daily; -Silodosin 8 MG, 1 capsule daily; -Lisinopril Hydrocortisone 20-125 MG, 1 tablet daily; -Solifenacin 10 MG, 1 tablet daily; -Gabapentin 100 MG, 2 capsules daily; -Aspirin 81 MG, 1 tablet daily; -Senna 8.6 MG, 2 tablets daily; -Pramipexole 0.25 MG, 1 tablet daily; and -Trazodone 50 MG, 1 tablet daily. However, a review of R4's medical record revealed that documentation of a MAR sheet for May 2026 was not available for review at the time of inspection. 6 . A review of R5's medical record revealed a signed medication order list for the following: -Carbidopa-levodopa 25-250 MG, 1 tablet daily; -Fexofenadine HCL 180 MG, 1 tablet daily; -Desvenlafaxine 25 MG, 1 tablet twice daily; -Solifenacin 5 MG, 1 tablet daily; -Trazodone 50 MG, 1 tablet daily; -Oxycodone 10 MG, 1 tablet three times daily; and -Pramipexole .25 MG, 1 tablet three times daily. However, a review of R5's medical record revealed that documentation of a MAR sheet for May 2026 was not available for review at the time of inspection. 7 . In an exit interview, the findings were discussed with E3, and no additional information was provided. This is a repeat deficiency from a compliance inspection conducted on June 23, 2023.”

“Based on observation, documentation review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented for storing medication. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a magnetic key attached to the switch faceplate next to the sink and on the side of the refrigerator in the kitchen. The Compliance Officers were able to use these keys to access the medication cabinet located in the kitchen. 2 . A review of facility documentation revealed a policy titled "Part II-Receiving, Storing Medication." The policy stated "Only the Manager and trained Caregivers shall be in possession of the keys to the medication storage area." 3 . In an exit interview, the findings were discussed with E3 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that food was stored to ensure it was free from spoilage, filth, or other contamination, and was safe for human consumption. The deficient practice posed a risk for potential food-borne illnesses. Findings include: 1. During an environmental inspection, the Compliance Officers observed an uncovered piece of meat sitting directly on a shelf in the refrigerator. 2. In an exit interview, the findings were discussed with E3, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months, and had a tag attached to the fire extinguisher that specified the date of the last servicing and the identification of the person who serviced the fire extinguisher. The deficient practice posed a risk if safety measures were not in place to protect residents in a fire. Findings include: 1. During the environmental inspection, the Compliance Officers observed a rechargeable fire extinguisher without a tag hanging on the wall in the dining room. 2. In an interview with E3, E3 reported that nobody serviced the fire extinguisher over the last year and that the fire extinguisher was dated 2024 on the bottom. 3. In an exit interview, the findings were discussed with E3, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that 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. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection, the Compliance Officers observed two gates with locks that blocked the stairs leading to the upper level. However, the keys for the two gates were in both of the locks. The Compliance Officers observed ambulatory residents at the time of inspection. 2. In an exit interview, the findings were discussed with E3, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection, the Compliance Officers observed a magnetic key on a switch next to the kitchen sink accessible to residents. The Compliance Officers were able to use the key on the counter to open a kitchen cabinet that contained the following poisonous or toxic materials: A bottle of Clorox multi-surface cleaner A can of Lysol disinfectant spray A can of Comet powdered bleach 2. In an interview with E3, E3 reported that E3 would move the keys somewhere inaccessible to residents. 3. In an exit interview, the findings were reviewed with E3, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on June 23, 2023.”

“Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution's standards. Findings include: 1. A review of R5's medical record revealed a service plan for directed care services. 2. A review of R5's medical record revealed an incident report dated July 08, 2024. The incident reported stated "R5 managed to open the front door of the facility when no staff was around and snuck out of the house and took one of the staff member's car and drove off." 3. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are trigged will be investigated immediately by the caregiver on duty." 4. In an interview, E2 acknowledged that the facility had a system to control or alert staff about residents' egress to outside areas. However, despite this system, the caregiver had been unaware of the general or specific whereabouts of R5.”

“Based on documentation review, record review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to ensure the safety of a resident who may wander. The deficient practice posed a risk if facility staff were unaware of the whereabouts of a resident. Findings Include; 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance officer observed three ambulatory residents. 3. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are trigged will be investigated immediately by the caregiver on duty." 4. A review of R5's medical record revealed an incident report dated July 08, 2024. The incident reported stated "R5 managed to open the front door of the facility when no staff was around and snuck out of the house and took one of the staff member's car and drove off." 5. During the environmental tour, the Compliance Officer observed that the facility had means of controlling and alerting employees to residents' egress to outside areas. However, during the incident involving R5 on July 08, 2024, the caregiver failed to investigate immediately when an alarm was triggered upon the resident's departure from the facility. 6. In an interview, E2 reported that R5 had wandered from the facility. In addition, R5 had managed to obtain E2's car keys and had driven away in E2's vehicle and was subsequently involved in an accident. E2 acknowledged policies and procedures were not implemented that ensure the safety of a resident who may wander.”

“Based on documentation review, record 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. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are trigged will be investigated immediately by the caregiver on duty." 3. A review of R5's medical record revealed an incident report dated July 08, 2024. The incident reported stated "R5 managed to open the front door of the facility when no staff was around and snuck out of the house and took one of the staff member's car and drove off." 4. During the environmental tour, the Compliance Officer observed that the facility had means of controlling and alerting employees to residents' egress to outside areas. However, during the incident involving R5 in July 08, 2024, the caregiver failed to investigate immediately when an alarm was triggered upon the resident's departure from the facility. 5. In an interview, E2 reported that R5 had wandered from the facility. In addition, R5 had managed to obtain E2's car keys and had driven away in E2's vehicle and was subsequently involved in an accident. E2 acknowledged that the facility had a system to control or alert staff about residents' egress to outside areas. However, despite this system, the caregiver had been unaware of the general or specific whereabouts of R5. This is a repeat deficiency from the compliance inspection conducted June 23, 2023.”

“Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Disaster Plan". However, the disaster plan was reviewed last on November 01, 2022. 2. A review of facility policies and procedures revealed a policy "Disaster plan, Relocation, Records, Medication, Food and Water," the policy stated "8. The disaster plan is reviewed and the review is documentation at least once every 12 months ..." 3. In an interview, E2 acknowledged there was no documentation available for review at the time of the inspection to indicate the disaster plan was reviewed at least once every 12 months.”