Hawthorn Court at Ahwatukee.

“Based on record review and interview, the manager failed to ensure that a caregiver or an assistant caregiver received orientation that was specific to the duties to be performed by the caregiver or assisted caregiver before they provided assisted living services to a resident, for two of four caregivers sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E4's and E5's personnel records revealed no completed documentation of orientation specific to the duties to be performed by the caregiver was not available for review at the time of inspection. 2. In an interview, E1 reported E4 and E5 were on the schedule for the week of April 1, 2026. 3. In an exit interview, the findings were reviewed with E1, E2, and E3 and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 before or within seven calendar days after the resident’s date of occupancy, for three of four residents sampled. The deficient practice posed a potential illness risk to residents. Findings include:  1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of facility documentation revealed policies and procedures. The policy titled "TB Testing and Screening” stated, “All documentations shall be maintained for tuberculosis risk assessment, tuberculosis screening test, signs or symptoms of an employee/volunteer and residents.” 3. A review of R1’s medical record revealed no documentation of a TB skin test, risks of prior exposure, or signs and symptoms of TB.  4. A review of R2’s medical record revealed documentation of risks of prior exposure and signs and symptoms of TB. However, the risk assessment was not signed by a medical practitioner and documentation of a TB skin test was not available for review.  5. A review of R4’s medical record revealed no documentation of a TB skin test, risks of prior exposure, or signs and symptoms of TB.  6. In an exit interview, the findings were discussed with E1, E2, and E3 and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed the following:  Laundry Detergent in an unlocked laundry room. Lysol Spray and Disinfecting Wipes in an unlocked upper cabinet in an unlocked activity room. 2. A review of facility documentation revealed policies and procedures. The policy titled "Environmental Safety” stated, “Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents.” 3. In an exit interview, the findings were discussed with E1, E2, and E3 and no additional information was provided.  This is a repeat deficiency from the complaint and compliance inspection conducted on March 7, 2025.”

“Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454(A). The deficient practice posed a risk to the physical health and safety of a resident. Findings include:   1. A.R.S. § 46-454(A) states: "A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online."   2. Arizona Administrative Code (A.A.C.) R9-10-101(111) stated “Immediate” means without delay.   3. A review of facility documentation revealed that an incident investigation dated December 17, 2025, at 4:50 PM, documented a resident-to-resident altercation involving physical aggression between R1 and R2. The documentation also reported that E1 was notified on December 17, 2025, at 5:05 PM. However, a review of the documentation revealed that E1 reported the alleged abuse incident to the adult protective services (APS) central intake unit on December 18, 2025, at 4:09 PM.   4. In an interview, E1 acknowledged that APS was not notified immediately. 5. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided. This is a repeat deficiency from the inspection conducted on August 6, 2025.”

“Based on documentation review and interview, the manager failed to immediately report suspected abuse according to A.R.S. § 46-454.   Findings include:   1. A.R.S. § 46-454(A) stated "...other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online."   2. A.R.S. § 46-454(B) stated "If an individual prescribed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law..."   3. R9-10-101.110 stated "Immediate" means without delay.   4. A review of R1’s medical record revealed a document titled “Investigation” dated August 4, 2025, which reflected a resident-to-resident physical altercation. The document reported “appropriate state and law enforcement agencies were notified”.   5. A review of the facility’s documentation revealed a document titled “ADHS complaint-Health Care Facility Complaint” dated August 4, 2025, which reflected that no other agency was notified.   6. In an interview, E1 reported that the Department was the only agency notified of the resident-to-resident altercation. E1 acknowledged that a peace officer or the adult protective services central intake unit was not contacted via telephone or email.”

“Based on observation and interview, the manager failed to ensure the premises 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 residents. Findings include: 1.  During the environmental inspection, the Compliance Officer observed the following: -The common area was torn and fraying in multiple areas, causing a tripping hazard. -The carpet was also fraying and separating from the transition strip from the wood flooring and carpeted area, posing a tripping hazard. -In the activity area, in the walkway, two large exposed holes in the carpet posed a tripping hazard. 2. In an interview, E1 reported that there was usually furniture placed to cover the holes in the carpet. 3. 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 establish and document a quality management program. The deficient practice posed a risk as a quality management program establish and document the necessary information required to effectively manage services provided.   Findings include:   1. Review of the facility's policies and procedures revealed a policy titled "Establishing a Quality Management Plan." This policy stated "The manager shall ensure that a plan is established, documented, and implemented for an ongoing quality management plan that includes a method to identify, document and evaluate incidents...". The facility’s quality management plan failed to establish and document a quality management plan failed to identify, collect and evaluate the methods required in R9-10-804.1.a-e.   2. During an interview, E1 acknowledged a quality management plan failed to establish and document a quality management plan failed to identify, collect and evaluate the methods required in R9-10-804.1.a-e.”

“Based on record review, observation, documentation review, and interview, the manager failed to ensure that a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record for two of four sampled residents.   Findings include:   1. A review of R1's medical record revealed a service plan dated February 5, 2025, which reflected R1 required assistance with transfers every shift, R1 required reminders and cues for all meals, and staff would cut all food and open containers three times a day. R1’s documentation of services provided reflected that R1 was not provided assistance with transfers from February 6, 2025, through February 20, 2025, and there was no documentation that R1 was assisted with reminders and cues for meals, or that R1’s food was cut and containers opened for all meals.   2. A review of R2's medical record revealed a service plan dated February 5, 2025, which reflected R2 required reminders and cues for all meals, and staff would cut all food and open containers three times a day.  R2’s documentation of services provided showed no documentation that R2 was provided assistance with reminders and cues for meals, and did not show that R2’s food was cut and containers opened for all meals.   3. In an interview, E1 reviewed and acknowledged that there was no documentation reflecting that the above assistance was provided to R1 and R2.”

“Based on record review and interview, the manager failed to ensure the service plan for one of one sampled resident receiving directed care services included coordination of communications with the resident's representative, family members, or other individuals identified in the resident's service plan for one of four sampled residents.   Findings include:   1. A review of R2's medical record revealed a service plan February 28, 2025. R2's service plan did not include coordination of communication with R2's representative, family members, or other individual identified in R2's service plan.   2. In an interview, E1 acknowledged R2's service did not include coordination of communication with R2's representative, family members, or other individual identified in R2's service plan.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were maintained in a locked area and were inaccessible to residents.   Findings include:   1. During a facility tour, the surveyor observed an unlocked cabinet inside the north court of the directed care unit kitchen. The cabinet contained a can of Lysol spray.   2. In an interview, E1 acknowledged that the poisonous or toxic materials were left in an unlocked area accessible to residents.”