Kellys Adult Care Home.

“Based on record review, documentation review and interview, the manager failed to ensure that a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. § 36-411(C). The deficient practice posed a risk if E1, E2, or E3 were a danger to a vulnerable population.   Findings include:   1. A.R.S. § 36-411.C states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 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. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459."   2. A record review of the personnel records for E1, E2, and E3 revealed, a fingerprint clearance check was not completed for any of the employees.   3. An online check by the Compliance Officer on November 12, 2025, of the Arizona Department of Public Safety (DPS) web portal at https://psp.azdps.gov/services/cardStatusRequest revealed, E1, E2, and E3 had a valid DPS fingerprint Clearance Card.   4. In an interview, E1 acknowledged that the manager failed to ensure that a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. § 36-411(C).”

“Based on documentation review and interview, the manager failed ensure that a documented report is submitted to the governing authority that includes an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1. A documentation review of the facility's Quality Management log revealed, the maintenance form was last completed in September 2025. 2. A documentation review of the facility's Policies and Procedures Manual titled, "Quality Management Programming Including Incident Reports" stated, "A copy of each filled out form regarding the incident, accident, emergency, unusual occurrence, immediate jeopardy, elopement, or event that outs the resident un danger, including incents regarding opioid-related adverse reactions or other negative outcomes a resident experiences, or opioid-related deaths, will be placed in the QOS Folder and the Quality of Service Monthly Recording Form." 3. In an interview, E1 acknowledged, the manager did not ensure that a documented report is submitted to the governing authority that includes an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care.”

“Based on documentation review, record review, and interview, the manager accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: R9-10-101.5. states: "Activities of daily living" means ambulating, bathing, toileting, grooming, eating, and getting in or out of a bed or a chair. R9-10-101.32. states: "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. 1. A review of Department documentation revealed the facility was not authorized to provide behavioral health services, per R9-10-802(2)(b). 2. A review of R2's medical record revealed a current written service plan for supervisory care dated November 2023, which stated "Primary Medical Diagnosis: Alcoholism", no other diagnosis was listed. 3. In an interview, E1 reported that R2 needed assistance with cooking and cleaning. E1 reported that R2's only diagnosis was alcoholism. E1 acknowledged R2 was accepted and retained when the primary condition for which R2 needed assisted living services was a behavioral health issue.”

“Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, 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. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility with E1, the Compliance Officer observed a door leading to a backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door did not have a device that alerted employees of the egress of a resident from the facility and was unlocked. 3. In an interview, E1 reported that the alarms had been taken down for repainting a few weeks prior, and had not been reinstalled. E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.”

“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. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed the following in a caregiver bathroom. The bathroom door was equipped with a privacy latch, however, this latch was able to be opened without a key or combination. -"Lysol All Purpose Cleaner" which stated "Warning: Keep out of reach of children"; -"Dawn Powerwash" which stated "Keep out of reach of children". 2. In the unlocked backyard, the Compliance Officer observed a container of "Oatey Clear Cleaner" which stated "Danger! May be fatal if swallowed and enters airways". 3. In an interview, E1 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on October 26, 2022 and August 30, 2021.”