Motherdear's Place I.

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411.C.2 for three of three personnel reviewed. The deficient practice posed a risk if any personnel were a danger to a vulnerable population.  Findings include: 1. A.R.S. § 36-411.C.2 states, "Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to verify the current status of a person's fingerprint clearance card." 2. A review of E1's, E2's, and E3's personnel records all revealed current fingerprint clearance cards; however, there was no documentation of the verification of the status for any of the cards.   3. A review of the facility's policies and procedures revealed a policy titled "Employee and Volunteer Qualifications." On page 28, the policy stated, "The manager will check and document fingerprinting requirements for each employee...The manager will call, fax, check online, or email DPS...to verify fingerprint clearance status. Documentation will be recorded in the employee or volunteer's personnel record." Further review revealed a second policy titled "Staffing and Recordkeeping." On page 64, the policy stated, "The manager shall maintain a personnel record for each employee...that includes: c. Documentation of compliance with DPS Fingerprint Clearance Card requirement in A.R.S. § 36-411(A) and (C)." 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. This is a repeat citation from the compliance inspection conducted on January 30, 2025.”

“Based on documentation review, interview, and observation, the manager failed to provide written notification to the Department of a resident’s elopement, within 24 hours of the elopement being discovered, for one of one applicable resident. Findings include: 1. A review of facility documentation revealed an incident report dated March 28, 2026, involving the elopement of R1. According to the incident report, the caregiver found R1 outside "with police and the community service." 2. A review of the facility's policies and procedures revealed a policy titled "Environmental and Physical Plant Safety." The policy stated, "2. Exit doors and windows to the outside that a wandering resident may use, will be alarmed to alert employees in the event such resident may wander." 3. In an interview, E3 explained that the audible alert on the front door had been working previously, but when the facility checked it after the incident, it wasn't working. E3 reported this to the manager and the manager ensured that the front door alert was immediately fixed. 4. Based on observation, the Compliance Officer observed the alert on the front door to be working at the time of the inspection. However, it was also observed that if the door that led to the garage was not secured, then the front door alert would not make an audible alert when the front door was opened. 5. In an interview, E1 reported that at the time of the incident, the police said they were going to notify APS. E1 further reported that E1 did not notify the Department of the elopement, as E1 did not know this was required. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review, interview, and documentation review, the manager failed to ensure that, before providing assisted living services to a resident, a manager provided current documentation of first aid (FA) training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of three personnel reviewed. 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 E1's personnel record revealed an expired CPR/FA card with an expiration date of August 28, 2025. There was no other documentation available for review to indicate E1 had current CPR/FA training.  2. In a phone interview, E1 stated that E1 had current CPR/FA training. E1 sent a copy of the certification to the Compliance Officer. 3. A review of E1's current CPR/FA card revealed a completion date of January 19, 2026. Therefore, E1's training had lapsed and E1 did not have documentation of current training from August 29, 2025 through January 18, 2026. 4. A review of the facility’s 2026 Employee Schedule (Jan-May) revealed that E1 worked January 3, 4, 10, 11, 17, and 18, 2026, alone for 24-hour shifts. E1 was also on the schedule as "On-Call" for all of the other days. A previous schedule for 2025 was not readily available for review at the time of the inspection. 5. In an interview, E1 acknowledged that E1’s CPR/FA training had expired and there had been a gap before E1 received E1's new certification.  6. A review of the facility's policies and procedures revealed a policy titled "Employee and Volunteer Qualifications." The policy stated, "Employment Requirements: ...8. Current first aid and CPR training." 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure that the means of exiting the facility 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. While on-site, the Compliance Officer observed one ambulatory resident (R1). 3. A review of facility documentation revealed an incident report dated March 28, 2026, that involved the elopement of R1, in which R1 was able to exit through the front door without the caregiver being alerted of the egress. 4. A review of facility documentation revealed a policy titled "Environmental and Physical Plant Safety." The policy stated, "2. Exit doors and windows to the outside that a wandering resident may use, will be alarmed to alert employees in the event such resident may wander." Further reviewed revealed another policy titled "Memory Care Services Policy and Procedure." The policy stated, "B.4. Prevention of unsafe wandering or exit seeking, which may include the use of alarms or tracking systems. a. Facility is equipped with door alarms and stay 'ON' at all times." 5. In an interview, E3 explained that the audible alert on the front door had been working previously, but when the facility checked it after the elopement of R1, it wasn't working. E3 acknowledged that the alert on the front door was not working at the time of the incident involving R1. 6. Based on observation, the Compliance Officer observed the alert on the front door to be working at the time of the inspection. However, it was also observed that if the door that led to the garage was not secured, then the front door alert would not make an audible alert when the door was opened. 7. 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 that for an assisted living facility authorized to provide directed care services, an elopement drill for employees was conducted every six months on each shift. Findings include: 1. A review of facility documentation revealed no documentation of elopement drills. 2. A review of the facility's policies and procedures revealed a policy titled "Memory Care Services Policy and Procedure." The policy stated, "B.7. Prevention of elopement and responding to elopement incidents promptly and effectively...e. Conduct an elopement drill every six months with participation from all staff and the manager/administrator. Document the date, time, and description of each elopement drill..." 3. In an interview, E1 acknowledged there was no documentation of elopement drills. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”