St Joseph Assisted Living LLC.

“Based on observation, record review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to the physical health and safety of a resident. Finding include:  1. Upon entry into the facility, the Compliance Officer was greeted by a person not employed by the facility. E1, E2, or E3 were not at the facility while residents were present. E3 was called after the Compliance Officer arrived on site. 2. A review of R1' medical records revealed, the resident was discharged four days after admission and went to reside in E2's personal residence. R1's legal guardian (O1) was not notified. R1 was transported across state lines to Las Vegas, Nevada by E2 on November 21, 2025 at the request of O2. R1 was dropped off to a non authorized person. 3. A review of R2's medical records revealed, the resident was on premise and a current resident of the facility with no caregiver present. 4. In an interview, E2 revealed, the employee went to the store to buy groceries. E3 was a back up caregiver who was called once the Compliance Officer arrived on site. E2 acknowledged the manager failed to ensure the health, safety, and welfare of a resident was not placed at harm.”

“Based on observation, record review, and interview, the manager failed to ensure a designated manager 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. Upon arrival at the facility, the Compliance Officer was greeted by a friend of E2. E1, E2, and E3 were not on the property. E2 was called by the friend who revealed, E3 was on the way. E3 arrived within 10 minutes and E2 a short time later. 2. A record review of the designated manager form revealed, E2 and E3 were listed as a designated managers in the absence of E1. 3. In an interview, E2 revealed, the employee went to the store to get a few groceries. E3 was a back up caregiver for this facility and only called when needed. 4. In an interview, E2 acknowledged the manager failed to ensure a designated manager 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. This is a repeat deficiency from the on-site Complaint inspection conducted on January 27, 2025.”

“Based on record review and interview, the manager failed to ensure an employee or a family member of an employee did not act as a resident’s representative for a resident who was not a family member of the employee. Findings include: 1. A record review of R1's medical records revealed, based on the resident's "Determination Form" the resident received Supervisory Care services from the facility. 2. A record review of text messages between O1 and E2 revealed, an arrangement was made for E2 to drop off R1 with family in Las Vegas, Nevada on November 21, 2025. 3. In an interview, E2 revealed, R1 was discharged from the facility on September 24, 2025 and moved into E2's personal residence. R1 also stayed with E2's brother temporarily until arrangements could be made to transport the resident to family. 4. In an interview, E2 acknowledged the manager failed to ensure an employee or a family member of an employee did not act as a resident’s representative for a resident who was not a family member of the employee.”

“Based on observation, record review, and interview, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home Findings include: 1. Upon arrival at the facility, the Compliance Officer was greeted by a friend of E2. E1, E2, and E3 were not on the property. E2 was called by the friend who revealed, E3 was on the way. E3 arrived within 10 minutes and E2 a short time later. 2. A record review of the designated manager form revealed, E2 and E3 were listed as a designated managers in the absence of E1. 3. In an interview, E2 revealed, the employee went to the store to get a few groceries. E3 was a back up caregiver for this facility and only called when needed. 4. In an interview, E2 acknowledged the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home This is a repeat deficiency from the on-site Complaint inspection conducted on January 27, 2025.”

“Based on observation, record review, and interview, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. The facility had a census of seven residents at the time of the inspection. 2. The Compliance Officer entered the facility around 5:55 pm and observed E2, E3, and E4 in the facility. It was approximately 6:07 pm when E1 was observed in the facility. 3. A review of E2’s, E3’s, and E4’s personnel records revealed E2 and E3 were hired as assistant caregivers. E4’s personnel record revealed E4 was hired as a caregiver however, E4 did not have a caregiver certificate available at the time of inspection. 4. In an interview, E4 reported that the Compliance Officer caught them at a bad time, as E1 leaves from 4 pm to 9 pm.  5. In an interview, E2 was heard talking to E1 when E1 rounded the corner into the kitchen. E2 was heard saying, “You got here fast” to E1. 6. In an interview, E1 reported that E1 was helping R2 to bed. However, R2 was unable to participate in an interview to confirm E1 was helping R2 to bed.  7. In an interview, R1 reported that E1 left around 4 pm - 4:30 pm that night. 8. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat deficiency from the inspections conducted on January 27, 2025, and July 1, 2025.”

“Based on documentation review, observation, and interview, the manager failed to ensure 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 monitored 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed that the alarm on the door leading to the backyard of the facility was not working. The alarm did not sound when the Compliance Officer opened the door. The Compliance Officer observed no monitoring system in place.  3. The Compliance Officer observed residents sitting outside of the facility in the backyard. 4. In an interview, E1 reported that the sensor had to be pushed back a little for it to work. When E1 pushed the sensor, the alarm faintly sounded when opened.  5. In an interview, E1 acknowledged the alarm was not working before E1 pushed the sensor. 6. In an exit interview, the findings were reviewed with E1 and no additional information was provided. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on June 26, 2025; this is an uncorrected citation from the complaint inspection conducted on January 29, 2025 and July 1, 2025; and this is a repeat citation from the compliance inspection conducted on June 17, 2024.”

“Based on observation and interview, the manager failed to ensure pets were controlled to prevent endangering the residents. This deficient practice posed a risk to the health and safety of the residents’ well-being. Findings include: 1. The Compliance Officer observed a dog in the facility. E2 chased the dog around the kitchen and managed to place the dog behind a locked door. 2. In an interview, R1 reported the dog bit one of R1’s nurses. 3. In an interview, E1 reported APS was out at the facility investigating the incident with the dog. E1 reported E1 did not know the department also investigated incidents when a dog bites a visitor. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on documentation review, interview, and observation, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as residents were alone with an individual who was not a certified caregiver. Findings include: 1. Arizona Revised Statutes § 36-401(A)(49) states, "'Supervision' means directly overseeing and inspecting the act of accomplishing a function or activity." 2. In an interview, E1 reported E3 was an assistant caregiver. E1 and E3 reported E3 recently took the caregiver certification course and failed but was planning to retake the test soon. 3. During an environmental inspection of the facility, the Compliance Officer observed residents in several areas of the facility, including common areas. On several occasions during the inspection, the Compliance Officer observed E3 was not within sight of E1 and the Compliance Officer. 4. In an interview, when the Compliance Officer reminded E1 that E3 could not interact with residents without being under the supervision of a manager or caregiver, E1 stated, “I know.” 5. On several occasions after the aforementioned interview with E1, the Compliance Officer observed E3 interacting with residents without being under the supervision of a manager or caregiver. Furthermore, the Compliance Officer observed E1 exit through the front door of the home for a short time while E3 was still inside with the residents. 6. In an interview, E1 reported E1 had gone outside to go around the side of the house to another entrance to obtain resident records. E1 reported E1 did not have the key to the door leading to the room with the resident records and had to go outside the facility and around to get them. While E1 was outside, residents were left without a certified caregiver in the facility. 7. In a separate interview, E1 acknowledged E3 interacted with residents without being under the supervision of a manager or caregiver.”

“Based on documentation review, observation, and interview, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as residents were alone with an individual who was not a certified caregiver and the Department was provided false or misleading information. Findings include: 1. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint inspection conducted on January 27, 2025. The POC indicated this deficiency was corrected on April 15, 2025. The POC stated: “The Owner…and any certified caregivers shall not leave the facility even for a grocery run when there are no caregivers left with the residents. Moving forward, the Owner shall ensure that at all times at least the manager or certified caregiver is always present in the facility when a resident is present.” 2. The Compliance Officer observed E1 and E3 were the only personnel at the facility during the inspection. The Compliance Officer observed residents in several areas of the facility, including common areas. On several occasions during the inspection, the Compliance Officer observed E3 was not within sight of E1 and the Compliance Officer. 3. In an interview, E1 reported E3 was an assistant caregiver. E1 reported E1 was the only caregiver currently in the facility. 4. The Compliance Officer later observed E1 exit through the front door of the home for a short time while E3 was still inside with the residents. 5. In an interview, when the Compliance Officer informed E1 that E1 could not leave the residents without a manager or caregiver in the home, E1 reported E1 had gone outside to go around the side of the house to another entrance to obtain resident records. E1 reported E1 did not have the key to the door leading to the room with the resident records and had to go outside and around to get them. This is a repeat citation from the complaint inspection completed on January 27, 2025.”

“Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that was reviewed and updated at least once every six months for a resident receiving personal care services, for one of two sampled residents receiving personal care services. The deficient practice posed a risk if the service plan did not include current, accurate information. Findings include: 1. A review of R2's medical record revealed a service plan dated December 23, 2024, which indicated R2 received personal care services. The service plan stated the “Service Plan renewal date” was June 22, 2025. However, the review revealed no updated service plan dated within six months after December 23, 2024, or thereafter. 2. In an interview, E1 acknowledged R2’s service plan should have been updated and reviewed by June 22, 2025, more than one week before the date of the inspection. E1 reported E1 still needed to send out to a third party company to get R2’s service plan updated. This is a repeat citation from the complaint inspection completed on January 27, 2025.”

“Based on documentation review, observation, and interview, the manager failed to ensure 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 monitored 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed a door in the kitchen leading to the back yard (the same door for which technical assistance was given during an inspection five days prior, and which was cited two other times prior). The Compliance Officer observed the facility did not have a monitoring system in place but the door did have an alert installed. However, the alert did not sound when the Compliance Officer opened the door and walked outside. The Compliance Officer observed no facility personnel within sight. 3. While outside and around the corner of the facility, the Compliance Officer overheard E3 state, “I don’t know where [the Compliance Officer] went.” 4. During the course of the inspection, the Compliance Officer observed multiple residents egress through the kitchen door. The Compliance Officer further observed three sets of double doors leading to the backyard without monitoring systems or alerts installed. The Compliance Officer observed the first set in the living room behind a couch, the second set in an occupied bedroom behind two nightstands, and the third set in another occupied bedroom. 5. In an interview regarding the three double doors, E1 stated, "There’s no chimes." E1 further stated, “We didn’t put the chimes ‘cause we don’t use these ones.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on June 26, 2025; this is an uncorrected citation from the complaint inspection conducted on January 29, 2025; and this is a repeat citation from the compliance inspection conducted on June 17, 2024.”

“Based on observation and interview, the manager failed to ensure that a refrigerator used by an assisted living facility to store food or medication contained a thermometer.     Findings include: 1. During a tour of the facility, the Compliance Officers observed that the refrigerator in the kitchen did not contain a thermometer.   2. In an interview, E2 acknowledged there was no thermometer in the kitchen refrigerator at the time of inspection.”

“B. A manager of an assisted living home shall ensure that: 4. At least the manager or a caregiver is present at an assisted living home when a resident is present in the assisted living home and: a. Except for nighttime hours, the manager or caregiver is awake; and b. If the manager or caregiver is not awake during nighttime hours:”

“C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: 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 provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident's date of occupancy, and 2. As specified in R9-10-113.”

“B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and 2. If an individual is requesting or is expected to receive behavioral health services, other than behavioral care, in addition to supervisory care services, personal care services, or directed care services from an assisted living facility: a. Includes whether the individual requires continuous behavioral health services, and b. Is signed and dated by a behavioral health professional.”

“D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 1. The individual's name; 2. Terms of occupancy, including: a. Date of occupancy or expected date of occupancy, b. Resident responsibilities, and c. Responsibilities of the assisted living facility; 3. A list of the services to be provided by the assisted living facility to the resident; 4. A list of the services available from the assisted living facility at an additional fee or charge; 5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours; 6. The policy for refunding fees, charges, or deposits; 7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident's service plan; 8. The policy and procedure for an assisted living facility to terminate residency; 9. The complaint process; and 10. The manager's signature and date signed.”

“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: ii. At least once every six months for a resident receiving personal care services, and”

“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;”

“C. A manager shall ensure that a resident's medical record contains: 1. Resident information that includes: a. The resident's name, and b. The resident's date of birth; 2. The names, addresses, and telephone numbers of: a. The resident's primary care provider; b. Other persons, such as a home health agency or hospice service agency, involved in the care of the resident; and c. An individual to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency; 3. If applicable, the name and contact information of the resident's representative and: a. The document signed by the resident consenting for the resident ' s representative to act on the resident's behalf; or b. If the resident's representative: i. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or ii. Is a legal guardian, a copy of the court order establishing guardianship; 4. The date of acceptance and, if applicable, date of termination of residency; 5. Documentation of the resident's needs required in R9-10-807(B); 6. Documentation of general consent and informed consent, if applicable; 7. Except as allowed in R9-10-808(B)(2), documentation of freedom from infectious tuberculosis as required in R9-10-807(A); 8. A copy of resident's health care directive, if applicable; 9. The resident's signed residency agreement and any amendments; 10. Resident's service plan and updates; 11. Documentation of assisted living services provided to the resident; 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication; 13. Documentation of medication administered to the resident re”

“Based on interview, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. In an interview, E2 reported E2 had to go to the store to pick up some groceries for the facility. E2 reported E2 left another person on site who was not a caregiver or manager to watch over the residents while E2 was gone. E2 reported E2 left the facility around 2:45 PM and returned to the facility around 4:00 PM after being informed the ombudsman was on site. 2. In an interview, E2 acknowledged a manager or caregiver was not present at the assisted living home when a resident was present at the assisted living home.”

“Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of two sampled residents. The deficient practice posed a health and safety risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's current service plan revealed R1 required assistance with "Bathing/Hygeine: Shower 2/Week." However, a review of R1's Activities of Daily Living (ADL) sheet revealed R1received a shower every day from June 1, 2024 through June 17, 2024. 2. A review of R2's current service plan revealed R2 required assistance with "Bathing/Hygeine: Shower 2/Week." However, a review of R2's Activities of Daily Living (ADL) sheet revealed R2 received a shower every day from April 1, 2024 through April 21, 2024. 3. In an interview, E2 reported E2 had been marking the ADL sheets every day to indicate the service was offered to R1 and R2. However, E2 reported R1 and R2 had not taken a shower every day between the aforementioned dates. E2 acknowledged the services were not accurately recorded on R1's and R2's ADL sheets.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for one of two sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation route to be used in an emergency. Findings include: 1. A review of R1's medical record revealed documentation titled "Resident Orientation." The document stated "Please check in each space below as the corresponding task is completed." However, not all items listed on the "Resident Orientation" were checked to indicate the task was completed at time of inspection. 2. In an interview, E2 acknowledged documentation of R1's orientation was incomplete.”

“Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away 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 facility documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed a door leading from the kitchen to the back yard. However, the alert placed on the door was not functional at the time of inspection. The Compliance Officer also observed a door with a double-sided deadbolt leading from a resident bedroom to the back yard. However, the door was unlocked at the time of inspection. 3. In an interview, E2 acknowledged means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, did not control or alert employees of the egress of a resident from the facility at the time of the inspection.”

“Based on observation, documentation review, and interview, the manager failed to ensure a food menu included any food substitutions no later than the morning of the day of meal service with a food substitution. The deficient practice posed a risk if the origin of a food-borne illness could not be identified. Findings include: 1. At approximately 11:30 AM, The Compliance Officer observed a staff member making lunch for the residents. The Compliance Officer observed the staff member preparing spaghetti and meatballs in a pan. 2. In an interview, E2 reported the residents were having spaghetti and meatballs for lunch. 3. A review of facility documentation revealed a menu for the week of June 17, 2024 through June 23, 2024. On June 17, 2024 (the date of the inspection), the menu stated "Roast Chicken, Mashed Potato" would be served for lunch. 4. In an interview, E2 acknowledged the food menu did not include any food substitutions no later than the morning of the day of meal service with a food substitution.”

“Based on observation and interview, the manager failed to ensure poisonous or 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 residents with access to the materials. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a container of "Suavitel" fabric softener, two containers of "Arm and Hammer Oxi Clean" and a bottle of "Clorox" performance bleach in an unlocked cabinet above the washer and dryer. The washer and dryer were accessible to residents of the facility. 2. In an interview, E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked area and inaccessible to residents at the time of the inspection. This is a repeat citation from the previous compliance inspection conducted on December 15, 2022.”