White Violet.

“Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available and accessible in a bedroom or residential unit being used by a resident receiving personal care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. During the environmental inspection, the Compliance Officer went into all of the resident bedrooms and observed bells, intercoms, or other mechanical means to alert employees to a resident's needs, were missing or not available to residents. 2. A few of the residents revealed they previously had bells but the bells were taken and given to other residents. 3. In an interview, E4 acknowledged the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available and accessible in a bedroom or residential unit being used by a resident receiving personal care services.”

“Based on observation, documentation review, record review, and interview, the governing authority failed to notify the Department according to A.R.S. § 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager.   Findings includes:   1. During the environmental inspection upon entry into the facility, the Compliance Officer observed the manager's certificate hanging on the wall. The name on the certificate was E1.   2. A review of the Department's facility's information revealed, E4 was listed as the manager of the facility. 3. A record review of E1's personnel record revealed, E1's hire date was in September 2025.   4. In an interview, E4 acknowledged that the Department was not notified of the change of managers.”

“Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver 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. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility.   Findings include:   1. Upon arrival at the facility, the Compliance Officer was greeted by E3. There were no other caregivers present at the facility. 2. A documentation review of the manager designation form revealed, E3 was not listed as a manager designee.   3. In an interview, E3 revealed, the employee was not listed as a designed manager when E1 was not present.   4. E2 arrived at the facility after being called by E4. E2 was listed as a designated manager in the absence of E1. 5. In an interview, E4 acknowledged that no manager or designee 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. This is a repeated deficiency from the on-site Compliance inspection completed on June 26, 2025.”

“Based on observation, record review, and interview, the manager failed to ensure that 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. During the compliance inspection, E3 greeted the Compliance Officer upon entering the facility and E3 was the only employee at the facility at the time. 2. A record review of personnel records revealed, E3 did not have a personnel record available for review. 3. In a phone interview, E4 acknowledged the manager did not ensure that the manager or a caregiver was present at an assisted living home.”

“Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation required by this rule, for one of three personnel sampled. The deficient practice posed a risk as required information for a personnel member could not be verified.   Findings include:   1. Upon arrival at the facility, the Compliance Officer was greeted by E3. There were no other caregivers present at the facility. 2. A record review of personnel records revealed, E3 did not have a personnel record available for review at the time of the inspection. 3. In an interview, E4 acknowledged no personnel record for E3 was available that contained the requite components.”

“Based on observation, record review, and interview, the manager failed to ensure medical records were maintained for 1 of 2 residents sampled. The deficient practice posed a risk as the required information could not be verified.   Findings include:   1. During the environmental inspection, the Compliance Officer was informed by E2, that R2 had recently been, but was no longer a resident of the facility.   2. The Compliance Officer requested to review the medical records for R1 and R2.   3. The medical records for R2 were not provided for review.   4. In an interview, E2 acknowledged the manager did not ensure the medical records for R2 were maintained as required.”

“Based on observation and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record for all five residents. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. During the compliance inspection, the Compliance Officer requested to review the Medical Administration Records (MARS) for R1 and R2. 2. The MARS were not available during the compliance inspection. 3. In an interview, E2 revealed, E4 took the MARS off property and had not returned. E2 contacted E4 via phone and text messages to find out how soon the MARS could be returned. 4. In an phone interview, E4 acknowledged the manager did not ensure a medication administered to a resident was documented in the resident's medical record.”

“Based on records review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for one of three sampled employees.   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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E3’s personnel record revealed that based on E3's hire date, this documentation was required.   4. E3 submitted a TB skin test dated December 4, 2023. E3 submitted a TB screening form that was dated December 4, 2023 but signed December 4, 2024.   5. In an interview, E2 acknowledged that E3 did not provide documentation of freedom from infectious TB.”

“Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver 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. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility.   Findings include:   1. Upon arrival at the facility, the Compliance Officer met with caregiver E2.   2. Documentation review of the manager designation form did not list E2 nor E3 as manager designees.   3. In an interview, E2 revealed that the employee was not listed as a designated manager. E2 acknowledged that there were no other caregivers at the facility designated as manager in the absence of E1.”

“Based on record review and interview, the manager the manager failed to obtain a statement from the resident's primary care provider or other medical practitioner, who examined the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition, reviewed the assisted living facility's scope of services, and signed and dated a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility.   Findings include:   1. A review of R2's service plan, revealed that the resident received Personal Care services and was wheelchair bound. 2. A review of the facility's "Physician, behavioral health professional, or medical practitioner authorization" form, stated, " This authorization is required at the onset of the above circled condition or within 30 calendar days of acceptance and at least once every six months throughout the duration of the resident's condition." Based on the resident's admission date, the initial or continuation medical authorization form was required. 3. A review of the "Physician, behavioral health professional, or medical practitioner authorization" form dated February 17, 2025 was signed with a "W" and did not list the name of the medical provider. 4. A review of the "Determination and Continuation of Care" form dated February 19, 2025, that was signed by the resident or the resident's representative, was signed with the same "W" as the physician statement form. 5. In an interview, E2 acknowledged that the manager failed to obtain a statement from the resident's primary care provider or other medical practitioner, who examined the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition, reviewed the assisted living facility's scope of services, and signed and dated a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility.”

“Based on observations, documentation review, 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. 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 documentation revealed the facility was authorized to provide Directed Care services. 2. During the environmental inspection, the Compliance Officer observed that patio door did not alert or alarm when opened. The Compliance Officer observed that the alarm was switched off.   3. A documentation review of the facility's Policies and Procedures titled, "Emergency and Safety: Entry /Exits" stated, "the residents have a Monitoring System, Security System, and Wireless Bell System that allows the caregivers to be alerted to the needs of the residents."   4. In an interview, E2 acknowledged that there were no controls or alerts to notify employees of the egress of a resident from the facility.”