New Horizons Adult Care Home #2.

“Based on record review, documentation review, and interview, the governing authority failed to ensure that 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. A record review of an incident report dated December 1, 2025, revealed that R1 was discovered missing from the facility at 11:06 pm. The resident was found by a concerned passerby, who called the police department and reported that R1, with a walker, was stumbling and then fell on the sidewalk along N Glassford Hill Rd. The police contacted the facility at 12:00 am to notify the facility that R1 was found on the sidewalk and is currently at the hospital for evaluation.  2. A documentation review of the facility's Policies and Procedures titled "Precautions Taken for a Resident Who May Wander” stated, “supervision of the resident who wanders will increase to constant while the resident is awake. Night-time audio supervision will be constant, and Constant supervision and frequent checks will be maintained on all the locks and on any residents who are prone to wander”. 3. In an interview, E1 reported that no one was sure when R1 left the facility, but it was believed that it occurred when E3 was in another room helping another resident.  4. In an interview, E1 acknowledged that the manager failed to ensure the health, safety, and welfare of R1.”

“Based on 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. A record review of an incident report dated December 1, 2025, revealed that R1 was discovered missing from the facility at 11:06 pm. The resident was found by a concerned passerby, who called the police department and reported that R1, with a walker, was stumbling and then fell on the sidewalk along N Glassford Hill Rd. The police contacted the facility at 12:00 am to notify the facility that R1 was found on the sidewalk and is currently at the hospital for evaluation.  3. A documentation review of the facility's Policies and Procedures titled "Precautions Taken for a Resident Who May Wander” stated, “supervision of the resident who wanders will increase to constant while the resident is awake. Night-time audio supervision will be constant, and Constant supervision and frequent checks will be maintained on all the locks and on any residents who are prone to wander”. 4. In an interview, E1 reported that E3 was not alerted to the egress of R1, since E3 was helping another resident in a room.  5. In an exit interview with E1, the findings were reviewed, and no additional information was provided.”

“Based on documentation, record review, and interview, the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A for two of two residents sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency.   Findings include:   1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives."   2. A review of R1's and R2's medical records revealed no documentation or standardized form which included all information required by statute.   3. In an interview, E1 acknowledged the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A.”

“Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by the health care institution, and annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a potential TB exposure risk to residents.   Findings include:   1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)."   2. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel."   3. A review of R1's and R2's medical record revealed completion of TST testing. However, no documentation of a baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the R1 and R2 had signs or symptoms of TB was available for review.   4. A review of E1's and E2's personnel record revealed completion of two-step TST testing. However, no documentation of a baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the E1 and E2 had signs or symptoms of TB was available for review.   5. Review of facility documentation revealed no documentation of training and education related to recognizing the signs and symptoms of tuberculosis was available for review.   6. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available.   7. In an interview, E1 acknowledged the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by the health care institution, and annually assessing the health care institution's risk of exposure to infectious tuberculosis.”

“Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a review date of March 20, 2020. No documentation of further review was available for Compliance Officer review. 2. In an interview, E1 acknowledged that the polices and procedures were not reviewed at least once every three years and updated as needed.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge are verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services and according to policies and procedures for two of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs.   Findings include:   1. A review of facility policy and procedures revealed a policy stating “Personnel files include the following: 1. Name, date of birth, contact… 2. The individual’s qualifications and skills.”   2. A review of E2's and E3's personnel records revealed no documentation verifying a caregiver's or assistant caregiver's skills and knowledge.   3. A review of the facility's employee schedule for October 2024 revealed E2 providing services the following dates from 10:00AM to 6:00PM: - February 3 – February 4, 2025; - February 6, 2025; - February 10 – February 11, 2025; and - February 13, 2025.   4. A review of the facility's employee schedule for October 2024 revealed E3 providing services the following dates and times: - February 4, 2025 from 6:00PM to 10:00 AM; - February 5, 2025 from 10:00PM to 10:00AM; - February 11, 2025 from 6:00PM to 10:00 AM; and - February 12, 2025 from 10:00PM to 10:00AM.   5. In an interview, E1 acknowledged E2's and E3's skills and knowledge were not verified and documented before E2 and E3 provided physical health services.”

“Based on record review and interview, the manager failed to ensure that a resident's written service plan was signed by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, for one of two residents sampled.   Findings include:   1. A review of R1's medical record revealed a service plan from December 2024. However, the service plan did not include a signature from R1 or R1's representative, the manager, and the nurse who reviewed the service plan.    2. In an interview, E1 acknowledged R1's service plan were not signed by the resident or resident's representative, the manager, and the nurse who reviewed the service plan.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d) for one of two residents sampled. The deficient practice posed a potential illness risk to residents.   Findings include:  1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R2's medical record revealed notification of the availability of flu and pneumonia vaccinations dated January 2023. However, R1's medical record did not include documentation of R1's notification of the availability of flu and pneumonia vaccinations annually. Based on R1's acceptance date, this documentation was required.   3. In an interview, E1 acknowledged R1's medical record did not contain documentation of R1's notification of the availability of vaccinations according to A.R.S. § 36-406(1)(d).”