Carriage House On West Garden Lane.

“Based on record review and interview, the manager failed to ensure, if applicable to take immediate action to stop the suspected abuse, neglect, or exploitation, report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454. Document the suspected abuse, neglect, or exploitation, any action taken according to subsection (J)(1); and the report in subsection (J)(2). Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2). Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2). The dates, times, and description of the suspected abuse, neglect, or exploitation. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident’s physical, cognitive, functional, or emotional condition. The names of witnesses to the suspected abuse, neglect, or exploitation, and the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated. Findings Include: 1. A review of E1, E2, E3, E4 medical records revealed no incident reports. 2. In an interview, E1 reported that APS was at the facility on July 16th, 2025, regarding an incident involving R4. However, there was no incident report documented or investigation completed.”

“Based on record review and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis, on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in R9-10-113. Findings include: 1. A review of E3's personnel record (date of hire December 31, 2024) revealed documentation showing two negative tuberculosis skin tests. 2. Further review of E3's personnel record revealed no documentation of tuberculosis screening and risk assessment. 3. In an interview, E1 acknowledged E3's personnel record did not contain a tuberculosis screening and risk assessment as specified in R9-110-113.”

“Based on record review and interview, the manager failed to ensure that two residents provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy, and as specified in R9-10-113. Findings Include: 1. A review of R1's and R4's medical records revealed that tuberculosis skin tests were being done yearly. 2. Further review of R1's and R4's medical records revealed no tuberculosis screening and risk assessment documentation. 3. In an interview, E1 acknowledged R1's and R4's medical records did not include freedom from infectious tuberculosis as specified in R9-10-113.”

“Based on a record review and interview, the manager failed to ensure that a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. Findings Include: 1. A review of R1's, R2's, R3's, and R4's medical records revealed resident rights and resident agreements signed and dated. 2. Further review of R1's, R2's, R3's, and R4's medical record revealed no documentation that included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. 3. In an interview, E1 acknowledged that R1, R2, R3, and R4 did not have documentation that included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. E1 also reported that none of the residents would have documentation in their medical records.”

“Based on the record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record. Findings Include: 1. A review of R1's, R2's, R3's, and R4's medical records revealed service plans that described what services would be provided by the facility. 2. Further review of R1's, R2's, R3's, and R4's medical records revealed no activities of daily living. 3. In an interview, R2 reported that food, medication, fluids, cleaning, incontinence care, and bathing were provided. 3. In an interview, E1 reported that they were unaware that services provided by the facility needed to be documented, and all residents would be missing activities of daily living, but all services were being provided.”

“Based on record review and interview, the manager failed to ensure that when a resident had an accident or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver immediately notified the resident's emergency contact. Findings include: 1. Review of the incident report belonging to R1, dated November 8, 2024 revealed that on November 8, 2024 at 6:45pm the resident fell and sustained an injury that required medical services. Records indicate that the resident's emergency contact was not contacted, although a message was left for the resident's primary care provider at 6:45pm. 2. During an interview, E1 acknowledged the resident sustained an injury that required medical services and the caregiver did not immediately notify the resident's emergency contact.”