House of Hope Assisted Living LLC.

“Based on record review, documentation review, and interview, the health care institution failed to ensure a training program for all staff regarding fall prevention and fall recovery, which included initial training and continued competency, was implemented. The deficient practice posed a risk to the physical health and safety of a resident.       Findings include:        1. A review of E2’s and E3’s personnel record revealed evidence of documentation indicating E2 and E3 had received ongoing training in fall prevention and fall recovery in May 2024. However, evidence of documentation indicating E2 or E3 had received additional training in fall prevention and fall recovery since May 2024 was unavailable for review.       2. A review of facility documentation revealed a fall prevention and fall recovery program compliant with A.R.S. § 36-420.01. The program stated, “All House of Hope employees are required to review fall prevention yearly.”       3. In an interview, E1 acknowledged E2 and E3 had not completed annual fall training as required.”

“Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities, including annual training and education for employees, related to recognizing the signs and symptoms of TB.       Findings include:       1. A review of E2's and E3’s personnel records revealed evidence of documentation of training in recognizing signs and symptoms of TB in 2023. However, evidence of documentation of training after 2023 was unavailable for review.           2. In an interview, E1 admitted they had not received training in recognizing the signs and symptoms of TB annually as required.”

“Based on document review, 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.       Findings include:       1. A review of Department documentation revealed the facility was licensed at the directed care level.       2. During a tour of the facility, the Compliance Officer observed R1 to be ambulatory, without assistance. The Compliance Officer observed two separate sets of French doors, each equipped with locking door handles, which required a key to open, and an electronic mechanism designed to alert caregivers of the egress of a resident. Each mechanism was turned off, and the locks were not engaged. When the Compliance Officer opened each set of doors, there was no alert. On separate occasions, the Compliance Officer observed both E1 and E2 redirect R1, who appeared to be wandering.        3. A review of E2’s and E3’s personnel records revealed evidence of documentation of fall prevention and fall recovery training conducted in May 2024. However, evidence of documentation of continued competency training since May 2024 was unavailable for review.       4. A review of facility documentation revealed a fall prevention and recovery program, which indicated facility employees were required to maintain continued competency on an annual basis.       5. A review of facility documentation revealed an incident report, dated July 24, 2025, documenting a fall by R3, in which the resident suffered a bruise to their right ear, bruising to their right side, and a skin tear.  A second incident report, dated July 30, 2025, documented R3’s refusal to get out of bed due to “pain,” and being “unable to get up.” The incident report also documented R3’s “left hip swollen and toes bruised.” The report indicated R3 was transported to the hospital.        6. In an interview, E1 acknowledged R3’s injuries documented on July 30, 2025, were dissimilar to those documented on July 24, 4045. E1 advised E1 suspected R3 may have had an undocumented fall during the night of July 29, 2025, because that was the last shift E2 worked. E1 said E2 had been terminated on August 1, 2025, because E2 was “always late or calling off work,” and E2 refused to keep their fingernails short, which E1 felt posed a safety risk to residents.”

“Based on documentation review, observation, and interview, the manager failed to ensure the location where the most recent Department inspection report and any resulting plan of correction may be viewed.       Findings include:       1.  A review of facility documentation revealed the most recent on-site compliance inspection at the facility had been conducted on August 26, 2024. Documentation revealed citations were issued, and a corresponding plan of correction had been submitted.       2. During a tour of the facility, the Compliance Officer observed the location where the most recent Department inspection report and corresponding plan of correction could be reviewed was not conspicuously posted.       3. In an interview, E1 acknowledged the location where the most recent Department inspection report and corresponding plan of correction could be reviewed was not conspicuously posted.       Technical assistance regarding the requirement in R9-10-803(D)(4) was provided on August 26, 2024.”

“Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident’s date of occupancy. The deficient practice posed a potential TB exposure risk to residents.       Findings include:       1. Arizona Administrative Code (A.A.C.) R9-10-113(A)(2)(a)(i-ii) states: “a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, baseline 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 [TB], ii. Determining if the individual has signs or symptoms of [TB].”       2. A review of R1’s and R2’s medical records revealed evidence of documentation of a negative TB skin test. However, evidence of baseline screening for signs, symptoms, and risk of exposure to TB was unavailable for review.       3.  In an interview, E1 acknowledged R1 and R2 had not provided evidence of freedom from infectious TB, including baseline screening, as specified in R9-10-113, before or within seven calendar days of their respective dates of occupancy.”

“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, which 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 general or specific whereabouts of a resident.       Findings include:       1. A review of the license issued by the Department revealed the facility was authorized to provide directed care services.       2. While at the facility, the Compliance Officer observed R1 to be ambulatory, without assistance. On separate occasions, the Compliance Officer observed both E1 and E2 redirect R1, who appeared to be wandering.          3. During a tour of the facility, the Compliance Officer observed two separate sets of French doors, which led to a secure area behind the facility.  Each set of doors was equipped with an electronic door chime, designed to alert caregivers of the egress of a resident. Each mechanism was turned off, and the locks were not engaged. When the Compliance Officer opened each set of doors, there was no alert. Batteries for the electronic door chimes were replaced and made operational while the Compliance Officer was on-site.       4. In an interview, E2 advised there was no monitoring system for the doors, other than the attached electronic chimes. E1 agreed there was a means of exiting the facility, which allowed residents to be at least 30 feet away from the facility, but did not monitor or alert employees of the egress of a resident.”

“Based on documentation review, observation, record review, and interview, the governing authority failed to designate a manager who had either a temporary or permanent manager's certificate from the Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers, which posed a health and safety risk. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable rules. Findings include: 1. A review of department documentation revealed the following: "09/21/2023, Notification [E1] is no longer the on-site manager effective 09/19/2023. see attached", and " 7/25/2024, online sub of late fees were received 07/02/2024. CO will need to check the manager's expiration at the next inspection". 2. A review of department documentation revealed the following: " September 18, 2023, To: Arizona Department of Health Services, Re: Termination of Management, Manager license number: 008853. This Letter is to inform the department that, as of September 19, 2023, I [E1], located at 1938 W. Riverview, Tucson AZ 85704, License No. AL11914H. For questions regarding this matter. I can be reached via cell 520-743-6548, Attentively [E1]". 3. On August 26, 2024, after entering the facility, the Compliance Officer asked caregiver E2, if the manager was on-site, and who is the manager. E2 stated [E1], however [E1] was not on-site. E2 proceeded to call E1. E2 reported that [E1] is on the way to the facility. During a tour of the facility the Compliance Officer observed E1's manager's license posted on the wall. 4. When E1 arrived at the facility the Compliance Officer asked E1 if E1 was still the manager. E1 reported "yes". The Compliance Officer told E1 that the department received a letter stating E1 was no longer the manager on 09/21/2023, A response was never given to the Compliance Officer. 5. In an online search of the Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers website the Compliance Officer observed the license number assigned to E1 had been Suspended due to disciplinary action. 6. The Compliance Officer asked E1 if E1 knew of the suspension. E1 stated "yes". E1. E1 showed the compliance officer a letter from the Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA). The letter stated the following: "Consent Agreement and Order for Stayed Suspension, Probation and Continuing Education". This document was an agreement between the NCIA board and E1. The document stated "Suspension: Respondent's Certificate Number ALM-009953 is immediately suspended, but the suspension is stayed as long as the terms of the Order are met with Probationary period specified below: Probation. Respondent's Certificate Number ALM-008853 is placed on a term of probation for a period of three (3) months from the effective date of this Order. During the probationary period, Respondent shall complete the following". E1 was to pay a fine of $523.88, and complete three hours of continuing education in the following areas. Personnel Requirements, and Record Keeping, which would total six hours of continuing education. The document also stated if E1 fails to fulfill the requirements of the order the stay will be lifted and E1's certificate would be immediately suspended. The document was signed by the Executive Director on May 17, 2024. 7. During a review of E1's personnel record the Compliance Officer observed a letter in the back of the file. The letter had the following address: "Board of Examiners of Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers 1740 W. Adams, Suite 2490, Phoenix, AZ 85007", and a date stamp of August 22, 2024. The letter stated the following: "The Director of the Arizona State Board of Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers, hereby issues this Order lifting the Stay of Suspension of manager certificate no. ALM-008853, issued to [E1] (Respondent), which was imposed via consent agreement and order dated May 17, 2024. This is based upon the following matters of public record: 1. On May 17, 2024, Respondent entered into a "Consent Agreement and Order for Stayed Suspension, Probation and Continuing Education" (Consent Agreement) with the Board. 2. The Consent Agreement mandated the completion of all probationary terms within three (3) months of the effective date of the Consent Agreement. ... Order IT IS THEREFORE ORDERED, under the terms of the May 17, 2024 Consent Agreement, the Board hereby lifts the stay of suspension of Respondent's manager certificate no. ALM-00853, effective immediately. During this time period Respondent's certificate is SUSPENDED and Respondent is prohibited from working as an Assisted Living Facility Manager. Respondent's certificate is suspended until such time as they request the Board lift the suspension, and are granted the request. The Board shall have sole discretion to determine when and whether to lift the suspension". The effective date of the suspension is August 19, 2024. 8. In an interview, E1 acknowledged not fulfilling the requirements set by the NCIA board and E1's certification was suspended.”

“Based on record review, observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. A review of R1's medical record revealed R1 was supervisory level of care and self-administers own medications. 2. A review of R1's medical record revealed R1's doctor signed the following document "Medication Management and Administration". The document stated the following: "A resident who has been certified by their primary physician to be mentally and physically capable of self-administration or managing their own medication and treatments maybe allowed to do so. Manager shall ensure that caregivers will: ... Management 1. All medications must be stored in a locked cabinet. 2. Container or area that is inaccessible to other residents". 3. During the facility tour the Compliance Officer observed when entering R1's room the door was unlocked. In R1's room R1 was storing medication under the bed in an unlocked box. The Compliance Officer asked R1 if the box can be locked R1 stated no. The Compliance Officer observed the box was unable to be locked. The Compliance Officer asked R1 if R1 locks the door when R1 leaves the room. R1 stated no I always leave it unlocked. 4. In an interview, E1 reported being unaware R1's medications were in an unlocked room and a unlocked box under R1's bed.”

“Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and were inaccessible to residents. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. During an environmental tour the Compliance Officer observed in an open and unlocked garage the following poisonous or toxic materials: - three (3) 1-gallon containers of "O'Reilly Dex-cool Compatible Antifreeze & Coolant"; - one (1) plastic gallon container with no label, just hand-written "Weed Killer"; and - one (1) green and one (1) pink metal gasoline containers with gas. 2. A review of the facility's policy and procedures revealed "Facility Safety (818-820)". ... "11). Poisonous and toxic chemicals will be kept locked where they're inaccessible to residents and away from food storage, preparation, medications, and dining area. 12). Flammable, combustible, and hazardous material will be stored in their original containers or a safety container in a locked area that is inaccessible to residents". 3. In an interview, E1 and E2 acknowledged poisonous and toxic materials, and flammable, combustible, and hazardous materials stored by the assisted living facility, were not in a locked area and inaccessible to residents.”