HAWTHORN COURT AT AHWATUKEE

INSP-0157095

Complete

Date: 8/6/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-09-16

Summary:

The following deficiencies were found during the on-site investigation of complaint 00138582 conducted on August 6, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-803.J.1-6. Administration J. If a manager has a reasonable basis, according to A.R.S. § 46- 454, to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility’s manager, caregiver, or assistant caregiver, the manager shall: 1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454; 3. Document: a. The suspected abuse, neglect, or exploitation; b. Any action taken according to subsection (J)(1); and c. The report in subsection (J)(2); 4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2); 5. 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): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. 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; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and 6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Evidence/Findings:

Based on documentation review and interview, the manager failed to immediately report suspected abuse according to A.R.S. § 46-454. Findings include: 1. A.R.S. § 46-454(A) stated "...other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. A.R.S. § 46-454(B) stated "If an individual prescribed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law..." 3. R9-10-101.110 stated "Immediate" means without delay. 4. A review of R1’s medical record revealed a document titled “Investigation” dated August 4, 2025, which reflected a resident-to-resident physical altercation. The document reported “appropriate state and law enforcement agencies were notified”. 5. A review of the facility’s documentation revealed a document titled “ADHS complaint-Health Care Facility Complaint” dated August 4, 2025, which reflected that no other agency was notified. 6. In an interview, E1 reported that the Department was the only agency notified of the resident-to-resident altercation. E1 acknowledged that a peace officer or the adult protective services central intake unit was not contacted via telephone or email.

Permanent Solution:

Manager will ensure that Adult Protected Services or a peace officer is notified of any abuse, neglect, or exploitation.

Person Responsible:

Michelle Estrada, Manager

INSP-0136388

Complete

Date: 7/21/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-08-22

Summary:

The following deficiencies were found during the on-site investigation of complaints 00136896 and 00132707 conducted on July 21, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-820.A.1.b. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During the environmental inspection, the Compliance Officer observed the following: -The common area was torn and fraying in multiple areas, causing a tripping hazard. -The carpet was also fraying and separating from the transition strip from the wood flooring and carpeted area, posing a tripping hazard. -In the activity area, in the walkway, two large exposed holes in the carpet posed a tripping hazard. 2. In an interview, E1 reported that there was usually furniture placed to cover the holes in the carpet. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Temporary Solution:

The Manager instructed the Environmental Services Director to repair the frayed carpet at the designated transition points. Additionally, the ESD was directed to reposition the tables and chairs to conceal the torn section, ensuring the area maintains a safe and presentable appearance.

Permanent Solution:

Michelle Estrada, Manager, directed the Environmental Services Director (ESD) to obtain quotes for the replacement of flooring. Upon receipt, the manager will submit the proposals for formal approval from the ownership

Person Responsible:

Michelle Estrada, Manager

INSP-0100464

Complete

Date: 3/7/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-04-18

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00121228 conducted on March 6, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

R9-10-804.1.a-e. Quality Management A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to residents; c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority;

Evidence/Findings:

Based on documentation review and interview, the manager failed to establish and document a quality management program. The deficient practice posed a risk as a quality management program establish and document the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Establishing a Quality Management Plan." This policy stated "The manager shall ensure that a plan is established, documented, and implemented for an ongoing quality management plan that includes a method to identify, document and evaluate incidents...". The facility’s quality management plan failed to establish and document a quality management plan failed to identify, collect and evaluate the methods required in R9-10-804.1.a-e. 2. During an interview, E1 acknowledged a quality management plan failed to establish and document a quality management plan failed to identify, collect and evaluate the methods required in R9-10-804.1.a-e.

Permanent Solution:

Chardae Baker, Manager, reviewed and revised the community's Quality Management Policy to include an established plan to identify, document, and evaluate incidents.

Person Responsible:

Chardae Baker, Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-808.C.1.a-g. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident's service plan; b. Is only assigned to provide the assisted living services the caregiver or assistant caregiver has the documented skills and knowledge to perform; c. Provides assistance with activities of daily living according to the resident's service plan; d. If applicable, suggests techniques a resident may use to maintain or improve the resident's independence in performing activities of daily living; e. Provides assistance with, supervises, or directs a resident's personal hygiene according to the resident's service plan; f. Encourages a resident to participate in activities planned according to subsection (E); and g. Documents the services provided in the resident's medical record;

Evidence/Findings:

Based on record review, observation, documentation review, and interview, the manager failed to ensure that a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record for two of four sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated February 5, 2025, which reflected R1 required assistance with transfers every shift, R1 required reminders and cues for all meals, and staff would cut all food and open containers three times a day. R1’s documentation of services provided reflected that R1 was not provided assistance with transfers from February 6, 2025, through February 20, 2025, and there was no documentation that R1 was assisted with reminders and cues for meals, or that R1’s food was cut and containers opened for all meals. 2. A review of R2's medical record revealed a service plan dated February 5, 2025, which reflected R2 required reminders and cues for all meals, and staff would cut all food and open containers three times a day. R2’s documentation of services provided showed no documentation that R2 was provided assistance with reminders and cues for meals, and did not show that R2’s food was cut and containers opened for all meals. 3. In an interview, E1 reviewed and acknowledged that there was no documentation reflecting that the above assistance was provided to R1 and R2.

Permanent Solution:

Chardae Baker, Manager, audited all resident service plans and corresponding assigned care tasks to ensure that a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record. The manager reviewed the community's policies and procedures on service plans and care services which includes that care will be provided to all residents on an invdividual basis according to the service plan. The manager educated the Resident Care Director and Resident Care Coordinator on 4/01/25 on ensuring that caregivers are providing all care in the resident's service plan and documenting the services provided in the resident's medical record.

Person Responsible:

Chardae Baker, AL Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-815.C.7. Directed Care Services C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 7. Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure the service plan for one of one sampled resident receiving directed care services included coordination of communications with the resident's representative, family members, or other individuals identified in the resident's service plan for one of four sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan February 28, 2025. R2's service plan did not include coordination of communication with R2's representative, family members, or other individual identified in R2's service plan. 2. In an interview, E1 acknowledged R2's service did not include coordination of communication with R2's representative, family members, or other individual identified in R2's service plan.

Permanent Solution:

Chardae Baker, Manager, audited all resident service plans to ensure they included coordination of communications with the resident's representative, family members, or other individuals identified in the resident's service plan. The Manager educated the Resident Care Director and Resident Care Coordinator on ensuring every resident's service plan includes coordination of communications on 4/01/25.

Person Responsible:

Chardae Baker, AL Manager

Deficiency #4

Rule/Regulation Violated:

R9-10-819.A.11. Environmental Standards A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. Findings include: 1. During a facility tour, the surveyor observed an unlocked cabinet inside the north court of the directed care unit kitchen. The cabinet contained a can of Lysol spray. 2. In an interview, E1 acknowledged that the poisonous or toxic materials were left in an unlocked area accessible to residents.

Permanent Solution:

Chardae Baker, Manager, educated all staff on the proper storage of poisonous or toxic materials and that they are to be maintained in a locked area and are always inaccessible to residents. This education began on 3/12/25 and ended on 4/04/25. The manager reviewed the community's policies and procedures, which include the proper storage and inaccessibility of poisonous or toxic materials to residents.

Person Responsible:

Chardae Baker, AL Manager

INSP-0071642

Complete

Date: 8/13/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-08-22

Summary:

An on-site investigation of complaint AZ00214236 was conducted on August 13, 2024, and no deficiencies were cited.

✓ No deficiencies cited during this inspection.

INSP-0071641

Complete

Date: 5/24/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-07-05

Summary:

An on-site investigation of complaint AZ00210312 was conducted on May 24, 2024, and no deficiencies were cited.

✓ No deficiencies cited during this inspection.

INSP-0071639

Complete

Date: 5/4/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-06-01

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaint AZ00190419 conducted on May 5, 2023:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

A. A governing authority shall:
7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager;

Evidence/Findings:

Based on documentation review, observation, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 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 determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of Department documentation revealed E6 was the assisted living manager on record for the facility as of December 15, 2021.

2. The Compliance Officer observed E1's manager's license posted on a wall, with an issue date of July 19, 2022.

3. In an interview, E1 reported E1 was the facility's manager as of April 14, 2023.

4. A review of Department documentation revealed no evidence to indicate the governing authority notified the Department when there was a change in the manager and identified the name and qualifications of the new manager.

5. In an interview, E1 acknowledged the facility did notify the Department of a change in the facility's manager.

Deficiency #2

Rule/Regulation Violated:

E. A manager shall ensure that, unless otherwise stated:
1. Documentation required by this Article is provided to the Department within two hours after a Department request; and

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. A review of Department documentation revealed the governing authority failed to notify the Department when there was a change in the manager and identify the name and qualifications of the new manager.

2. A review of E4's personnel record revealed no documented, good faith efforts to contact previous employers to obtain information or recommendations relevant to E4's fitness to work in a residential care institution.

3. In an interview, E1 acknowledged documentation required by this Article was not provided to the Department within two hours after a Department request.

Deficiency #3

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
c. Documentation of:
ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(C), for one of four personnel members sampled.

Findings include:

1. A.R.S. \'a7 36-411(C) states "Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency."

2. A review of E4's personnel record revealed no documented, good faith efforts to contact previous employers to obtain information or recommendations relevant to E4's fitness to work in a residential care institution.

3. In an interview, E1 reported E1 contacted E4's previous employers, however, E1 could not locate the documentation. E1 acknowledged E4's personnel record did not contain the documentation required in A.R.S. \'a7 36-411(C).

Deficiency #4

Rule/Regulation Violated:

C. A manager shall not accept or retain an individual if:
1. The individual requires continuous:
a. Medical services;

Evidence/Findings:

Based on record review and interview, the manager accepted an individual requiring continuous medical services, for one of four residents sampled. The deficient practice posed a risk as an assisted living facility cannot provide continuous medical services.

Findings include:

1. A review of R4's medical record revealed a document titled "MOVE-IN ORDERS ARIZONA" The document stated "DOES THE RESIDENT REQUIRE CONTINUOUS MEDICAL OR NURSING CARE...YES...NO..." A box next to "YES" was marked to indicate R4 required continuous medical services. The document was signed by a medical practitioner.

2. In an interview, E1 reported R4 does not receive continuous medical services. E1 reported the box indicating R4 required continuous medical services was marked in error.

Deficiency #5

Rule/Regulation Violated:

C. A manager shall not accept or retain an individual if:
1. The individual requires continuous:
b. Nursing services, unless the assisted living facility complies with A.R.S. § 36-401(C); or

Evidence/Findings:

Based on documentation review, record review and interview, the manager retained an individual requiring continuous nursing services, for one of four residents sampled. The deficient practice posed a risk as an assisted living facility cannot provide continuous nursing services.

Findings include:

1. A review of R4's medical record revealed a document titled "MOVE-IN ORDERS ARIZONA" The document stated "DOES THE RESIDENT REQUIRE CONTINUOUS MEDICAL OR NURSING CARE...YES...NO..." A box next to "YES" was marked to indicate R4 required continuous nursing services. The document was signed by a medical practitioner.

2. In an interview, E1 reported R4 does not receive continuous nursing services. E1 reported the box indicating R4 required continuous nursing services was marked in error.

Facility Information

Inspection History

INSP-0157095

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0136388

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0100464

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0071642

Summary:

INSP-0071641

Summary:

INSP-0071639

Summary:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings: