JOSHUA SPRINGS SENIOR LIVING

INSP-0161432

Enforcement

Date: 10/14/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-11-04

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00145903 conducted on October 14, 2025:

Deficiencies Found: 10

Deficiency #1

Rule/Regulation Violated:

R9-10-113.A.2.a-f. Tuberculosis Screening A. 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, 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 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); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on documentation review and interview, the health care institution failed to ensure the health care institution documented and implemented tuberculosis (TB) infection control activities required in R9-10-113(A)(2)(d). . The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of facility documentation revealed that an annual assessment of the health care institution’s risk of exposure to infectious TB was not available for review. 2. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided.

Deficiency #2

Rule/Regulation Violated:

R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411 and

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record included documentation of compliance with the requirements in A.R.S. § 36-411, for four of eight personnel sampled. The deficient practice posed a risk to the health and safety of residents, as there was no evidence to show that E2, E3, E5, and E7 were fit to work at the assisted living facility. Findings include: 1. A.R.S. § 36-411 states, "... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work." 2. A.R.S. § 36-411(C) states: "C. Owners shall make documented, good faith efforts to: ... 2. Verify the current status of a person's fingerprint clearance card..." 3. A review of facility documentation revealed a policy titled "WATERMARK RETIREMENT COMMUNITIES - Associate Engagement/HR Associate Fingerprinting – AZ Only." The policy stated, "It is the policy of Watermark Retirement Communities, LLC (WRC) and its affiliates… To ensure that every associate who meets the Arizona Department of Health Services definition of a caregiver or assistant caregiver and those who actually provide direct care to the provider residents has an acceptable fingerprint clearance through the Arizona Department of Public Safety... I. All associates providing direct care to residents, including the Assisted Living and Dementia Program Directors, as outlined above, must provide proof that they have a valid Fingerprint Clearance Card as conducted by the Arizona Department of Public Safety... VIII. If the associate does not have proof of the credentials listed in #1 above, they must complete a form for a D.P.S. fingerprint background check within 10 days of starting work. Processing of the fingerprint forms is handled by the Business Office." 4. A review of E2’s personnel record revealed that E2 was hired as an assistant caregiver on February 26, 2025. The record included an application for a fingerprint clearance card. An internet search of the Arizona Department of Public Safety website (https://psp.azdps.gov/services/cardStatusRequest) showed that the application was received on April 15, 2025. However, the application was not submitted within twenty working days of employment, as required, but rather thirty-six working days after the hire date. During this period, E2 was providing assisted living services and direct care to residents without a valid fingerprint clearance card. 5. A review of E3’s personnel record revealed that E3 was hired as an assistant caregiver on February 26, 2025. The record included for a fingerprint clearance card issued May 24, 2025. An internet search of the Arizona Department of Public Safety website (https://psp.azdps.gov/services/cardStatusRequest) showed that the application was received on October 25, 2024. However, the fingerprint clearance card was not issued until May 24, 2025, and the facility failed to verify that E3 possessed a valid fingerprint clearance card or confirm the status of the card from the time of hire until the date of issuance. During this period, E3 was providing assisted living services and direct care to residents without a valid fingerprint clearance card. 6. A review of E5’s personnel record revealed that E5 was hired as a caregiver on July 1, 2019. The record showed that E5’s fingerprint clearance card expired on December 26, 2024, and a new card was issued on April 9, 2025. An internet search of the Arizona Department of Public Safety website (https://psp.azdps.gov/services/cardStatusRequest) indicated that the application was received on March 31, 2025, approximately three months after the previous card had expired. During this period, E5 was providing assisted living services and direct care to residents without a valid fingerprint clearance card. 7. A review of E7’s personnel record revealed that E7 was hired as a caregiver on March 25, 2025. The record showed that E7’s fingerprint clearance card expired on March 11, 2025, and a new card was issued on August 04, 2025. An internet search of the Arizona Department of Public Safety website (https://psp.azdps.gov/services/cardStatusRequest) indicated that the application was received on July 03, 2025, approximately four months after the previous card had expired. During this period, E7 was providing assisted living services and direct care to residents without a valid fingerprint clearance card. 8. In an interview, E9 and E11 reported that the fingerprint clearance card applications were not submitted within twenty working days of employment, and the renewals were not completed before the previous cards expired. As a result, E2, E3, E5, and E7 were providing assisted living services and direct care to residents without valid fingerprint clearance cards. 9. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided.

Deficiency #3

Rule/Regulation Violated:

R9-10-806. Personnel A. A manager shall ensure that:l 1. A caregiver:l b. Provides documentation of:l i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers;l ii. For supervisory care services, employment as a manager or caregiver of a supervisory care home before November 1, 1998;l iii. For supervisory care services or personal care services, employment as a manager or caregiver of a supportive residential living center before November 1, 1998; orl iv. For supervisory care services, personal care services, or directed services, one of the following:l (1) A nursing care institution administrator’s license issued by the Board of Examiners;l (2) A nurse’s license issued to the individual under A.R.S. Title 32, Chapter 15;l (3) Documentation of employment as a manager or caregiver of an unclassified residential care institution before November 1, 1998; orl (4) Documentation of sponsorship of or employment as a caregiver in an adult foster care home before November 1, 1998;l

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Departement or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of eight sampled personnel. The deficient practice posed a risk if the employees were not qualified to provide the required services. Findings include: 1. A review of E8’s personnel record revealed that E8 was hired as a caregiver on August 20, 2024. The personnel record did not contain documentation of a caregiver training certificate. 2. In an interview, the Compliance Officers requested E8’s caregiver training certificate approved by the Department or the NCIA Board; however, the facility provided a “Certificate of Attendance” awarded to E8 for attending a three-hour in-service on Medication Administration Basics conducted by Saliba’s Pharmacy. 3. A review of the https://azcg.tmutest.com/search website revealed no documentation of a caregiver training certificate for E8. 4. A review of personnel schedules from November 2024 to the present revealed that E8 had been working as a caregiver/medication technician. 5. In an interview, E9 and E11 reported that E8 was employed at the facility as a caregiver/medication technician and acknowledged that there was no documentation available to demonstrate completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. 6. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided.

Deficiency #4

Rule/Regulation Violated:

R9-10-806.A.10. Personnel A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training, for one of eight employees sampled. The deficient practice posed a risk if an employee was unable to meet the needs of residents. Findings include: 1. A review of facility policies and procedures revealed a policy titled "Administering CPR, First Aid, Fall Prevention Training, Fall Recovery Training – AZ Only." The policy stated, Upon employment and prior to providing services to residents, all caregivers will provide verification of current training in cardiopulmonary resuscitation (CPR) and First Aid. Caregivers will be required to submit new training documentation prior to the expiration date and will need to attend training at a qualified American Heart Association, or American Red Cross or National Safety Council training program, which includes a demonstration of the staff member’s ability to perform CPR.” 2. A review of E5's personnel record revealed E5 worked as a caregiver. The personnel record revealed a first aid and CPR card with an expiration date of April 29, 2024. There was no other current documentation of first aid and CPR training in E5's personnel record. 3. A review of facility documentation revealed a document titled “Course Participation – American Heart Association.” The document listed employees who participated in a “Basic Life Support” class, including E5; however, although the course was completed on May 10, 2025, no corresponding CPR or First Aid certificate was available for review. 4. In an interview, E9 reported that all staff were required to have current CPR and First Aid certification completed before providing assisted living services to residents. 5. A review of personnel schedules revealed that E5 had been working as caregivers/medication technicians and was providing assisted living services to residents. 6. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided. 7. This is a repeat deficiency from the inspection conducted on October 30, 2024.

Deficiency #5

Rule/Regulation Violated:

R9-10-807.B.1.a-b. Residency and Residency Agreements B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of eight residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings included: 1. Review of R4’s medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services or restraints. Based on R4’s acceptance date, this documentation was required. 2. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided.

Deficiency #6

Rule/Regulation Violated:

R9-10-808.A.3.b. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 3. Includes the following: b. The level of service the resident is expected to receive;

Evidence/Findings:

Based on documentation review, interview, observation, and record review, the manager failed to ensure a resident had a written service plan which accurately included the level of service the resident was expected to receive, for one of eight resident records reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: A.R.S. § 36-401.50 "Supervisory care services" means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in self-administering prescribed medications. A.R.S. § 36-401.41 "Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. A.R.S. § 36-401.16 "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. In an interview, E9 and E10 reported that R5 was receiving directed care services and was living on the assisted living side. 2. The Compliance Officers observed that R5 was alert and responsive, answering and engaging appropriately during the interview. Based on these observations, R5 did not appear to meet the definition for directed care services. 3. Review of R5’s service plan dated March 2025 listed R5’s level of care as both personal care services and directed care services. 4. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided. 5. This is a repeat deficiency from the inspections conducted on June 14, 2023, and January 9, 2024.

Deficiency #7

Rule/Regulation Violated:

R9-10-815.C.6.a-b. 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: 6. Documentation: a. Of the resident’s weight, or b. From a medical practitioner stating that weighing the resident is contraindicated;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for two of three residents reviewed receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Review of R1's medical record revealed a service plan for directed care services dated September 15, 2025. This service plan revealed no documentation of R1's weight. In addition, R1's record revealed no documentation of R1's weight or documentation from a medical practitioner stating that weighing R1 was contraindicated. 2. Review of R8's medical record revealed a service plan for directed care services dated October 2, 2025. This service plan revealed no documentation of R8's weight. In addition, R8's record revealed no documentation of R8's weight or documentation from a medical practitioner stating that weighing R8 was contraindicated. 3. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided.

Deficiency #8

Rule/Regulation Violated:

R9-10-817.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one out of eight residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1’s medical record revealed an electronically signed medication order which stated, “Gabapentin 100 mg take 1 capsule by mouth three times daily” with the start date for this medication order on September 15, 2025. 2. Review of R1’s medical record revealed an electronic medication administration record (eMAR) for the month of October 2025. In this eMAR, it revealed Gabapentin 100 mg was documented as “MU”. The following was the time and days “MU” was documented:- October 12, 2025 at 1400 and 2000,- October 13, 2025 at 0800, 1400, and 2000; and- October 14, 2025 at 0800.According to the key on the eMAR, “MU” meant medication unavailable. 3. In an interview, E10 acknowledged R1 did not receive Gabapentin 100 mg on October 12th, 13th, and the 14th. 4. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided.

Deficiency #9

Rule/Regulation Violated:

R9-10-820.A.10. Environmental Standards A. A manager shall ensure that: 10. Oxygen containers are secured in an upright position;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. The Compliance Officers observed, in R8’s room, an unsecured oxygen tank leaning up against a corner of the room next to the bathroom door. The oxygen tank only had a black sleeve covering it. 2. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided.

Deficiency #10

Rule/Regulation Violated:

R9-10-820.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 documentation review, observation, and interview the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed in an unlocked cabinet in the dining area a 3.78 L of Lime-A-Way Multipurpose Lime Scale remover. 2. The Compliance Officers observed an unsupervised housekeeper cart. On the housekeeper cart was a spray bottle of Rapid Multi Surface Disinfectant Cleaner. 3. The Compliance Officers observed in an unlocked service laundry room:- A one gallon Pink Lotion Skin Cleanser- Two bottles of Low Temp Laundry Solid Chlorine Sanitizer. 4. In an exit interview, the findings were reviewed with E9, E10, and E11, and no additional information was provided.

INSP-0074480

Complete

Date: 12/26/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-01-29

Summary:

No deficiencies were found during the investigation of complaints AZ00218715 and AZ00220333 conducted on December 26, 2024.

✓ No deficiencies cited during this inspection.

INSP-0074481

Complete

Date: 10/30/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-12-12

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaints AZ00206793, AZ00210730, and AZ00217489 conducted on October 30, 2024.

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

A manager shall ensure that:
2. A documented report is submitted to the governing authority that includes:
a. An identification of each concern about the delivery of services related to resident care, and
b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care;

Evidence/Findings:

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the plan.

Findings include:
1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority on a "monthly" basis.
2. The last report submitted to the governing authority was dated July 3, 2024.
3. During an interview, E1 acknowledged that the required documentation was not submitted to the governing authority per the frequency established in the plan.

This is a repeat deficiency from the compliance inspection conducted on December 30, 2021, and the compliance inspection and complaint investigation conducted on June 14, 2023.

Deficiency #2

Rule/Regulation Violated:

A. A manager shall ensure that:
8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis:
a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and
b. As specified in R9-10-113;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that two of four sample personnel records, for personnel who work more than eight hours per week, contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113.

Findings include:
1. The record for E1 (Manager Designee) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. Based on the employee's date of hire this documentation would be required.
2. The record for E3 (Manager Designee) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. Based on the employee's date of hire this documentation would be required.
3. During an interview, E1 acknowledged that the employees worked more than eight hours per week and the documentation did not reflect that the employee records contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure for two of four sample records, that before providing services to a resident, a manager or caregiver provides documentation of first aid training.

Findings include:
1. The record for E1 (hired February 1, 2024), failed to reveal documentation of first aid certification.
2. The record for E3 (hired January 14, 2023), revealed documentation of first aid certification that expired on May 11, 2024.
3. During an interview, E1 acknowledged that the caregivers provided services to residents without current documentation of first aid training certification.

Deficiency #4

Rule/Regulation Violated:

A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis:
1. Before or within seven calendar days after the resident's date of occupancy, and
2. As specified in R9-10-113.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that one of four sample resident records contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113.

Findings include:
1. The record for R4 contained no documentation of freedom from TB. No current documentation was available for review. Based on the resident's date of acceptance, this documentation was required.
2. During an interview, E1 acknowledged that the record did not contain current evidence of freedom from TB.

Deficiency #5

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A food menu:
c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served,

Evidence/Findings:

Based in observation and interview, the manager failed to ensure that a food menu was conspicuously posted at least one calendar day before the first meal on the food menu is served.

Findings include:
1. No menu was observed posted in the in the facility memory care unit.
2. During an interview, E1 acknowledged that no menu was conspicuously posted in the unit.

INSP-0074478

Complete

Date: 2/15/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-03-14

Summary:

No deficiencies were found during the investigation of complaints AZ00205991 and AZ00206458 conducted on February 15, 2024.

✓ No deficiencies cited during this inspection.

INSP-0074477

Complete

Date: 1/9/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-01-17

Summary:

The following deficiencies were found during the investigation of complaints AZ00201189, AZ00204671, AZ00204546, AZ00204071, AZ00202144, AZ00204321, and AZ00201871 conducted on January 9, 2024:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
3. Includes the following:
b. The level of service the resident is expected to receive;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that two of six sample resident records contained a service plan that included the level of service the resident was expected to receive.

Findings include:
1. The record for R5 contained a service plan dated July 27, 2023 that did not include the level of service the resident was receiving.
2. During an interview, E2 stated, "The resident is directed care."
3. The record for R6 contained a service plan dated June 12, 2023 that did not include the level of service the resident was receiving.
4. During an interview, E2 stated, "The resident is directed care."
5. During an interview, E2 acknowledged the resident records did not contain the required information.
This is a repeat deficiency from the complaint investigation conducted on June 14, 2023.

Deficiency #2

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f):
b. As follows:
iii. At least once every three months for a resident receiving directed care services; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that four of six sample resident records, had service plans that were reviewed and updated at least once every three months for a resident receiving directed care services.

Findings include:
1. The record for R1 contained a service plan that was last updated on July 31, 2023.
2. The record for R3 contained a service plan that was last updated on August 27, 2023.
3. The record for R5 contained a service plan that was last updated on July 27, 2023.
4. The record for R6 contained a service plan that was last updated on June 12, 2023.
5. During an interview, E2 acknowledged that service plan documentation did not reflect that updates were conducted at least once every three months.
This is a repeat deficiency from the compliance inspections conducted on December 30, 2021, and June 14, 2023.

Deficiency #3

Rule/Regulation Violated:

C. A manager shall ensure that food is obtained, prepared, served, and stored as follows:
7. Tableware, utensils, equipment, and food-contact surfaces are clean and in good repair.

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that equipment was in good repair.

Findings include:
1. Observation of the memory unit, dining room chairs revealed that the seat cushions were cracked and the vinyl surfaces were peeling off.
2. During an interview, E3 stated, "We are planning to replace those."
3. During an interview, E2 acknowledged the memory unit, dining room chairs were not in good repair.

INSP-0074475

Complete

Date: 6/14/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-07-05

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaint #AZ00185888, AZ00190593, AZ00194971, AZ00195563 and AZ00196101 conducted on June 14, 2023.

Deficiencies Found: 14

Deficiency #1

Rule/Regulation Violated:

36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01.

Findings include:
1. Review of the record for E1 (hired March 9, 2019), failed to reveal documentation of fall prevention and fall recovery training.
2. Review of the record for E5 (hired February 23, 2022), revealed that fall prevention and fall recovery training had not been conducted annually. Documentation indicated that the last training had been conducted on May 17, 2022.
3. During an interview, E6 indicated that training for fall prevention and fall recovery had not been conducted as required in A.R.S. \'a7 36-420.01.

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the plan that includes an identification of each concern about the delivery of services related to resident care and any change made or action taken as a result of the identification of a concern.

Findings include:
1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority on an annual basis.
2. No report that includes an identification of each concern about the delivery of services related to resident care and any change made or action taken as a result of the identification of a concern, was available for review.
3. During an interview, E6 stated, "I don't have a report like that, just 'Point Click Care' data."
4. During an interview, E1 acknowledged that the required documentation was not included in the report.
This is a repeat deficiency from the compliance inspection conducted on December 30, 2021.

Deficiency #3

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
1. Is completed no later than 14 calendar days after the resident's date of acceptance;

Evidence/Findings:

Based on record review and interview the manager failed to ensure that one of three sample resident records contained documentation reflecting that a resident had a written service plan that was completed no later than 14 calendar days after the resident's date of acceptance.

Findings include:
1. Based on the resident's date of acceptance, the record for R3 (directed care) contained a service plan that was incomplete and lacked the required signatures.
2. During an interview, E6 acknowledged the plan had not been completed within 14 calendar days after the resident's date of acceptance.

Deficiency #4

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
3. Includes the following:
a. A description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments;
b. The level of service the resident is expected to receive;
c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication;
d. For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner;
e. For a resident who requires behavioral care:
i. Any of the following that is necessary to provide assistance with the resident's psychosocial interactions to manage the resident's behavior:
(1) The psychosocial interactions or behaviors for which the resident requires assistance,
(2) Psychotropic medications ordered for the resident,
(3) Planned strategies and actions for changing the resident's psychosocial interactions or behaviors, and
(4) Goals for changes in the resident's psychosocial interactions or behaviors; and
ii. Review by a medical practitioner or behavioral health professional; and
f. For a resident who will be storing medication in the resident's bedroom or residential unit, how the medication will be stored and controlled;

Evidence/Findings:

Based on record review and interview the manager failed to ensure that the record for one of five residents contained a written service plan that included all the information specified in subsections a. through f. of this rule.

Findings include:
1. The record for R5 did not contain a service plan.
2. During an interview, E6 acknowledged the required documentation was not available for review.

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that one of five sample resident records contained a service plan that included the level of service the resident is expected to receive.

Findings include:
1. The record for R1 contained a service plan dated October 7, 2021 that did not include the level of service the resident was receiving.
2. During an interview, E6 acknowledged the resident's record did not contain the required information.

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that three of five sample resident records, had service plans that were reviewed and updated at least once every three months for a resident receiving directed care services.

Findings include:
1. The record for R4 contained a service plan that was last updated on July 3, 2022.
2. The record for R1 contained a service plan that was last updated on October 7, 2021.
3. The record for R2 contained service plans dated September 23, 2022 and February 17, 2023.
4. During an interview, E6 acknowledged that service plan documentation did not reflect that updates were conducted at least once every three months.
This is a repeat deficiency from the compliance inspection conducted on December 30, 2021.

Deficiency #7

Rule/Regulation Violated:

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;

Evidence/Findings:

Based on record review, observation and interview, the manager failed to ensure that a caregiver or an assistant caregiver provides a resident with the assisted living services in the resident's service plan.

Findings include:
1. Review of the service plan dated June 23, 2022 for R2 (directed care) indicated that grooming and oral hygiene would be maintained and that caregivers would "stand by with all grooming tasks" and assist the resident when needed.
2. Review of resident record documentation revealed that caregivers failed to assist the resident with oral hygiene per the service plan, resulting in a severe condition requiring medical care.
3. During an interview, E6 acknowledged the resident was not being provided the services specified in the service plan.

Deficiency #8

Rule/Regulation Violated:

C. A manager shall ensure that a resident's medical record contains:
17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that two of two sample resident records contained documentation of notification to the resident of the availability of vaccinations for influenza and pneumonia.

Findings include:
1. The record belonging to R2 contained no documentation indicating that the resident had been notified of the availability of either the influenza or pneumonia vaccination on a yearly basis. No additional documentation indicating when the resident had been offered, refused or received either vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
2. The record belonging to R4 contained no documentation indicating that the resident had been notified of the availability of either the influenza or pneumonia vaccination on a yearly basis. No additional documentation indicating when the resident had been offered, refused or received either vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
3. During an interview, E6 acknowledged that the vaccinations had been made available to the residents on a yearly basis however, the records did not contain the required documentation.
This is a repeat deficiency from the compliance inspection conducted on December 30, 2021.

Deficiency #9

Rule/Regulation Violated:

A. A manager shall ensure that:
2. Meals and snacks provided by the assisted living facility are served according to posted menus;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that snacks provided by the assisted living facility were served according to posted menus.

Findings include:
1. The posted menus failed to reveal a record of snacks provided.
2. No additional snack menu documentation was available for review.
3. During an interview, E6 stated, "The residents get snacks, we don't have the documentation."
4. During an interview, E6 acknowledged that the required documentation was not available for review.

Deficiency #10

Rule/Regulation Violated:

A. A manager shall ensure that:
3. Documentation of the disaster plan review required in subsection (A)(2) includes:
a. The date and time of the disaster plan review;
b. The name of each employee or volunteer participating in the disaster plan review;
c. A critique of the disaster plan review; and
d. If applicable, recommendations for improvement;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that documentation of the disaster plan review included: A critique of the disaster plan review and if applicable recommendations for improvement.

Finding include:
1. Review of the facility Disaster Plan Review dated June 7, 2023 revealed that the content of the review failed to include a critique of the disaster plan review and if applicable recommendations for improvement.
2. During an interview, E6 acknowledged that the required documentation was not available for review.

Deficiency #11

Rule/Regulation Violated:

A. A manager shall ensure that:
4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:
1. Twelve months of facility disaster drill documentation was requested. Review of the disaster drill documentation provided revealed that disaster drills were conducted for each shift on May 2, 2023. No other disaster drill documentation was available for review.
2. During an interview, E6 acknowledged the requested documentation was not available for review.

Deficiency #12

Rule/Regulation Violated:

A. A manager shall ensure that:
5. An evacuation drill for employees and residents:
a. Is conducted at least once every six months; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for residents was conducted at least once every six months.

Findings include:
1. Twelve months of facility evacuation drill documentation was requested. Review of the evacuation drill documentation provided revealed that no evacuation drills were conducted for residents. No other evacuation drill documentation was available for review.
2. During an interview, E6 acknowledged the requested documentation was not available for review.

Deficiency #13

Rule/Regulation Violated:

D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver:
2. Documents the following:
a. The date and time of the accident, emergency, or injury;
b. A description of the accident, emergency, or injury;
c. The names of individuals who observed the accident, emergency, or injury;
d. The actions taken by the caregiver or assistant caregiver;
e. The individuals notified by the caregiver or assistant caregiver; and
f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.

Evidence/Findings:

Based on record review, documentation review and interview, the manager failed to ensure that when a resident has an accident, emergency, or injury that results in the resident needing medical services, a caregiver documents a. The date and time of the accident, emergency, or injury; b. A description of the accident, emergency, or injury; c. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver; e. The individuals notified by the caregiver or assistant caregiver; and f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.

Findings include:
1. Review of the record for R1 revealed that on May 18, 2022 the resident experienced a medical emergency that required medical services. No documentation of the medical emergency was available for review.
2. During an interview, E6 acknowledged the required documentation was not available for review.

Deficiency #14

Rule/Regulation Violated:

A. A manager shall ensure that:
14. If pets or animals are allowed in the assisted living facility, pets or animals are:
b. Licensed consistent with local ordinances; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that one of one pet that was allowed in the facility, was licensed consistent with local ordinances.

Findings include:
1. Documentation for O1, a dog allowed in the facility failed to reflect that the dog was licensed.
2. During a telephone interview with the local authority it was determined that the dog required a license.
3. During an interview, E6 acknowledged that facility documentation failed to indicate the dog had a current license.

Facility Information

Inspection History

INSP-0161432

Summary:

Deficiencies Found: 10

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:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #10

Rule/Regulation Violated:

Evidence/Findings:

INSP-0074480

Summary:

INSP-0074481

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:

INSP-0074478

Summary:

INSP-0074477

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

INSP-0074475

Summary:

Deficiencies Found: 14

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3