AGELESS ANGELS ALH 2

INSP-0162042

Enforcement

Date: 10/21/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-10-31

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on October 21, 2025:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

A.R.S. § 36-420.01.A. 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, documentation review and interview, the manager failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for two of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E1’s personnel record revealed no documentation of fall prevention and recovery training before hire and no fall prevention and recovery training 12 months after their latest training. E1's latest fall prevention and recovery training was completed March 14, 2024. 2. A review of E2’s personnel record revealed no documentation of fall prevention and recovery training before hire and no fall prevention and recovery training 12 months after their latest training. E2's latest fall prevention and recovery training was completed March 14, 2024. 3. A review of the facility’s policies and procedures revealed a document titled "Fall Prevention and Recovery" with the following verbiage, "Fall Prevention and Recovery Training is required upon hire and at least 12 months thereafter." 4. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Deficiency #2

Rule/Regulation Violated:

R9-10-113.A.1-2. 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: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 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, 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 record review and interview, the health care institution failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis, for two of two employees sampled. Findings include: 1. A review of E1's personnel record revealed training and education related to recognizing the signs and symptoms of tuberculosis, completed March 23, 2024. No current documentation was available. 2. A review of E2's personnel records revealed no documentation of training and education related to recognizing the signs and symptoms of tuberculosis. 3. A review of the facility's documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis. 4. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Deficiency #3

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 compliance with A.R.S. § 36-411, for two of two employees sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A review of A.R.S. § 36-411 states "Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A review of E1 and E2's personnel records revealed no documentation that E1 and E2 were not on the adult protective services registry. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Deficiency #4

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 interview, record review, and documentation review, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of two caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. In an interview, E3 and E4 reported E2 worked as a caregiver. E3 and E4 reported E2 administered medication and assisted with resident care. 2. A review of E2's personnel record revealed an employment application that indicated E2 worked as a caregiver. 3. A review of the personnel schedule dated October 2025 revealed E2 was not listed on the schedule. 4. A review of the R1 and R2's October 2025 medication administration records revealed E2 administered medication to both residents. 5. A review of E2's personnel record revealed no documentation of a completed caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers was available. 6. A review of the https://azcg.tmutest.com/search website revealed no documentation of a caregiver training certificate for E2. 7. A review of the facility's policies and procedures revealed a document titled, "Employees and Volunteers Qualifications," with the following verbiage "Procedures: The hiring individual or manager shall hire at least one certified caregiver per shift and assistant caregivers and volunteers to provide duties as instructed in order to cover the scheduled and unscheduled needs of the residents. A caregiver: Is 18 years of age or older, and provides documentation of completion of a caregiver training program approved by the Department or by the NCIA Board..." 8. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Deficiency #5

Rule/Regulation Violated:

R9-10-808.A.1-5. 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: 1. Is completed no later than 14 calendar days after the resident’s date of acceptance; 2. Is developed with assistance and review from: a. The resident or resident’s representative, b. The manager, and c. Any individual requested by the resident or the resident’s representative; 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 and ancillary 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; 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): a. No later than 14 calendar days after a significant change in the resident’s physical, cognitive, or functional condition; and b. As follows: i. At least once every 12 months for a resident receiving supervisory care services, ii. At least once every six months for a resident receiving personal care services, and iii. At least once every three months for a resident receiving directed care services; and 5. When initially developed and when updated, is signed and dated by: a. The resident or resident’s representative; b. The manager; c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that a resident had a service plan, for one out of two residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed no documentation of a service plan. Based on R2's date of acceptance, this documentation was required. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Deficiency #6

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander; 2. There is a 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 that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area that 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 facility license revealed the facility was licensed at the directed care level. 2. The Compliance Officer also observed an unlocked door in the bedroom of R2 and R3 that led to the backyard of the facility. The door did not have an alarm or any form of a monitoring system. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Deficiency #7

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 that medication administered to a resident was administered in compliance with a medication order for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a September and October 2025 medication administration records(MAR) that showed the following:<ul><li>Cilopirox, 8%, apply every night, and indicated the medication was administered at 8pm every night October 1-20;</li><li>Tramadol 50mg 1 tab po, every six hours as needed for pain, and indicated the medication was last administered September 30, 2025, time not recorded; and</li><li>Clotrimazole cream, 1%, apply two times a day, and indicated the medication was administered at 8am and at 8pm October 1-20.</li></ul> 2. A review of R1's medical record revealed no documentation of signed medication orders for Cilopirox, 8%, Tramadol 50mg, or Clotrimazole cream 1%. 3. In an observation of R1's medications, Cilopirox 8%, Tramadol 50mg, and Clotrimazole cream 1% were observed. 4. In an interview, E3 reported the medications were administered per the MAR. 5. The findings were reviewed with E3 and no additional information was provided.

Deficiency #8

Rule/Regulation Violated:

R9-10-817.B.3.c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident’s medical record.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R2's medical record revealed signed medication orders dated for August 25, 2025. The medication order stated "Antifungal Powder, apply to groin/... two times a day, and leave groin open to air during the day. However, no documentation of administration for this medication was available. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Facility Information

Inspection History

INSP-0162042

Summary:

Deficiencies Found: 8

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:

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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:

INSP-0057097

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings: