BROOKDALE CENTRAL PARADISE VALLEY

Assisted Living Center | Assisted Living

Facility Information

Address 13240 North Tatum Boulevard, Phoenix, AZ 85032
Phone (602) 953-3600
License AL6708C (Active)
License Owner BLC PHOENIX-GC, LLC
Administrator Brandy Cooper
Capacity 155
License Effective 6/1/2025 - 5/31/2026
Services:
6
Total Inspections
29
Total Deficiencies
5
Complaint Inspections

Inspection History

INSP-0134815

Complete
Date: 6/24/2025
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2025-07-17

Summary:

The following deficiency was found during the on-site investigation of complaints 00133123 and 00133789 conducted on June 24, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:
A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document<br> A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following:<br> 1. The reason or reasons the emergency responder was requested on behalf of the resident.<br> 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered.<br> 3. The name, address and telephone number of the resident's current pharmacy.<br> 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive.<br> 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative.<br> 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known.<br> 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week.<br> 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization.<br> 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives.
Evidence/Findings:
<p>Based on interview, documentation review, and record review, the manager of an assisted living center who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. In an interview, E1 reported R2 had an accident, emergency, or injury on June 13, 2025, that resulted in facility personnel contacting an emergency responder on behalf of R2.</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed an incident report confirming E1’s report.</p><p><br></p><p><br></p><p>3. A review of R2’s medical record revealed a document titled “AZ EMERGENCY PACKET” used by the facility for compliance with this rule. However, the packet did not include the following:</p><p><br></p><p>- The reason or reasons the emergency responder was requested on behalf of R2;</p><p><br></p><p>- The point-of-contact information for the assisted living center, including the email address; and</p><p><br></p><p>- A copy of R2's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R2's discharge.</p><p><br></p><p><br></p><p>4. In an interview, E1 reported the “AZ EMERGENCY PACKET” was the only documentation provided to the emergency responders. Regarding the HIPAA release form, E2 stated, “We didn’t send it out.” Regarding the packet missing the email address of the facility, E2 stated, “We need to update that form.”</p>
Temporary Solution:
Plan of Correction
License #: AL6708C
Rule Number: A.R.S. § 36-420.04.A.1-9.
Name, Title of person responsible for implementing the corrective action:
Cincy Perry, Health & Wellness Director
Date the correction will be completed: 07/25/2025

Correction on both a temporary and permanent basis:
On 7/22/2025 the Operations Specialist and Health & Wellness Director re-in serviced and re-trained direct care staff on the process for providing emergency responders with the required hospital transportation documentation and on the AZ Hospital/ER Transportation Guide QRG. Effective 07/22/2025 updated AZ Emergency Packet/Cover Sheet has been implemented.
Monitoring System:
To monitor for on-going compliance, the Health & Wellness Director or designee will conduct weekly audits for two months to verify that residents transported to the hospital have the required copies of the emergency responder documentation. The Health & Wellness Director and Interim Operations Specialist or designee will review the results of the audits once a month for two month’s during the Quality Management Meeting. The Operations Specialist or designee will document the audits in the Quality Management Meeting Minutes and keep in the Quality Management Binder.
Permanent Solution:
Correction on both a temporary and permanent basis:
On 7/22/2025 the Operations Specialist and Health & Wellness Director re-in serviced and re-trained direct care staff on the process for providing emergency responders with the required hospital transportation documentation and on the AZ Hospital/ER Transportation Guide QRG. Effective 07/22/2025 updated AZ Emergency Packet/Cover Sheet has been implemented. On 9/8/25 around 4:00pm, HWD, Cincy Perry, contacted the local EMT's via phone and reviewed the revised discharge form with them. On 9/10/25, HWD, Cincy Perry, is meeting with the local EMT's and will review the previous missing information and answer any questions they may have.
Person Responsible:
Brandy Cooper, District Director of Operations

INSP-0134797

Complete
Date: 6/23/2025
Type: Modification
Worksheet: Assisted Living Center
SOD Sent: 2025-06-23

Summary:

An off-site desktop review to increase the licensed capacity from 141 to 155 was completed on June 23, 2025. 

✓ No deficiencies cited during this inspection.

INSP-0115654

Complete
Date: 4/3/2025 - 4/16/2025
Type: Complaint;Compliance (Annual)
Worksheet: Assisted Living Center
SOD Sent: 2025-05-28

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00106879, 00108187, 00104853, 00105305, 00105494, 00123150, and 00125014 conducted on April 3, 2025:

Deficiencies Found: 12

Deficiency #1

Rule/Regulation Violated:
A.R.S. § 36-420.B.2. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition<br> B. Each health care institution:<br> 2. Shall provide appropriate first aid in accordance with its certification training for first aid before the arrival of emergency medical services to a resident who is in distress and to a noninjured resident who has fallen, appears to be uninjured and is unable to reasonably recover independently. The first aid shall be in accordance with the resident's advance directives, if known. Staff who are certified in first aid shall be available at all times.
Evidence/Findings:
<p>Based on interview and documentation review, the health care institution failed to provide appropriate first aid before the arrival of emergency medical services to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. In an interview, R9 reported R9’s bed broke in late 2024. R9 reported facility personnel could not lift R9 had to call 911 for a lift assist. R9 reported firefighters helped R9 into R9’s wheelchair.</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed no incident report for the aforementioned incident.</p><p><br></p><p><br></p><p>3. In an interview, E1 reported E1 was unaware of the incident.</p><p><br></p><p><br></p><p>4. A review of Department documentation revealed two reports from the local fire department regarding a lift assist performed on R9 on September 12, 2024. The first report stated: “Staff failed to recover patient [per ARS 36-420. Inappropriate utilization of the 911 system. This is a repeat occurrence. On Scene Narrative (Author): E31 asked by brookdale staff to pick up uninjured pt from floor after [R9’s] bed broke. Staff states pt was too big to pick up. No hoyer lift present. No lift belts seen on scene. It appears if any effort was made to pick up [R9] it was minimal and inadequate.” The second report confirmed the first, stating: “Pt at assisted living facility had bed break and is need of getting help up from floor. Pt describes minor knee pain. Pt alert and oriented x4 speaking clearly. Pt denies hitting [R9’s] head or any serious injury. Pt states [R9] doesn’t not need eval or transportation to hospital. Pt helped to wheel chair to wait until [R9’s] bed is fixed or replaced.”</p>
Temporary Solution:
HWD re-trained all staff on 5/5/25 on when to call EMS. The HWD discussed purchase of a Hoyer lift with resident’s responsible party on 4/4/25.
Permanent Solution:
New staff will receive training upon hired on appropriate 911 use. Assessment of resident for transfer status to occur as needed by clinical team, proper DME will be sourced as appropriate.
Person Responsible:
Cincy Perry, HWD, Penelope Watkins, former ED

Deficiency #2

Rule/Regulation Violated:
R9-10-803.A.9. Administration<br> A. A governing authority shall: <br> 9. Ensure compliance with A.R.S. § 36-411.
Evidence/Findings:
<p>Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for one of ten sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population and the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A.R.S. § 36-411(C)(1) states: "C. Each residential care institution, nursing care institution and home health agency 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.”</p><p><br></p><p><br></p><p>2. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint inspection conducted on March 11, 2024. The POC indicated this deficiency was corrected on July 31, 2024. The POC stated: “All new hire paperwork will be checked by ED or designee prior to first day with resident.”</p><p><br></p><p><br></p><p>3. A review of facility documentation revealed a series of personnel schedules which indicated E5 worked on a regular basis between July 2024 and September 2024, including before July 31, 2024.</p><p><br></p><p><br></p><p>4. A review of E5's personnel record revealed E5 was hired as a caregiver before July 31, 2024 (the date the correction was completed according to the POC). The review revealed an “Application For Employment" which indicated E5 had previous employers. However, the review revealed facility personnel did not contact E5’s previous employers until September 12, 2024, after E5’s starting date of employment and contrary to the POC.</p><p><br></p><p><br></p><p>5. In an interview, E1 acknowledged facility personnel did not contact E5’s previous employers before E5 provided services at the facility.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint inspection conducted on March 11, 2024, the complaint and compliance inspection conducted on October 11-12, 2023, and the compliance inspection conducted on September 1, 2022.</p>
Temporary Solution:
CORRECTION ON BOTH TEMPORARY AND PERMANENT BASIS
An audit of personnel records for all associates was completed by Executive Director (ED) and Business Office Manager (BOM) on 5/15/25 to check for required reference checks. Will obtain checks where indicated.
Permanent Solution:
On 5/15/25 the Executive Director retrained the Business Office Manager on the requirement to have 2-3 reference checks completed prior to a new associates first day of direct contact with residents.
Personnel audit tool will be maintained and updated with new hires to reflect reference requirements completed prior to first day with residents.
Person Responsible:
ED, Penelope Watkins (initially), now Andrea Henry and Brandy Cooper (District Support) and Gayle Lemenager, BOM Len

Deficiency #3

Rule/Regulation Violated:
R9-10-803.C.1.e.i-iv. Administration<br> C. A manager shall ensure that policies and procedures are: <br> 1. Established, documented, and implemented to protect the health and safety of a resident that: <br> e. Except as provided in subsection (M), cover cardiopulmonary resuscitation training for applicable employees and volunteers, including: <br> i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation; <br> ii. The qualifications for an individual to provide cardiopulmonary resuscitation training; <br> iii. The time-frame for renewal of cardiopulmonary resuscitation training; and <br> iv. The documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training;
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident that covered cardiopulmonary resuscitation (CPR) training for applicable employees and volunteers, including the method of cardiopulmonary resuscitation training and the qualifications for an individual to provide cardiopulmonary resuscitation training. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled “CPR and First Aid Training” dated November 2022. However, the P&P did not include the method and content of CPR training and the qualifications for an individual to provide CPR training.</p><p><br></p><p><br></p><p>2. In an interview, when the Compliance Officer brought the aforementioned missing information to E1’s attention, E1 stated, “Okay.”</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint and compliance inspection conducted on October 11-12, 2023.</p>
Temporary Solution:
The Arizona “CPR and First Aid Training Requirements” policy was revised on June 12, 2025 to include the method and content of CPR training and the qualifications for an individual to provide CPR training.
Permanent Solution:
Staff in-service of policy update was completed on July 9th, 2025 by Business Office Manager and Health and Wellness Director.
Person Responsible:
Cincy Perry, HWD and Gayle Lemenager, BOM

Deficiency #4

Rule/Regulation Violated:
R9-10-806.A.10. Personnel<br> A. A manager shall ensure that: <br> 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:
<p>Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of nine sampled caregivers. The deficient practice posed a risk if a manager or a caregiver was unable to meet a resident's needs during an emergency.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled “CPR and First Aid Training” dated November 2022. The P&P stated: "3. The CPR and first aid certificates will be renewed according to the approved trainer guidelines but no later than 2 years from the issued date of the certificates. 4. The community Assisted Living Executive Director/Manager/designee will verify the certificates are current…6. The Assisted Living Executive Director/Manager/designee will routinely monitor the training certificates to ensure timely renewals.” The review further revealed a series of personnel schedules which indicated E5 worked on a regular basis between February 2025 and the date of the inspection.</p><p><br></p><p><br></p><p>2. A review of E5's personnel record revealed E5 was hired as a caregiver. The review revealed first aid and CPR certifications dated as expired on February 28, 2025, more than one month before the date of the inspection. The review revealed no current first aid and CPR certification.</p><p><br></p><p><br></p><p>3. In an interview, E1 stated, “We’re calling [E5] right now ‘cause we don’t have the updated one.”</p><p><br></p><p><br></p><p>4. In a separate interview, E1 acknowledged E5 failed to provide current documentation of first aid and CPR training certification specific to adults before providing assisted living services to residents. E1 stated, “[E5] is getting [E5’s certification] today.”</p><p><br></p><p><br></p><p>5. In a telephonic interview conducted on April 16, 2025, E1 reported E5 took a first aid and CPR training course after the inspection.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint inspection conducted on March 11, 2024, and the complaint and compliance inspection conducted on October 11-12, 2023.</p>
Temporary Solution:
E5 obtained current CPR and First Aid Training on 4/4/25.
An audit was completed by BOM on 5/15/25 to verify all required staff have current CPR and First Aid training.
Permanent Solution:
On 7/7/25 the BOM was re-trained on the CPR and First Aid training requirement and the process for utilizing the Brookdale Personnel Record checklist and tickler file to monitor that required associates have CPR and First training documentation per state regulation.
Person Responsible:
Penelope Watkins, ED/now Andrea Henry and Brandy Cooper (District Support) , Gayle Lemenager, BOM

Deficiency #5

Rule/Regulation Violated:
R9-10-806.A.8.a-b. Personnel<br> A. A manager shall ensure that: <br> 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: <br> a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and <br> b. As specified in R9-10-113;
Evidence/Findings:
<p>Based on documentation review, record review, and interview, the manager failed to ensure a manager and a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for three of ten sampled personnel members. The deficient practice posed a potential TB exposure risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. R9-10-113(A)(2)(a)(i-iii) states: "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…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)."</p><p><br></p><p><br></p><p>2. R9-10-113(B)(1)(a)(i) and (c)(i-ii) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC). c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and ii. Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution.”</p><p><br></p><p><br></p><p>3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel."</p><p><br></p><p><br></p><p>4 A review of E4’s personnel record revealed E4 was hired as a caregiver. The review revealed a positive blood test result dated more than 12 months before E4’s starting date of employment. The review further revealed a written statement indicating E4 was free from infectious tuberculosis, signed by a medical practitioner more than 12 months before E4’s starting date of employment. However, the review revealed no negative test(s) or written statement demonstrating E4 was free from infectious tuberculosis, signed by a medical practitioner or local health agency dated within 12 months before the date E4 began providing services at or on behalf of the health care institution.</p><p><br></p><p><br></p><p>5. A review of facility documentation revealed a series of personnel schedules which indicated E4 worked without evidence of freedom from infectious TB.</p><p><br></p><p><br></p><p>6. A review of E5's personnel record revealed E5 was hired as a caregiver. The review revealed documentation assessing risks of prior exposure to infectious tuberculosis and determining if E5 had signs or symptoms of tuberculosis dated August 19, 2024. The review revealed two negative TSTs dated as read on July 24, 2024, and August 9, 2024.</p><p><br></p><p><br></p><p>7. A review of facility documentation revealed a series of personnel schedules which indicated E5 worked before E5’s first TST was read and before E5’s risk assessment and signs and symptoms screening.</p><p><br></p><p><br></p><p>8. A review of E8's personnel record revealed E8 was hired as a caregiver. The review revealed two negative TSTs dated as read on March 14, 2025, and March 26, 2025.</p><p><br></p><p><br></p><p>9. A review of facility documentation revealed a series of personnel schedules which indicated E8 worked before E8’s second TST was read.</p><p><br></p><p><br></p><p>10. In an interview, E1 acknowledged E4, E5, and E8 began providing services before providing evidence of freedom from infectious TB.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule and a related deficiency was cited during the complaint and compliance inspection conducted on October 11-12, 2023.</p>
Temporary Solution:
An audit of personnel records for all associates was completed on 5/15/25 by BOM and ED to verify associate TB requirements are met and any missing documentation was obtained where indicated.
Retraining for department heads team completed 5/5/25 by Executive Director regarding weekly audit expectations.
Permanent Solution:
A Personnel audit tool will be maintained by the Business Office Manager and updated with every new hire to reflect TB regulatory requirements.
Person Responsible:
Penelope Watkins, ED/now Andrea Henry and Brandy Cooper (District Support), Gayle Lemenager, BOM

Deficiency #6

Rule/Regulation Violated:
R9-10-808.C.1.g. Service Plans<br> C. A manager shall ensure that: <br> 1. A caregiver or an assistant caregiver: <br> g. Documents the services provided in the resident's medical record; and
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of ten residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R9's medical record revealed a service plan dated October 7, 2024. The service plan indicated R9 was to receive assistance with dressing two times per day and showers daily. The review revealed documentation of assisted living services provided to R9 (ADLs) between March 1, 2025, and April 3, 2025. However, the ADLs revealed no documentation demonstrating R9 received assistance with dressing and R9 only received four showers per week instead of the required seven.</p><p><br></p><p><br></p><p>2. In an interview, regarding assistance with dressing not being documented on the ADLs, E3 stated, “Yeah, I don't see dressing.” E3 reported R9 received assistance with dressing and showers as stated in R9’s service plan but the services were not documented properly.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint inspection conducted on March 11, 2024, the complaint and compliance inspection conducted on October 11-12, 2023, and the compliance inspection conducted on September 1, 2022.</p>
Temporary Solution:
ADL's documentation been documenting accurately 10/1/2025. Staff will have on going training regarding ADL's documentation. Nurse will check documentation to ensure it is accurate and complete. ADL's Will be discussed during all staff meeting on a monthly basis. Nurse will check ADL's documentation after each shift to ensure we are in compliance, and all tasks are documented accurately.
Permanent Solution:
Going forward the ADL's will be reviewed by Nurse and Manager every Friday during one- on one meeting to ensure they are documented accordingly. Nurse will complete a monthly audit at the end of each month to ensure all tasks are completed and documented. As of 10/01/2025 all ADL's documentation been documenting accurately.
Person Responsible:
Cincy Perry, HWD

Deficiency #7

Rule/Regulation Violated:
R9-10-810.B.1. Resident Rights<br> B. A manager shall ensure that: <br> 1. A resident is treated with dignity, respect, and consideration;
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed an “INCIDENT INVESTIGATION” report. The report stated: “on 01/10/2025 it was brought to the EDs attention that [R8’s family member] had sent a Brookdale Survey in with complaints regarding [R8’s] care. Complaints: consistently left lying in urine for hours; developed a rash and sore that required special attention that [R8] was not receiving; two hour check that [R8’s family member] paid for; one night know [<em>sic</em>] one entered [R8’s] room at all.” The report continued: “[E13] was interviewed and stated that at approximately 11pm [E14] asked [E13] for the nystatin powder for [R8]. [E13] told [E14] the powder was in [R8’s] apartment and [E13] believed [E14] asked about the powder because [E14] was going to change [R8] at that time. [E13] stated [E13] was going on [E13’s] rounds as normal at 4:00am when [R8’s family member] came to the door. When [R8’s family member] came in [R8’s family member] was upset and stated that nobody changed [R9] all night and that was neglect. [E14] stated that at approximately 10:30-11:00pm [E14] inquired as to where the powder for [R8] was to [E13] and told [E13] told [E13] it was in [R8’s] room. [E14] assumed that [E13] was going to change [R8] because [E13] told [E14] it was in the room already…It was approx.. 4:00am when [E13] told [E14] that [R8’s family member] was there in the room and [R8’s family member] was upset that [E13 and E14] didn't change [R8] all night. [E14] was confused and asked [E13] what [E13] meant. [E13] said [E13] thought [E14] changed the resident. [E14] went up to [R8’s room] and [R8’s family member] was in the resident’s room and appeared to be upset. [R8’s family member] asked why the resident wasn’t changed all night. [E14] explained to [R8’s family member] it was a miscommunication between [E14] and [E13] and [E13 and E14] began to change [R8] at that point.”</p><p><br></p><p><br></p><p>2. In an interview, E3 reported R8’s family member had a camera and R8’s family member said facility personnel did not go into R8’s room for four hours. E3 reported facility personnel were to check on R8 and apply the nystatin powder every two hours. E3 acknowledged R8 was not treated with dignity, respect, and consideration.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint and compliance inspection conducted on October 11-12, 2023.</p>
Temporary Solution:
On 6/4/25 employees involved were re-coached on communication as a team.
Permanent Solution:
Care staff was provided re-education on the providing services in accordance with the care plan and the proper way to provide certain services by HWD on 7/9/25. Re-education on Resident Rights and Abuse, Neglect and Exploitation was provided to all staff on 05/05/25 by ED.
Person Responsible:
Cincy Perry, HWD, Former ED, Penelope Watkins and now Andrea Henry and Brandy Cooper, District Support

Deficiency #8

Rule/Regulation Violated:
R9-10-816.B.3.b. Medication Services<br> B. If an assisted living facility provides medication administration, a manager shall ensure that: <br> 3. A medication administered to a resident: <br> b. Is administered in compliance with a medication order, and
Evidence/Findings:
<p>Based on record review, documentation review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for four of ten sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1’s medical record revealed a service plan which indicated R1 received medication administration. The review revealed a medication order dated May 20, 2024, for “Digoxin 125 mcgs (0.125mg) tab…Give 1 tab PO QD.” The review further revealed a MAR dated January 2025 which indicated R1 did not receive digoxin on January 1 and 4, 2025.</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed an “INCIDENT INVESTIGATION” report for R2. The report stated: “On 12/2/2024 resident, [R2], was transferred to the hospital due to escalated behaviors, as well as not being able to sleep…[R2’s family member] stated that [R2] may behave this way when [R2] is not taking [R2’s] Temazepam medication…Review of medication administration logs showed that the Temazapam [<em>sic</em>] order was transcribed appropriately, but missed several days of scheduled sleeping medication due to it not being available…Med omission suspected to cause sleeplessness and increased behaviors.”</p><p><br></p><p><br></p><p>3. A review of R2’s medical record revealed a service plan which indicated R2 received medication administration. The review revealed a medication order dated November 21, 2024, for “temazepam PO 15mg QHS” and “fluticasone nasal 1 spray Q12hs.” The review further revealed a series of MARs dated November 2024 through December 2024. The MARs revealed the following:</p><p><br></p><p>- R2 did not receive temazepam on November 22-30, 2024;</p><p><br></p><p>- R2 did not receive temazepam on December 1, 2024;</p><p><br></p><p>- R2 did not receive R2’s first dose of fluticasone on November 23-25, 2024; and</p><p><br></p><p>- R2 did not receive R2’s second dose of fluticasone on November 23, 2024.</p><p><br></p><p><br></p><p>4. A review of R4’s medical record revealed a service plan which indicated R4 received medication administration. The review revealed a medication order dated December 4, 2023, for the following medications:</p><p><br></p><p>- “[A]torvastatin 10 mg oral tablet…1 tab, Oral, Daily;”</p><p><br></p><p>- “[D]onepezil 5 mg oral tablet…1 tab, Oral, Daily;”</p><p><br></p><p>- “[M]emantine 5 mg oral tablet…1 tab, Oral, Daily;” and</p><p><br></p><p>- “QUEtiapine 25 mg oral tablet…1 tab, Oral, BID.”</p><p><br></p><p><br></p><p>The review revealed a medication order dated January 22, 2024, for “amLOCIPine 5 mg oral tablet 2 tablet(s) Oral Daily.” The review further revealed a series of medication administration records (MARs) dated December 2023 and January 2024. The December 2023 MAR revealed the following:</p><p><br></p><p>- R4 did not receive atorvastatin on December 21-22, 2023;</p><p><br></p><p>- R4 did not receive donepezil on December 7, 2023;</p><p><br></p><p>- R4 did not receive memantine on December 7, 2023; and </p><p><br></p><p>- R4 did not receive R4’s first dose of quetiapine on December 7, 2023.</p><p><br></p><p><br></p><p>The January 2024 revealed revealed the following:</p><p><br></p><p>- R4 did not receive donepezil on January 17, 2024;</p><p><br></p><p>- R4 did not receive memantine on January 17, 2024;</p><p><br></p><p>- R4 did not receive R4’s first dose of quetiapine on January 13, 15, and 17, 2024; and</p><p><br></p><p>- R4 did not receive R4’s second dose of quetiapine on January 12-15, 2024.</p><p><br></p><p><br></p><p>5. A review of facility documentation revealed an “INCIDENT INVESTIGATION” report which indicated R8 did not receive nystatin powder every two hours during the night shift on January 5-6, 2024.</p><p><br></p><p><br></p><p>6. A review of R8’s medical record revealed a service plan which indicated R8 received medication administration. The review revealed a medication order dated December 31, 2024, for “nystatin 100,000 unit/gram topical powder…APPLY TO THE AFFECTED AREA(S) BY TOPICAL ROUTE EVERY TWO HOURS.” The review further revealed a MAR dated January 2025 which indicated R8 did not receive nystatin powder at 12:00 AM and 2:00 AM on January 6, 2025.</p><p><br></p><p><br></p><p>7. In an interview, E1 acknowledged medications administered to R1, R2, R4, and R8 were not administered in compliance with medication orders.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint and compliance inspection conducted on October 11-12, 2023, and the compliance inspections conducted on September 1, 2022, and March 25, 2021.</p>
Temporary Solution:
Nurse will check MAR after each shift to ensure medications are administered per doctor order. Med tech training started as of June 2025 on a monthly basis to ensure all Med Tech's are trained properly on medication administration per MD order. All medications have been administered accurately per MD order as of 10/1/2025.
Permanent Solution:
Health and Wellness Director or designee will audit MAR on a daily basis to ensure medications are administered accurately. Nurse will audit the MAR at the end of each month to ensure medication administration are documented accurately and administered per MD order. Nurse will continue with daily and every Friday audit to ensure meds are administered accurately. As of 10/1/25 all medications have been administered accurately per MD order.
Person Responsible:
Cincy Perry, HWD, Penelope Watkins, former ED, Brandy Cooper and Andrea Henry, District Support

Deficiency #9

Rule/Regulation Violated:
R9-10-818.A.4. Emergency and Safety Standards<br> A. A manager shall ensure that: <br> 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a series of personnel schedules which indicated the facility used three shifts. The review further revealed documentation of a series of disaster drills. The documents revealed facility personnel conducted disaster drills during the first shift in January 2024, July 2024, and January 2025, but not in April 2024 and October 2024. The review revealed disaster drills for employees were not conducted on the first shift at least once every three months.</p><p><br></p><p><br></p><p>2. In an interview, E1 confirmed facility personnel did not conduct disaster drills in April 2024 and October 2024. E1 reported facility personnel conducted evacuation drills in April 2024 and October 2024 instead.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint and compliance inspection conducted on October 11-12, 2023.</p>
Temporary Solution:
Disaster Drill was conducted by Maintenance director on 4/30/25 for first shift for immediate correction. Executive Director provided retraining to Maintenance Director on disaster drill requirements on 4/4/25.
Permanent Solution:
Maintenance Director, ED and/or designee will complete disaster drills once per shift every 3 months and recorded. ED, and/or designee will review disaster drill completion in monthly QA to ensure its completed.
Person Responsible:
Steve Mills, MD, Penelope Watkins (former ED), Brandy Cooper and Andrea Henry, District Support

Deficiency #10

Rule/Regulation Violated:
R9-10-819.A.1.b. Environmental Standards<br> A. A manager shall ensure that: <br> 1. The premises and equipment used at the assisted living facility are: <br> b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;
Evidence/Findings:
<p>Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may have caused a resident or other individual to suffer physical injury. The deficient practice posed a risk to the health and safety of a resident.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. The Compliance Officer observed a pool in an inner courtyard with a fence surrounding it. However, the pool fence was not locked, making the pool accessible to residents.</p><p><br></p><p><br></p><p>2. In an interview, E1 reported the pool fence had never been locked on a regular basis.</p><p><br></p><p><br></p><p>3. In R11’s unlocked residential unit, the Compliance Officer observed a variety of prescription medications on a nightstand next to R11’s bed.</p><p><br></p><p><br></p><p>4. In an interview, E1 reported the door to R11’s unit was typically locked, stating, “[R11] usually does…lock it.”</p>
Temporary Solution:
The fence surrounding the pool was locked on 4/4/2025. Residents who wish to use the pool must request the key to access the pool from the front desk.
The Maintenance Director was trained on this new process 4/4/25 Executive Director.
Re-education provided to R11 on securing apartment or medications prior to exiting unit on 4/8/25 Executive Director. Health and Wellness Director completed new self-medication administration on 4/8/25 with R11 to verify understanding and compliance.
Permanent Solution:
Staff informed at 5/5/25 meeting, department heads also trained on 5/5/25 at separate meeting By Executive Director.
Person Responsible:
Steve Mills, MD, Penelope Watkins (former ED), Cincy Perry, HWD

Deficiency #11

Rule/Regulation Violated:
R9-10-819.A.11. Environmental Standards<br> A. A manager shall ensure that: <br> 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:
<p>Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to residents with access to the poisonous or toxic materials.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. The Compliance Officer observed a pool in an inner courtyard with a fence surrounding it. However, the pool fence was not locked. Inside the fence, the Compliance Officer observed a gate with a warning sign leading to a storage area. The Compliance Officer observed a lock hanging near the gate. However, the gate was not locked. Inside the storage area, the Compliance Officer observed a variety of poisonous or toxic materials, including algae control, phosphate remover, pool maintenance cleaner, and soda ash.</p><p><br></p><p><br></p><p>2. In an interview, E1 reported staff may have been performing pool maintenance recently and must have forgotten to lock the storage area.</p>
Temporary Solution:
Pool shed was immediately locked on 4/3/25 and is checked by [who is responsible] on daily rounds.
Permanent Solution:
Vendors will have Maintenance tech with them when they need access to the pool shed. Re-education provided to R11 on securing apartment or medications prior to exiting unit on 4/8/25 Executive Director. Health and Wellness Director completed new self-medication administration on 4/8/25 with R11 to verify understanding and compliance.
Person Responsible:
Steve Mills, MD, Penelope Watkins (former ED), Cincy Perry, HWD

Deficiency #12

Rule/Regulation Violated:
R9-10-819.A.3.a-b. Environmental Standards<br> A. A manager shall ensure that: <br> 3. Garbage and refuse are: <br> a. Stored in covered containers lined with plastic bags, and<br> b. Removed from the premises at least once a week;
Evidence/Findings:
<p>Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. The Compliance Officer observed garbage in uncovered containers in R5’s living room, R11’s bathroom, R11’s bedroom, the second floor kitchen, outside the back door of the second floor kitchen, and in R9’s living room.</p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged the garbage can did not have covers.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint and compliance inspection conducted on October 11-12, 2023, the compliance inspection conducted on September 1, 2022, and the complaint inspection conducted on August 3, 2021.</p>
Temporary Solution:
Covered trash cans were purchased on 6/4/25 and will be used for residents in Assisted Living and Memory Care units. One lidded can per unit. Residents encouraged to accept covered garbage cans, but resident rights are followed for positioning of cans
Permanent Solution:
Residents who do not wish to have a covered trash can in their apartment will have this preference documented in their service plan. Retraining on the rule provided to associates on 5/5/25 by Executive Director. Community leaders assigned on 5/5/25 to audit resident apartments for compliance with rule.
Person Responsible:
Penelope Watkins (former ED)

INSP-0064415

Complete
Date: 11/21/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2025-01-02

Summary:

An on-site investigation of complaint AZ00219040 was conducted on November 21, 2024, and the following deficiency was cited :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:
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:
2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454;
Evidence/Findings:
Based on documentation review and interview, a manager who had a reasonable basis to believe abuse, neglect, or exploitation occurred on the premises failed to report the suspected abuse, neglect, or exploitation of the resident according to Arizona Revised Statutes (A.R.S.) \'a7 46-454.

Findings include:

1. A.R.S. \'a7 46-454(A) states: "A health professional... or 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 vulnerable 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...The reports required by this subsection shall be made immediately by telephone or online."

2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay."

3. A review of facility documentation revealed an "INCIDENT INVESTIGATION" report. The report stated: "On 11/13/24 at approximately 6 p.m., former Brookdale employee [E3] informed Brookdale Human Resources via telephone that memory care resident [R1]...confided in [E3] about '4-6 weeks ago' that [R1] had been sexually assaulted by [E2]." The review further revealed a printout of a confirmation email from Adult Protective Services (APS) demonstrating facility personnel reported the suspected abuse to APS. However, the email indicated the report was not submitted until 9:50 PM, more than three hours after Human Resources was aware of the suspected abuse.

4. In an interview, E1 reported E1 started making the report to APS at 9:04 PM when so instructed by E1's supervisor and the facility's legal team.

INSP-0064412

Complete
Date: 3/11/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-04-22

Summary:

An on-site investigation of complaints AZ00204702, AZ00205138, and AZ00206527 was conducted on March 11, 2024, and the following deficiencies were cited :

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:
A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.
Evidence/Findings:
Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(A) and (C), for five of five personnel members sampled. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population, or was unqualified to work in a residential care institution, and the Department was provided false or misleading information.

Findings include:

1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 or contracted work."

2. A.R.S. \'a7 36-411(C)(1) and (2) states: "C. 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. Verify the current status of a person's fingerprint clearance card."

3. A review of E4's personnel record revealed E4 was hired as an assistant caregiver. The review revealed a photocopy of E4's fingerprint clearance card. However, the card expired on May 20, 2022, more than one year before E4 was hired. The review further revealed a printout of the Arizona Department of Public Safety (DPS) fingerprint clearance card verification website dated February 5, 2024, indicating the status of E4's fingerprint clearance card was "Not Valid". E4's personnel record also contained an application receipt for a new fingerprint clearance card, dated February 6, 2024, and a current fingerprint clearance card dated as issued on February 12, 2024.

4. A review of the DPS fingerprint clearance card verification website revealed E4's fingerprint clearance card was expired when E4 was hired and E4's current fingerprint clearance card was valid.

5. In an interview, E1 reported E4 applied for a new fingerprint clearance card once the facility found out E4's previous fingerprint clearance card was expired.

6. A review of E5's personnel record revealed E5 was hired as a caregiver/medication technician. The review revealed a photocopy of E5's fingerprint clearance card and documentation demonstrating the governing authority verified the status of E5's fingerprint clearance card. However, the verification was not completed until approximately three months after E5's hire date.

7. A review of E6's personnel record revealed E6 was hired as an assistant caregiver The review further revealed an application receipt for a fingerprint clearance card dated approximately six months after E6's hire date.

8. A review of the DPS fingerprint clearance card verification website revealed E6's fingerprint clearance ard application number from the aforementioned receipt belonged to another individual, and not to E6. The review revealed no evidence to indicate E6 possessed a fingerprint clearance card and or applied for one within twenty working days of employment.

9. In an interview, E2 reported E2 gave E6 the necessary paperwork to obtain a fingerprint clearance card, but E6 never went to get fingerprinted and never got the card.

10. A review of E7's personnel record revealed E7 was hired as a caregiver/medication technician. The review revealed a photocopy of E7's fingerprint clearance card and documentation demonstrating the governing authority verified the status of E7's fingerprint clearance card. However, the verification was not done until approximately four months after E7's hire date.

11. A review of E8's personnel record revealed E8 was hired as a caregiver. The review revealed a photocopy of E8's fingerprint clearance card and documentation demonstrating the governing authority verified the status of E8's fingerprint clearance card. However, the verification was not done until approximately two months after E8's hire date.

12. In an interview, E1 acknowledged the governing authority did not ensure compliance with A.R.S. \'a7 36-411(A) and (C).

This is a repeat citation from the compliance and complaint inspection conducted on October 11-12, 2023, and the compliance inspection conducted on September 1, 2022.

Deficiency #2

Rule/Regulation Violated:
A. A manager shall ensure that:
4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented:
a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and
b. According to policies and procedures;
Evidence/Findings:
Based on record review, documentation review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, for three of five caregivers or assistant caregivers sampled. The deficient practice posed a risk if a caregiver or assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs.

Findings include:

1. A review of E5's personnel record revealed E5 was hired as a caregiver/medication technician. The review further revealed a document titled "Arizona Caregiver Skills Competency Checklist." However, the checklist was not completed until approximately two months after E5's hire date.

2. A review of E6's personnel record revealed E6 was hired as an assistant caregiver. The review further revealed a document titled "Arizona Caregiver Skills Competency Checklist." However, the checklist was not completed until approximately six months after E6's hire date.

3. A review of E8's personnel record revealed E8 was hired as a caregiver. The review further revealed a document titled "Arizona Caregiver Skills Competency Checklist." However, the checklist was not completed until approximately three months after E8's hire date.

4. A review of facility documentation revealed personnel schedules dated between December 2023 and March 2024. The schedules revealed the following:
-E5 provided physical health services on a regular basis between December 2023 and January 16, 2024, when E5's skills and knowledge were verified;
-E6 provided physical health services on a regular basis between December 2023 and March 5, 2024, when E6's skills and knowledge were verified; and
-E8 provided physical health services on multiple shifts in February 2024, before E8's skills and knowledge were verified.

5. In an interview, E1 acknowledged E5's, E6's, and E8's skills and knowledge were not verified and documented before E5, E5, and E8 provided physical health services.

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 documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of three caregivers sampled. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of E7's personnel record revealed E7 was hired as a caregiver/medication technician. The review revealed a printout of E7's previous CPR training certification from "NationalCPRFoundation" and a photocopy of E7's current CPR training certification from "HSI" dated as issued on January 2, 2024.

2. A review of the "NationalCPRFoundation" website revealed the training was online-only and did not include a demonstration of E7's ability to perform CPR.

3. A review of facility documentation revealed personnel schedules dated December 2023 and January 2024. The schedules revealed E7 provided physical health services in December 2023 and January 2024 without valid CPR training.

4. In an interview, E1 acknowledged E7's training from "NationalCPRFoundation" did not include a demonstration of E7's ability to perform CPR.

This is a repeat citation from the complaint and compliance inspection conducted on October 11-12, 2023.

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:
b. The level of service the resident is expected to receive;
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a resident's written service plan accurately included the level of service the resident was expected to receive, for one of five residents sampled. The deficient practice posed a risk if the resident did not receive the appropriate level of care.

Findings include:

1. A review of R5's medical record revealed three service plans dated May 31, 2023, August 31, 2023, and December 5, 2023, respectively. Each of the service plans indicated R5 required personal care services.

2. In an interview, E1 reported R5 was in the assisted living portion of the facility from R5's admission date until May 1, 2023, when R5 moved into the memory care unit. E1 reported R5 had been in the memory care since May 1, 2023, and received directed care services since moving to the memory care unit. E1 acknowledged the service plans after May 1, 2023 included the incorrect level of service for R5.

Technical assistance was provided on this rule during the complaint and compliance inspection conducted on October 11-12, 2023.

Deficiency #5

Rule/Regulation Violated:
C. A manager shall ensure that:
1. A caregiver or an assistant caregiver:
g. Documents the services provided in the resident's medical record; and
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R1's medical record revealed a service plan dated September 27, 2023. The service plan stated, "[R1] requires 1 person assistance with showering and bathing on Wednesday and Saturday evenings." The review revealed documentation of assisted living services provided to R1 between January 1, 2024, and March 11, 2024. However, the documentation contained no evidence to indicate R1 was assisted with showering and bathing on Saturday, March 9, 2024.

2. A review of R4's medical record revealed a service plan dated October 12, 2023. The service plan stated: "[R4] is independent with showering however, [R4] does need standby assistance when showering. Shower days are Monday and Thursday evening." The review revealed documentation of assisted living services provided to R4 between January 1, 2024, and March 11, 2024. However, the documentation contained no evidence to indicate R4 was assisted with showering and bathing on Monday, January 22, 2024, and Monday, February 5, 2024.

3. In an interview, E1 acknowledged a caregiver or an assistant caregiver failed to document all instances of showering and bathing provided to R1 and R4. E1 stated the caregiver(s) "just didn't sign."

This is a repeat citation from the compliance and complaint inspection conducted on October 11-12, 2023, and the compliance inspection conducted on September 1, 2022.

Deficiency #6

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:
f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.
Evidence/Findings:
Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a potential risk of re-injury.

Findings include:

1. A review of facility documentation revealed an incident report involving R4 dated December 28, 2023. The report indicated R4 had an accident, emergency, or injury that resulted in R4 needing medical services. However, the document did not include any action taken to prevent the accident, emergency, or injury from occurring in the future.

2. In an interview, E1 confirmed R4 was sent to the emergency room. E1 acknowledged the aforementioned incident report did not include any action taken to prevent the accident, emergency, or injury from occurring in the future.

INSP-0064411

Complete
Date: 10/11/2023 - 10/12/2023
Type: Complaint;Compliance (Annual)
Worksheet: Assisted Living Center
SOD Sent: 2023-11-02

Summary:

This revised statement of deficiencies supersedes the previous statement of deficiencies for event ID 3ML411. The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00186901, AZ00191337, AZ00198770, AZ00200034, and AZ00200080 conducted on October 11-12, 2023:

Deficiencies Found: 9

Deficiency #1

Rule/Regulation Violated:
A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.
Evidence/Findings:
Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for two of six personnel members sampled. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411(C)(1)-(2) states, "C. 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. Verify the current status of a person's fingerprint clearance card."

2. A review of the personnel records for E8 and E9 revealed E8 and E9 were hired as assistant caregivers. The review revealed E8 and E9 had fingerprint clearance cards and previous employment. However, the review revealed no documentation demonstrating the governing authority made documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E8's fitness to work in a residential care institution, or to verify the current status of E8's and E9's fingerprint clearance cards.

3. A review of the Arizona Department of Public Safety website revealed E8's and E9's fingerprint clearance cards were valid.

4. In an interview, E2 reported having checked the personnel records for all required documentation prior to providing them to the Compliance Officer. However, E1 and E2 acknowledged the governing authority failed to ensure compliance with A.R.S. \'a7 36-411 for E8 and E9.

This is a repeat citation from the previous compliance inspection conducted on September 1, 2022.

Deficiency #2

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 documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for three of six personnel members sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "CPR and First Aid Training" dated November 2022. The policy and procedure stated: "Cardiopulmonary Resuscitation (CPR) and First Aid Training are required for Arizona nurses, caregivers, managers or volunteers who provide direct care to residents...Nurses, caregivers, managers or volunteers who provide direct care to residents will be required to complete CPR and first aid training as required by Arizona regulations...This training will be validated by a demonstration of the nurse's, caregiver's, manager's or volunteer's ability to perform CPR and first aid...The community Assisted Living Executive Director/Manager/designee will verify the certificates are current...The Assisted Living Executive Director/Manager/designee will routinely monitor the training certificates to ensure timely renewals."

2. A review of the personnel records for E4, E5, and E6 revealed E4, E5, and E6 were hired as caregivers. The review revealed the following:
-A photocopy of a photo of E4's "CPR / AED / First-Aid" training certificate from "NationalCPRFoundation" dated March 15, 2022. The training was online and did not include a demonstration of E4's ability to perform CPR;
-A photocopy of E5's "Basic Life Support (CPR and AED) Program" training certificate from the American Heart Association dated November 2, 2021. The training did not include first aid;
-A printout of E6's "Basic Life Support (CPR and AED) Program" training certificate from the American Heart Association dated May 28, 2021. The training did not include first aid; and
-A photocopy of E6's "CPR / AED / First Aid" training certificate from American Emergency Response Training dated August 2023 (the "Class Completion Date" was illegible due to a hole being punched through it, although the expiration date was two years later on August 3, 2025).

3. A review of the NationalCPRFoundation website revealed a page titled "CPR & First-Aid Certification Class (AED)." The page stated, "Help Save Lives Today with Your Online CPR Certification Training!...The CPR and First-Aid certification program covers all of the necessary information and can be completed in as little as 25 minutes. While it may seem like a lot of information to cover in a short amount of time, the step-by-step instruction and helpful illustrations make the entire process a breeze...Our helpful videos and photographs will illustrate the entire process, offering you a complete understanding...CPR and First-Aid certification test: A total of ten questions are presented, seven of which must be answered correctly to receive certification. If you fail the test, no problem, as you can retry as many times as necessary before purchasing your certification...Each of our available courses offer the option of skipping straight to the final exam portion."

4. A review of facility documentation revealed a series of personnel schedules dated between October 1, 2022, and September 29, 2023. The schedules revealed the following:
-E4 worked multiple shifts each week between April 4, 2023, and September 29, 2023, without qualifying CPR training;
-E5 worked multiple shifts each week between May 7, 2023, and September 27, 2023, without first aid training;
-E6 worked multiple shifts each week between May 29, 2023, and August 2, 2023, without CPR training; and
-E6 worked multiple shifts each week between March 6, 2023, and August 2, 2023, without first aid training.

5. In an interview, E1 reported E4, E5, and E6 worked as caregivers. E1 reported not knowing E4's "NationalCPRFoundation" CPR certification was done online and did not include a demonstration of E4's ability to perform CPR as required by rule and the facility's policies and procedures. E1 confirmed E5 did not have first aid training, and acknowledged E6 did not have first aid training before August 3, 2023, and did not have current CPR training between May 28, 2023, and August 3, 2023.

Deficiency #3

Rule/Regulation Violated:
C. A manager shall ensure that:
1. A caregiver or an assistant caregiver:
g. Documents the services provided in the resident's medical record; and
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of twelve residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information.

Findings include:

1. A review of R6's medical record revealed documentation of assisted living services provided to R6. The document stated: "Initials and Signatures: Signature indicates all ADL's have been completed in accordance [with the] resident service plan." The document revealed the initials of a personnel member in the cell for the night shift on "September 31, 2023."

2. In an interview, E1 reported the personnel member must have signed off in the wrong cell.

This is a repeat citation from the previous compliance inspection conducted on September 1, 2022.

Deficiency #4

Rule/Regulation Violated:
B. A manager shall ensure that:
1. A resident is treated with dignity, respect, and consideration;
Evidence/Findings:
Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated.

Findings include:

1. A review of facility documentation revealed a printout of an "Adult Protective Services Online Submission Form" dated July 28, 2023. The form stated: "At 9:50am on 7/28/23 (today) an associate of BCPV witnessed another associate [E7] hitting a memory care resident in the side of the head and [E7] had [E7's] cell phone in [E7's] hand. [W]hile receiving this report, the same associate was trimming [R12's] nails and [R12] was yelling for [E7] to stop multiple times. [T]his was witnessed by two BCPV department heads and reported. Associate was immediately removed and suspended pending investigation."

2. In an interview, E1 reported E7 was clipping R12's nails, R12 yelled for E7 to stop, and E7 did not stop. E1 reported E7's employment was terminated because E7 did not show remorse for not treating R12 with dignity, respect, and consideration.

Deficiency #5

Rule/Regulation Violated:
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 documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of twelve residents sampled. The deficient practice posed a risk of an adverse health condition due to a medication not being administered as ordered.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Medication & Treatment - Administration/Assistance" dated March 31, 2022. The policy and procedure stated, "Medication assistance and administration should be in accordance with the prescriber's orders."

2. A review of R2's medical record revealed a service plan dated April 4, 2023. The service plan revealed R2 received medication administration services. The review further revealed a series of medication orders for the following medications:
-"Donepezil 10 mg (milligrams) oral tablet 1 tab Oral QBedtime, 90 days" dated June 7, 2023;
-"MEMANTINE HCL 10 MG TABLET TAKE 1 TABLET BY MOUTH AT BEDTIME" dated July 4, 2023;
-"Metoprolol Tartrate 25 mg oral tablet take \'bd tablet by mouth twice daily" dated November 29, 2022; and
-"Rimegepant 75 mg oral tablet, disintegrating 1 tab Oral Q24h-interval,x30 days, Instr:take 1 tablet by mouth every other day" dated July 3, 2023.

3. A review of R2's medical record revealed a series of medication administration records (MARs) dated between August 1, 2023, and September 30, 2023. The MARs revealed the following:
-R2 did not receive R2's "donepezil" on August 3-4, 2023;
-R2 did not receive R2's "donepezil" between August 7, 2023, and September 5, 2023;
-R2 did not receive R2's "memantine" on September 9, 2023;
-R2 did not receive R2's second dose of "metoprolol tartrate" on September 9, 2023; and
-R2 did not receive R2's "rimegepant" between August 1, 2023, and August 31, 2023.

4. In an interview, E2 confirmed R2 received medication administration services. E10 reported a check mark on the MAR indicated the medication was administered and all other codes or blank spaces meant the medication was not given.

This is a repeat citation from the two previous compliance inspections conducted on September 1, 2022 and March 25, 2021.

Deficiency #6

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

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed a series of food menus posted in a hallway near the dining room in the memory care unit. However, the menus were dated between October 1, 2023, and October 7, 2023. There was no current food menu conspicuously posted.

2. In an interview, E1 acknowledged the posted menu was not the menu for the current week. E1 reported the personnel member responsible for posting the current menu had not yet posted the current menu.

Deficiency #7

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 an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement a disaster plan and evacuate the residents during an emergency.

Findings include:

1. A review of facility documentation revealed a series of evacuation drill documents. The documents revealed the last evacuation drill for employees and residents was conducted on March 21, 2023.

2. In an interview, E1 acknowledged the evacuation drill dated March 21, 2023, was conducted more than six months before the date of the inspection. E1 stated the "evacuation drill is going to be next week."

Technical assistance was provided on this rule during the compliance inspection conducted on September 1, 2022.

Deficiency #8

Rule/Regulation Violated:
A. A manager shall ensure that:
3. Garbage and refuse are:
a. Stored in covered containers lined with plastic bags, and
Evidence/Findings:
Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed an uncovered container for garbage lined with a plastic bag in R9's bathroom. Inside the uncovered container, the Compliance Officer observed garbage consisting of a used brief, a toilet paper roll, and colored packaging or paper.

2. In an interview, E1 acknowledged the garbage container in R9's bathroom was not covered.

This is a repeat citation from the compliance inspection conducted on September 1, 2022 and complaint inspection conducted on August 3, 2021.

Deficiency #9

Rule/Regulation Violated:
R9-10-113. 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);
Evidence/Findings:
Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for five of six personnel members sampled and six of twelve residents sampled. The deficient practice posed a potential TB exposure risk to residents.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)."

2. A review of the CDC website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used."

3. A review of facility documentation revealed a series of personnel schedules dated between October 1, 2022, and September 29, 2023. The schedules revealed the following:
-E4 first provided services at or on behalf of the assisted living facility on April 4, 2023;
-E5 first provided services at or on behalf of the assisted living facility on May 7, 2023;
-E6 first provided services at or on behalf of the assisted living facility on March 6, 2023; and
-E9 first provided services at or on behalf of the assisted living facility on July 5, 2023.

4. A review of the personnel records of E4, E5, E6, E8, and E9 revealed the following:
-E4, E5, and E6 were hired as caregivers;
-E8 and E9 were hired as assistant caregivers;
-One TST for E5 dated as read on April 6, 2023;
-One blood test for E6 dated on February 14, 2023, administered more than 12 months before the date E6 began providing services at or on behalf of the health care institution;
-One TST for E6 dated as read on March 10, 2023, after E6 began providing services at or on behalf of the health care institution;
-One TST for E8 dated as read on September 18, 2023;
-One TST for E9 dated as read on May 6, 2023;
-No documentation to indicate E4, E5, E6, E8 and E9 were assessed for risks of prior exposure to infectious TB;
-No documentation to determine if E4, E5, E6, E8 and E9 had signs or symptoms of TB; and
-No second TST for E5, E6, E8, and E9 as recommended by the CDC.

5. A review of the medical records of R1, R3, R6, R7, R8, and R10 revealed the following:
-One TST for R6 dated as administered seven calendar days after R6's date of occupancy and read nine calendar days after R6's date of occupancy;
-No documentation to indicate R1, R3, R6, R7, R8, and R10 were assessed for risks of prior exposure to infectious TB; and
-No documentation to determine if R1, R3, R6, R7, R8, and R10 had signs or symptoms of TB.

The review further revealed a series of documents titled "Physician/Healthcare Provider Plan of Care" for R1, R3, R7, R8, and R9. The documents contained fields for the "Date of Mantoux TB skin test," "Date of last chest x-ray," and the "Result[s]" for both. The documents revealed the following:
-R1's document revealed Rl had a negative chest x-ray on April 15, 2023, but no TST;
-R3's document revealed all four sections were left blank and a wavy line was drawn through them;
-R7's document revealed all four sections were left blank;
-R8's document revealed R8 had a negative chest x-ray on February 22, 2023, but no TST; and
-R10's document stated "none" in the field for the "Date of last chest x-ray" and the other three fields were left blank.

6. In an interview, when the Compliance Officer asked if the facility still had tuberculosis-related documentation to be filed for the aforementioned personnel members and residents, E3 stated, "That's all we have." E2 reported having checked the personnel records for all required documentation prior to providing them to the Compliance Officer.

Technical assistance was provided on this rule during the compliance inspection conducted on September 1, 2022.

Data sourced from AZ CareCheck - Arizona Department of Health Services

Report generated: 2025-11-27T17:55:20.722Z