COTTAGES AT PEORIA

<p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">Based on documentation review and interview, the facility exceeded the licensed capacity of residents as specified by the license issued by the Department. The deficient practice posed a risk to the health and safety of residents as the occupancy of the health care institution was outside the scope of the licensed assisted living facility subclass.</span></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p><br></p><p>1 . A review of facility documentation revealed a resident roster for October 24, 2025. The resident roster listed 99 current residents.</p><p><br></p><p><br></p><p><br></p><p>2 . A review of facility and Department documentation revealed the facility was licensed for a maximum occupancy of 98 residents.</p><p><br></p><p><br></p><p><br></p><p>3 . In an interview, E1 reported calling the Compliance Officer of the Day to clarify if the residents could reside together and the square footage required for two residents; however, E1 was unsure if any questions were raised about exceeding occupancy for a couple sharing a room.</p><p><br></p><p><br></p><p><br></p><p>4 . In an exit interview, the findings were discussed with E1 and no additional information was provided.</p><p><br></p><p><br></p>

<p>Based on observation and interview, the manager failed to ensure that toxic materials stored by the assisted living facility were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials.</p><p><br></p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1 . During an environmental inspection of the facility, the Compliance Officer observed an unattended cleaning cart located in the hallway of cottage 5. The following items were sitting on top of the cart:</p><p>-A bottle of "Lysol" toilet bowl cleaner;</p><p>-A can of "Ajax" bleach cleaner; and</p><p>-A bottle of "Ecolab" glass cleaner.</p><p><br></p><p><br></p><p><br></p><p>2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.</p><p><br></p><p><br></p><p><br></p><p>3. This is a repeat deficiency from the compliance/complaint inspection conducted October 7, 2024.</p>

<p><span style="color: rgb(68, 68, 68);">Based on record review, documentation review and interview, the manager failed to ensure that a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. § 36-411(A). The deficient practice posed a risk as required information could not be verified for E3.</span></p><p><span style="color: rgb(68, 68, 68);"> </span></p><p><span style="color: rgb(68, 68, 68);">Findings include:</span></p><p><span style="color: rgb(68, 68, 68);"> </span></p><p><span style="color: rgb(68, 68, 68);">1. A.R.S. § 36-411.C states: "C. Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card."</span></p><p><span style="color: rgb(68, 68, 68);"> </span></p><p><span style="color: rgb(68, 68, 68);">2. A review of E3’s personnel record, revealed that the employee was hired on October 10, 2022.</span></p><p><br></p><p><span style="color: rgb(68, 68, 68);">3. A review of the personnel document printed by the facility revealed that E3’s fingerprint clearance card was showing "In Process" status as pf October 6, 2022. </span></p><p><span style="color: rgb(68, 68, 68);"> </span></p><p><span style="color: rgb(68, 68, 68);">4. An online check by the Compliance Officer of the Arizona Department of Public Safety (DPS) web portal at </span><a href="https://psp.azdps.gov/services/cardStatusRequest" target="_blank" style="color: rgb(11, 92, 171);">https://psp.azdps.gov/services/cardStatusRequest</a><span style="color: rgb(68, 68, 68);"> revealed that E3’s fingerprint card was "Not Valid", verified on May 23, 2025.</span></p><p><span style="font-size: 10pt; color: rgb(68, 68, 68);"> </span></p><p><span style="color: rgb(68, 68, 68);">5. A documentation review of the facility's employee schedule for April and May 2025, revealed that E3 was documented as working on May 18,13, 12, 11, 7, 6, 5, 4 and April 30, 29, 28, 27, and 23, 2025, without a valid fingerprint card.</span></p><p><span style="font-size: 10pt; color: rgb(68, 68, 68);"> </span></p><p><span style="color: rgb(68, 68, 68);">6. In an interview, E1 acknowledged that the manager failed to ensure that the personnel record for E3 included documentation of compliance with the requirements in A.R.S. § 36-411(A)</span></p>

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training, for two of three personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency or an accident.

Findings include:

1. A review of E2's and E3's personnel records revealed documentation of CPR training from NationalCPRFoundation.

2. A review of NationalCPRFoundation.com revealed a section under "FAQ" titled "Do you offer hands-on training?" The section stated, "No, we do not offer hands-on training."

3. In an interview, E1 reported E1 thought the CPR documents were acceptable based on guidance provided during Covid.

4. In an interview, E1 acknowledged E2's and E3's personnel record did not include documentation of CPR training which included a demonstration portion.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for one of four employees sampled. The deficient practice posed a risk if E4 was a danger to a vulnerable population.

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 review of E4's personnel record revealed a fingerprint card which expired on February 6, 2024. An application for renewal of the fingerprint clearance card was located in the employee file. However, the application did not show up in process when looked up online, and documentation of a current valid fingerprint clearance card was not available for review at the time of inspection.

3. In an interview, E1 acknowledged E4's personnel record did not include documentation of compliance with the requirements in A.R.S. \'a7 36-411(A).

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

Findings include:

1. A review of R2's medical record revealed a document titled "Physician's Report (Arizona)." The document stated R2 required "continuous medical services" and "continuous nursing services".

2. A review of R3's medical record revealed a document titled "Physician's Report (Arizona)." The document stated R3 required "continuous medical services", "continuous nursing services" and "restraints".

3. A review of R4's medical record revealed a document titled "Physician's Report (Arizona)." The document stated R4 required "continuous medical services" and "continuous nursing services".

4. In an interview, E1 acknowledged R2, R3, and R4 had documentation reporting R2, R3, and R4 required continuous medical services.

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

Findings include:

1. A review of R2's medical record revealed a document titled "Physician's Report (Arizona)." The document stated R2 required "continuous medical services" and "continuous nursing services".

2. A review of R3's medical record revealed a document titled "Physician's Report (Arizona)." The document stated R3 required "continuous medical services", "continuous nursing services" and "restraints".

3. A review of R4's medical record revealed a document titled "Physician's Report (Arizona)." The document stated R4 required "continuous medical services" and "continuous nursing services".

4. In an interview, E1 acknowledged R2, R3, and R4 had documentation reporting R2, R3, and R4 required continuous medical services.

Based on observation and interview, the manager failed to ensure a toxic material stored by the facility was stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed bottles of "Ecolab" odor counteractant, multi-quat sanitizer, rapid multi surface disinfectant cleaner, "Renown" enzyme odor neutralizer and "Sysco" liquid pot and pan detergent in a cabinet underneath the kitchen sink in cottage 2. The cabinet was unlocked and was accessible to residents.

2. During the environmental inspection of the facility, the Compliance Officer observed bottles of "Ecolab" odor counteractant, multi-quat sanitizer, rapid multi surface disinfectant cleaner, and "Renown" enzyme odor neutralizer in a cabinet underneath the kitchen sink in cottage 3. The cabinet was unlocked and was accessible to residents.

3. In an interview, E1 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411 for one of two sampled employees. The deficient practice posed a risk to a vulnerable population.

Findings include:

A.R.S. \'a7 36-411 states, "... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work... 3. "Supportive services" has the same meaning prescribed in section 36-151."

1. A review of E1's (hired in 2021) personnel record revealed a fingerprint clearance card with an expiration date of May 29, 2024.

2. A review of the Arizona Department of Public Safety fingerprint clearance card website, conducted on September 23, 2024 revealed E1's fingerprint clearance card was "Waiting on applicant fingerprints".

3. In an interview, E1 acknowledged E1's fingerprint card had expired and did not meet the requirements of A.R.S. \'a7 36-411.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months, for four of nine residents sampled who received directed care services. The deficient practice posed a risk if changes to a resident's condition were not included on the service plan.

Findings include:

1. A review of R3's medical record revealed a written service plan for directed care services dated March 2021. There was no more recent service plan for R3 available for review.

2. A review of R4's medical record revealed a written service plan for directed care services dated January 2023. There was no more recent service plan for R4 available for review.

3. A review of R6's medical record revealed a written service plan for directed care services dated July 2022. There was no more recent service plan for R6 available for review.

4. A review of R7's medical record revealed a written service plan for directed care services dated Febuary 2021. There was no more recent service plan for R7 available for review.

5. In an interview, E1 reported all residents at the facility received directed care services. E1 acknowledged R3's, R4's, R6's, and R7's written service plans were not reviewed and updated at least once every three months.

This is a repeat citation from the previous on-site compliance inspection conducted on January 11, 2022.

Based on observation, documentation review, and interview, the manager failed to ensure the premises was cleaned according to policies and procedures. The deficient practice posed a risk as the facility had not established or documented a policy and procedure to reinforce and clarify standards expected of employees.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officers observed R5's bedroom and bathroom. The Compliance Officers observed the bedroom and bathroom smelled of urine and the floors were not cleaned.

2. A review of facility documentation revealed policies and procedures, approved in 2023. The policiec and procedures contaiend a policy titled "Exposure Control Policy". The policy stated: "All employees shall be responsible for complying with the following practices: cleaning/decontaminating all equipment and surfaces...at the end of the work day or shift if may have become contaminated since the last cleaning."

3. In an interview, E1 acknowledged the bathroom needed to be cleaned, and reported the smell of urine will go away after remodeling in the building occurred.