Caring Hearts Assisted Living Home

Based on record review and interview, for one of two sampled caregivers, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, to include initial training in fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E1’s personnel record did not include documentation of completed initial training on fall prevention and fall recovery. Given E1's date of hire, this documentation was required. 2. In an exit interview with E1, the findings were reviewed with E1. E1 indicated E1 was not aware that initial training for fall prevention and fall recovery was required. E1 indicated that is the reason E1 did not receive the training until 7 months after E1’s hire date when all staff completed their annual fall prevention and fall recovery training. This is a repeat deficiency from the Compliance inspections conducted on March 31, 2023 and March 8, 2024.

Based on document review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services for two of two certified caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings Include: 1. A review of the facility work schedule dated December 1, 2025 through December 27, 2025, reflected E1 was scheduled to work 24 hour shifts as a caregiver on various days throughout the month. The schedule reflected E2 was scheduled to work as a caregiver from 7am to 7pm for various days of the month. 2. A review of E1 and E2’s personnel files revealed no documentation of a completed skills assessment to reflect E1's and E2’s skills and knowledge were verified before providing physical health services. 3. In an exit interview, the findings were reviewed with E1. E1 acknowledged E1 and E2 did not have the documented skills and knowledge in their files.

Based on record review and interview, the manager failed to ensure that a resident’s medical record contained documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that included the date and time of administration, the name, strength, dosage, and route of administration, the name and signature of the individual administering or providing assistance in the self-administration of medication, and an unexpected reaction the resident has to the medication for one of two residents sampled. Findings Include: 1. A review of R2’s medical record revealed an initial service plan dated June 17, 2004 and a service plan review dated June 10, 2025 which indicated R2 received personal care services and medication administration. 2. A review of R2’s records revealed a Medication Administration Record (MAR) which stated, “Meds are given from pre-set box by VA nurse." The MAR did not list the name, strength, dosage, or route of administration for each medication. 3. In an exit interview, the findings were reviewed with E1. E1 stated R2’s VA nurse filled R2’s medication box monthly and the facility administered what was put in the box to R2. E1 stated the facility documents that the medications are given on the MAR, but did not know each medication was required to be listed individually.

Based on the documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed no documentation of a disaster plan review was available for the Compliance Officer to review. 2. In an exit interview, the findings were reviewed with E1. E1 acknowledged E1 was unaware that the facility had to review the disaster plan at least once every 12 months.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. Findings Include: 1. During an environmental tour of the facility, the Compliance Officer checked the water temperature of the bathroom by the dining room and it measured 130.3º F. 2. In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on record review, and interview, for one of two sampled residents reviewed, who received personal care services, the manager failed to ensure a written service plan was reviewed and updated at least once every six months. Findings include: 1. A review of R2's medical record revealed a service plan, dated May 11, 2023, for personal care services. However, an updated service plan dated on or before November 11, 2023 was not available for review. 2. In an interview, E1 was not able to communicate in English as required by this Article and a written description of the deficiency was provided to E1.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for one of three sampled staff regarding fall prevention and fall recovery. Findings include: 1. A review of E2's personnel record revealed training in fall prevention and fall recovery was not available for review. 2. In an interview, E1 was not able to communicate in English and a written description of the deficiency was provided to E1.

Based on documentation review, record review, and interview, the manager failed to ensure a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with Arizona Administrative Code (A.A.C.) R9-10-807(G), for two of two residents reviewed accepted by the assisted living facility on or after October 1, 2019. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's medical record revealed a residency agreement titled, "Caring Hearts Assisted Living Home Residency Agreement." The residency agreement included the facility's termination policy and procedure as required. However, the termination policy was not in compliance with the requirements in R9-10-807(G), and including the following provisions: - "The sponsor reserves the right to terminate this contract with 14 days written notice....should the resident refuse to comply with this residency agreement or facility rules"; and - "The sponsor reserves the right to terminate this residency agreement without notice...should the resident's urgent medical needs require immediate transfer to another health care institution; or should the resident's care and service needs exceed the services the facility is licensed to provide." 2. A review of R2's medical record revealed a residency agreement titled, "Caring Hearts Assisted Living Home Residency Agreement." The residency agreement included the facility's termination policy and procedure as required. However, the termination policy was not in compliance with the requirements in R9-10-807(G), and including the following provisions: - "The sponsor reserves the right to terminate this contract with 14 days written notice....should the resident refuse to comply with this residency agreement or facility rules"; and - "The sponsor reserves the right to terminate this residency agreement without notice...should the resident's urgent medical needs require immediate transfer to another health care institution; or should the resident's care and service needs exceed the services the facility is licensed to provide." 3. In an interview, E1 was not able to communicate in English as required by this Article and a written description of the deficiency was provided. This is a repeat deficiency from the on-site compliance inspection conducted on March 31, 2023.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan was not available for review. Based on R1's admission date, a complete service plan was required. 2. In an interview, E1 was not able to communicate in English as required by this Article and a written description of the deficiency was provided to E1.

Based on observation, documentation review, record review, and interview, the governing authority failed to ensure a caregiver who was able to read, understand, and communicate in English was on the assisted living facility's premises. The deficient practice posed a risk if the caregiver was unable to communicate with an English speaking resident in order to meet their needs. Findings include: 1. Upon arriving at the facility at approximately 9:50 a.m., the Compliance Officer observed E1 was the only caregiver present at the facility. The Compliance Officer observed eight residents were present at the facility. However, E1 was not able to communicate in English. 2. The Compliance Officer contacted E2 and asked if E2 was able to come to the facility to assist with the inspection. E2 reported E2 was not able to come to the facility for several hours. The Compliance Officer advised E2 of being unable to communicate with E1. E2 reported E1 spoke some English and the Compliance Officer advised E2 the inspection would be conducted with E1 in English. 3. At approximately 10:05 AM, the Compliance Officer provided E1 with a list of requested documentation, which included the following: - A current resident roster; - Staff Schedules (for the last 12 months); - Resident Medical Records for R1 and R2; - Personnel Records for E1 and E2; - Policies and Procedures; - Scope of Services; - Employee disaster drills; - Resident and employee evacuation drills; - Smoke Detector tests - Last 12 months; - Disaster Plan; and - Fall Prevention and Fall Recovery Training Program. 4. The Compliance Officer located some drills, smoke detector tests, and staff schedules posted on a bulletin board. However, the Compliance Officer requested some missing documentation and E1 did not understand the request. 5. At 10:16 AM, the Compliance Officer again requested the listed documentation, however, E1 did not provide any documentation. 6. At 10:44 AM, the Compliance Officer again requested the listed documentation, however, E1 did not provide any additional documentation. 7. At 10:55 AM, the Compliance Officer again requested the listed documentation, however, E1 did not provide any additional documentation. 8. At 11:13 AM, the Compliance Officer requested the resident charts and personnel files in Spanish and E1 provided some of the requested documentation. The Compliance Officer was not able to communicate the missing sections of the provided charts, such as service plans and documentation of services provided, and E1 was not able to understand the Compliance Officer's request for this documentation. 9. At 12:20 PM, the Compliance Officer attempted to perform an exit interview with E1, however, E1 was not able to understand the information being presented and was not taking notes or documenting the findings. The Compliance Officer provided E1 with a written summary of all findings, and E1 read through them and asked a few questions, indicating E1 did have some ability to read Eng

Based on observation, documentation review, and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. Findings include: 1. The Compliance Officer observed a posted work schedule, which indicated E3 worked as the only caregiver at the facility from 3-10 PM on March 4, March 5, March 6, and March 7, 2024. 2. The Compliance Officer observed a posted form titled, "Designation of Manager by the Governing Authority." The form stated, "The sponsor of caring hearts ALH, [E2] along with the Manager of the facility, [E4], has designated the following certified and trained caregivers who are 21 years of age to be present on the assisted living facility's premises and accountable for the assisted living facility when the Sponsor is not present on the assisted living facility premises." The form listed E1 and E2 as designees, however, the form did not designate E3. 3. In an interview, E1 was not able to communicate in English as required by this Article and a written description of the deficiency was provided to E1.

Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for three of three employees sampled. Findings include: 1. R9-10-113.A 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, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. R9-10-113.A.2.b.ii states, "Include: If an individual may have a latent tuberculosis infection, as defined in A.A.C R9-6-1201: Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101;" 4. R9-10-113.A.2.c states, "Annually providing training and education relating to recognizing the signs and symptoms of tuberculosis to individuals employees by or providing volunteer services for the health care institution." 5. A review of E1's personnel record revealed E1 had been hired as a caregiver in January of 2011. 6. A review of E1's personnel record revealed documentation annual training and education relating to recognizing the signs and symptoms of tuberculosis was not available for review. 7. A review of E2's personnel record revealed E2 had been hired as a caregiver in November of 1997. 8. A review of E2's personnel record revealed a "Known Positive Reactor" card from a local health agency. However, annual documentation of E2's freedom from symptoms of infectious tuberculosis, signed by a medical practitio

Based on observation, record review, and interview, the manager failed to ensure for one of three personnel members sampled, before providing assisted living services to a resident, a manager or caregiver provided current documentation of cardiopulmonary resuscitation (CPR) and First Aid training certification. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. The Compliance Officer observed E1 was the only caregiver or manager present at the facility during the inspection. 2. A review of E1's personnel record revealed E1 was hired as a caregiver in January of 2011. 3. A review of E1's personnel record revealed documentation of CPR and First Aid training dated September 30, 2021 with a marked expiration of September 30, 2023. 4. In an interview, E1 reported E1 could provide documentation of current CPR and First Aid training the following day. E1 acknowledged E1's personnel record did not include documentation of current CPR and First Aid training.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. Findings include: 1. R9-10-113.A 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, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R1's medical record revealed a baseline screening to include documentation of a Mantoux skin test (TST) or blood test, a risk assessment of prior exposure to infectious TB and a determination if R1 had signs or symptoms of TB, signed by an occupational health provider or medical practitioner, was not available for review. However, based on R1's acceptance date, this documentation was required. R1's medical record contained a negative chest X-ray. 3. In an interview, E1 acknowledged R1 had not provided documentation of baseline screening as specified in R9-10-113(A)(2)(a).

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two 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 and R2's medical records revealed documentation of services provided to each resident was not available for review. 2. During the on-site inspection, the Compliance Officer requested E1 provide R1's and R2's complete medical records six times. However, E1 was not able to communicate in English and not all of the requested documentation was provided. 3. In an interview, E1 was not able to communicate in English as required by this Article and a written description of the deficiency was provided to E1. This is a repeat deficiency from the on-site compliance inspection conducted on March 31, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two sampled residents. 1. A review of the facility's policies and procedures revealed three forms, intended for use at intake for all residents; a list of rights with a signature page to document residents had received a copy of their rights, a resident 'application' to obtain basic information including resident food and activity preferences, and a list of required notifications to document receipt of all required intake notices, which included an orientation to exits from the assisted living facility. 2. A review of R1's medical record revealed the three intake documents were not available for review, to include documentation of R1's orientation to exits from the facility. 3. A review of R2's medical record revealed the three intake documents were available for review, to include documentation of R2's orientation to exits from the facility, however, the forms had not been signed by R2 or R2's representative to indicate they had been received. 4. In an interview, E1 was not able to communicate in English as required by this Article and a written description of the deficiency was provided to E1.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of a resident's general or specific whereabouts. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During a facility tour, the Compliance Officer observed the front and back doors of the facility did not control egress or alert employees of the egress of a resident from the facility. The front door had the sensor section of a door alarm but was missing the magnet, and the back door did not have any installed alarm visible. 3. In an interview, E1 reported the housekeeper had removed the back door alarm because they were cleaning the area. E1 acknowledged the door alarms were not functional at the time of the on-site inspection. Technical assistance for this rule was provided during the on-site compliance inspection conducted on March 31, 2023.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan was not available. 2. A review of R1's medical record revealed an order, dated February 8, 2024, for the following: "Metformin ER 500 mg tablet, extended 24hr, take 1 tablet by oral route every day with evening meal, discontinue Metformin 1000mg." 3. A review of R1's medical record revealed orders, dated February 22, 2024, for the following: - "Metformin ER 500 mg tablet, extended release 24hr, take 2 tablet by oral route, every day with evening meal. Discontinue Metformin ER 500mg daily. See new order"; -"Memantine 10 mg tablet, take 1 tablet by oral route 2 times every day"; -"Cholestyramine Light 4 gram oral powder, take 1 scoop by oral route every day dissolved in 2 to 6 ounces of water or noncarbonated beverage before meals for diarrhea"; and -"Glipizide 5 mg tablet, take 1 tablet (5MG) by oral route BID before a meal." 4. A review of R1's medical record revealed a medication administration record (MAR) dated March 2024. The MAR indicated R1 had been provided the following: - "Metformin ER 500 mg tablet, take 1 tablet every evening," had been administered at 8 AM on each day in March. However, the medication had been administered at the incorrect time and dosage had been provided; and - "Memantine 10 mg tablet, take 1 tablet by mouth at PM," had been administered at "PM" on March 1,2,4,5,6, and 7. However, the medication had been administered at the incorrect time and amount. - "Cholestramine light 4gram oral powder, add 1 scoop by PO," had been administered at, "PM" on March 4,5,6 and 7. However, the medication had been administered at the incorrect time and frequency; - "Glipizide 5mg tablet, Take 1 tab by mouth at AM," had been administered at 8 AM on each day in March. However, the second daily dosage had not been administered. 5. The Compliance Officer requested E1 provide the February MAR six times, however, E1 was not able to communicate in English and the MAR was not made available. 6. A review of R2's medical record revealed an out-dated service plan dated May 11, 2023 for personal care services including medication administration. The Compliance Officer requested a current service plan for R2, however, E1 was not able to communicate in English and an updated service plan was not provided for review. 7. A review of R2's medical record revealed an order, dated February 29, 2024, for the following: "Trazodone, 25 mg, take 1 tablet by mouth every night at bedtime for sleep." 8. A review of R2's medical record revealed an order, dated March 7, 2024, for the following: "Increase Trazodone to 50 mg. at bedtime. Take two 25 mg tablets by mouth at bedtime until 50 mg tablets arrive." 9. A review of R2's medical record revealed an order, dated January 11, 2024, for the follo

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two sampled residents who received medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan was not available. 2. A review of R1's medical record revealed a signed list of medication orders. The list included the following: - "Atorvastatin 40mg tablet, Take 1 tablet by mouth at bedtime." 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated March 2024. The MAR documented the following: - "Atorvastatin, 40mg tab, Take 1 tablet by mouth at bedtime," had not been documented as administered on March 1, 2, or March 3, 2024. 4. The Compliance Officer requested to review February 2024 MARs for R1 and R2 six times during the on-site inspection. However, E1 was not able to communicate in English and no additional documentation of medications administered to R1 and R2 was provided for review. 5. In an interview, E1 was not able to communicate in English as required by this Article and a written description of the deficiency was provided to E1. This is a repeat deficiency from the on-site compliance inspection conducted on March 31, 2023.

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. Findings include: 1. A review of the facility work schedule revealed the facility worked two shifts per day, from 3 PM to 10 PM and from 10 PM to 3 PM. 2. A review of facility documentation revealed disaster drills during the previous 12 months had been conducted and documented as follows: - September 3, 2023 at 4:32 PM; and - March 3, 2023 at 10 AM. 3. The Compliance Officer requested E1 provide the additional missing drills, however, E1 was not able to communicate in English and did not provide additional documentation. 4. In an interview, E1 did not understand the Compliance Officer's description of the deficiency due to E1's inability to communicate in English. Technical Assistance for this rule was provided during the on-site compliance inspection conducted on March 31, 2023.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers and stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed laundry area was open and accessible to residents. In an unlocked cabinet in the laundry area, the Compliance Officer observed two containers of, "Hartz UltraGuard Flea & Tick Powder for dogs." 2. In an interview, E1 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents.