Caring Hearts Senior Care LLC

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "Fall Prevention and Recovery Training." The P&P stated, "The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery.” The P&P continued, “The established care home will provide and deliver training for employees on Fall Prevention and Fall Recovery.” 2. A review of E2's personnel record revealed E2 was hired as a housekeeper. However, the review revealed no documentation of training regarding fall prevention and fall recovery. 3. In an interview, E1 reported E1 thought E2 did not need the training since E2 was a housekeeper, stating, “That’s why I didn’t do it.”

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution, for one of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.” The webpage stated: “The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting…Initial TB training should be provided before the HCW starts working.” 2. A review of E2’s personnel record revealed E2 was hired as a housekeeper. However, the review revealed no documentation demonstrating E2 received training and education related to recognizing the signs and symptoms of TB. 3. In an interview, E1 reported E1 thought E2 did not need the TB training since E2 was a housekeeper, stating, “That’s why I didn’t do it.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on October 18, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-ii) 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…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 [and] ii. Determining if the individual has signs or symptoms of tuberculosis.” 2. A review of R2's medical record revealed R2 was admitted to the facility more than seven days before the date of the inspection. However, the review revealed no documentation assessing risks of prior exposure to infectious tuberculosis and determining if R2 had signs or symptoms of TB. 3. In an interview, when the Compliance Officer asked if the facility had the aforementioned documentation for R2, E1 stated, “I don’t have it” and “I forgot to do it.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on October 18, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk as the facility was unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed a door leading from the facility to the backyard. The Compliance Officer observed the door had an alert installed. However, upon opening the door, the Compliance Officer heard no alert. 3. In an interview, E1 reported the alert on the door triggered a sounding device plugged into an outlet in the dining room. 4. The Compliance Officer observed the sounding device was not plugged in. 5. In an interview, E1 reported a caregiver working the overnight shift likely unplugged it to go outside and forget to plug it back in.

Based on record review and interview, the manager failed to ensure a medication was administered to a resident under the direction of a medical practitioner, for one of two residents reviewed. The deficient practice posed a risk as medication administration was being completed by individuals who had not been approved by a qualified individual to provide medication administration services. Findings include: 1. Review of R1's medical record revealed a current written service plan dated September 29, 2023. This service plan indicated R1 received medication administration. Review of R1's medical record revealed medications were administered by facility caregivers. However, documentation from a medical practitioner stating a manager or caregiver could administer medications was not available. 2. Review of E1 and E3's personnel records revealed no documentation from a medical practitioner stating medications could be administered by a manager or caregiver or that E1 and E3 were nurses. 3. In an interview, E1 acknowledged the facility caregivers provided medication administration services to R1 without designation and authorization by a medical practitioner to administer medications to the resident.

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistance caregiver documented the action taken to prevent the accident, emergency, or injury from occurring in the future, for one of two residents who required medical services after an accident, emergency, or injury. The deficient practice posed a risk as the facility did not document preventative measures to protect the health and safety of residents. Findings include: 1. A review of facility documentation revealed an incident report (dated September 12, 2023). The report stated "Resident was feeling weak and thinking possible stroke... called 911 and the paramedics took [R2] to .... Hospital." However, documentation of any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review. 2. In an interview, E1 reported R2 was monitored for three days. 3. A review of facility documentation revealed an incident report (dated October 2, 2023). The report stated "blood discharge from genital area ... Resident Taken to Hospital." However, documentation of any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review. 4. In an interview, E1 reported R2 returned to facility with a catheter and antibiotics.