Compassionate Hands Assisted Living LLC

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed every 12 months. Findings include: 1 . A review of facility documentation revealed documentation of a disaster plan review conducted every 12 months was not available for review at the time of inspection. 2 . In an interview, E1 acknowledged documentation of a disaster plan review conducted every 12 months was not available for review at the time of inspection.

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training in fall prevention and fall recovery. Findings include: 1 . A review of facility documentation revealed a training program for all staff regarding fall prevention and fall recovery was not available for review at the time of inspection. 2 . In an interview, E1 acknowledged a training program for fall prevention and fall recovery was not available for review.

Based on record review and interview, the manager failed to ensure medication administered to a resident is documented in the resident's medical record, for five of six residents sampled. Findings include: 1 . In an interview, E1 confirmed all residents received medication administration. 2 . A review of R1's medical record revealed a signed medication order dated April 15, 2025, for the following medications: -Divalproex 125 MG 2 Tablets every 12 hours; -Mirtazapine 7.5 MG once a day; -Sertraline 50 MG once a day; -Trazadone 100 MG once a day; -Haloperidol 0.5 MG 1 tablet in the morning and 2 tablets in the evening; -Docasate 100 MG once a day; -Ferrous Sulfate 325 MG once a day; -Meloxicam 7.5 MG once a day; and -Senna 8.6 MG once every 12 hours. However, a review of R1's Medication Administration Record (MAR) sheet revealed the above medications were not documented as administered on April 26, 2025 and April 27, 2025. 3 . A review of R2's medical record revealed a signed medication order dated December 21, 2024, for the following medications: -Pantoprazole 40 MG once a day; -Alprazolam 0.25 MG once a day; -Seroquel 50 MG once a day; -Seroquel 25 MG once a day; and -Trazadone 50 MG once a day; However, a review of R2's Medication Administration Record (MAR) sheet revealed the above medications were not documented as administered on April 26, 2025 and April 27, 2025. 4 . A review of R3's medical record revealed a signed medication order dated April 10, 2025, for the following medications: -Calcium 600 MG tablet twice a day; -Vitamin D3 5 MCG tablet twice a day; -Levothyroxine 75 MCG 2 tablets once a day; -Eliquis 5 MG 1 tablet twice a day; -Amlodipine 5 MG tablet once a day; -Atenolol 50 MG tablet twice a day; -Magnesium 400 MG tablet once a day; -Cyanocobalamin 1,000 MCG tablet once a day; -Hydralazine 25 MG tablet three times a day; -Gabapentin 400 MG tablet four times a day; -Tizanidine 4 MG tablet once every eight hours -Levetiracetam 250 MG 3 tablets two times a day; and -Modafinil 100 MG tablet once a day. However, a review of R3's Medication Administration Record (MAR) sheet revealed the above medications were not documented as administered on April 26, 2025 and April 27, 2025. 5 . A review of R4's medical record revealed a signed medication order dated April 10, 2025, for the following medications: -Trazadone 50 MG once a day; -Losartan 100 MG tablet once a day; -Loratadine 10 MG tablet once a day; -Sertraline HCL 50 MG tablet once a day; -Meloxicam 7.5 MG tablet once a day; -Amlodipine 10 MG tablet once a day; -Atorvastatin 10 MG tablet once a day; -Levothyroxine 25 MCG tablet once a day; -Memantine HCL 5 MG tablet once a day; and -Acetaminophen 500 MG tablet twice a day. However, a review of R4's Medication Administration Record (MAR) sheet revealed the above medications were not documented as administered on April 26, 2025 and April 27, 2025. 6 . A review of R5's medical record revealed a signed medication order dated April 14, 2025,

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food or medication contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer did not observe a thermometer placed inside the refrigerator at the facility. 2 . In an interview, E1 acknowledged a thermometer had not been placed inside the refrigerator.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet in a resident bathroom under the sink. The cabinet had magnetic locks. However, the left cabinet magnetic lock was turned off, and the right magnetic lock was not functioning correctly. The Compliance Officer was able to access the following inside the cabinet: -A can of "Scrubbing Bubbles" bathroom cleaner; -A can of "Comet" bleach; and -A bottle of "Arm & Hammer" bathroom cleaner. 2 . In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were accessible to residents

Based on documentation review, the manager failed to ensure a pest control program is implemented and documented. Findings include: 1 . A review of facility documentation revealed documentation of an implemented pest control program was not available for review at the time of inspection. 2 . In an interview, E3 reported E3 had been spraying at the home, and did not have a certification. E1 acknowledged a pest control program was not implemented or documented.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental inspection of the facility with E3, the Compliance Officer observed a opened container of Great Value parmesan cheese and an opened container of Great Value ketchup in the kitchen pantry. These containers stated "Refrigerate after opening". 2. In an interview, E1, E2, and E3 acknowledged the foods were stored in the pantry and required refrigeration.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were 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 with E3, the Compliance Officer observed Great Value glass cleaner, Great Value all purpose cleaner, Comet, and Simple Green unlocked in the cabinet under the kitchen sink. This cabinet had a locking device, however the device was not locked. In addition, the Compliance Officer observed Great Value bleach and Xtra laundry detergent unlocked in the laundry room. The laundry room door had a locking device, however the door was not locked. 2. During an observation, E3 was the only employee at the facility when the Compliance Officer arrived and was not accessing the toxic materials at the time of arrival. 3. In an interview, E1, E2, and E3 acknowledged toxic materials were stored unlocked.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility documents revealed no documentation of a training program for all staff regarding fall prevention and fall recovery. 2. Review of E2's personnel record revealed E2 worked as the facility manager and had a hire date of June 1, 2013. The personnel record did not include documentation showing E2 completed fall prevention and fall recovery training. 3. Review of E3's personnel record revealed E3 worked as a facility caregiver and had a hire date of April 28, 2023. The personnel record did not include documentation showing E3 completed fall prevention and fall recovery training. 4. Review of E4's personnel record revealed E4 worked as a facility caregiver and had a hire date of June 2023. The personnel record did not include documentation showing E4 completed fall prevention and fall recovery training. 5. In an interview, E1 and E2 acknowledged E2, E3, and E4 had not completed a training program for fall prevention and fall recovery.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of three employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... 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..." 2. Review of E3's personnel record revealed E3 worked as a facility caregiver and had a hire date of April 28, 2023. The personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution. 3. Review of E4's personnel record revealed E4 worked as a facility caregiver and had a hire date of June 2023. The personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E4's fitness to work in a residential care institution. 4. Review of the Department of Public Safety (DPS) fingerprint clearance card database on August 21, 2023, revealed E3's and E4's fingerprint clearance cards were valid. 5. In an interview, E1 and E2 acknowledged documentation was not available showing E3's and E4's work references were obtained upon hire at the facility.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB), for one of three employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Review of E4's personnel record revealed no documentation of freedom from infectious TB. Based on E4's hire date, this documentation was required. 2. In an interview, E1 and E2 acknowledged E4 worked as a facility caregiver and did not have current documentation of freedom from infectious TB.

Based on record review and interview, the manager failed to ensure a caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of three caregivers. The deficient practice posed a risk if the employees were unable to meet resident's needs. Findings include: 1. Review of E4's personnel record revealed E4 worked as a facility caregiver and had a hire date of June 2023. The personnel record revealed no documentation showing E4 had received orientation specific to the duties to be performed. 2. In an interview, E1 and E2 acknowledged documentation was not available showing E4 had received orientation specific to the duties to be performed.

Based on documentation review, record review, and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility, for five of five residents. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. Review of Department documentation revealed a change of ownership from AL9096 to AL12574 on June 29, 2023. 2. Review of R1's medical record revealed a residency agreement between R1 and AL9096 prior to the change of ownership. However, an updated residency agreement between R1 and AL12574 was not available for review. 3. Review of R2's medical record revealed a residency agreement between R2 and AL9096 prior to the change of ownership. However, an updated residency agreement between R2 and AL12574 was not available for review. 4. Review of R3's medical record revealed a residency agreement between R3 and AL9096 prior to the change of ownership. However, an updated residency agreement between R3 and AL12574 was not available for review. 5. Review of R4's medical record revealed a residency agreement between R4 and AL9096 prior to the change of ownership. However, an updated residency agreement between R4 and AL12574 was not available for review. 6. Review of R5's medical record revealed a residency agreement between R5 and AL9096 prior to the change of ownership. However, an updated residency agreement between R5 and AL12574 was not available for review. 7. In an interview, E1 and E2 acknowledged R1's, R2's, R3's, R4's, and R5's residency agreements were not updated after the change of ownership. 8. Technical assistance was provided on this Rule in the administrative completeness letter emailed to the facility June 29, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area that 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 the general or specific whereabouts of a resident. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility with E3, the Compliance Officer observed an exit door on the east side of the facility did not have a device that alerted employees to the egress of a resident to the outside area. 3. During an environmental inspection of the facility with E3, the Compliance Officer observed an exit door on the north side of the facility had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not work. 4. In an interview, E1, E2, and E3 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated June 15, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated June 6, 2023. This medication order stated "Citalopram 10mg tablet 1 time a day". 3. Review of R1's medical record revealed an August 2023 medication administration record (MAR). This MAR stated "Citalopram 20mg 1 tab PO QD" and indicated one tab was administered at 8am August 1st - present. 4. During an observation of R1's medications, Citalopram 20mg was observed and one tab was observed prefilled in the "AM" slot of R1's medication organizer. 5. In an interview, E2 reported the medication was administered per the medication organizer and E1 and E2 acknowledged R1's medication was not administered in compliance with the available medication order.