Family Loving Kare Foothills

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery, to include initial training and continued competency training, for one of two sampled staff. Findings include: A review of the facility's policies and procedures revealed a policy titled "FLK Fall Precautions," and a policy titled "When an elderly falls." These policies covered fall prevention and fall recovery; however, they did not include initial training and continued competency training requirements. A review of the facility's Fall Prevention and Fall Recovery training records revealed a form titled "Skills Training Employee Review," located in the policy and procedure manual, which contained signatures of personnel between 2015 and 2026. However, E2's signature was not included. In an interview, E1 reported the "Skills Training Employee Review" form and signatures indicated training in multiple skills. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two sampled employees. Findings include; A review of E2's personnel record revealed a form titled "Employee Checklist." This form stated E2's hire date was October 27, 2025 and stated E2's "Start Date Supervised Training:" was October 27, 2025. A review of E2's personnel record revealed a copy of a fingerprint clearance card with an issue date of January 5, 2026. Online verification of E2's fingerprint clearance care revealed the card was valid, and had an application date of December 11, 2025, more than 20 working days after E2's date of hire. A review of E2's personnel record revealed documentation of verification of the status of E2's fingerprint clearance card was not available for review. A review of E2's personnel record revealed documented, good faith efforts to contact E2's prior employers was not available for review. A review of E2's personnel record revealed documentation of verification E2 was not on the Adult Protective Services Registry prior to E2's date of hire was not available for review In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review, record review and interview, the manager failed to ensure an assistant caregiver received orientation specific to the duties to be performed by the assistant caregiver, before providing assisted living services to a resident, for one of two sampled personnel. Findings include; A review of the facility work schedule revealed E2 was not on the work schedule. A review of R2's time cards revealed R2 had worked from approximately 7 AM until approximately 7 PM on February 9, 14,15, 16, 21, 22, 23, 28, and March 1, 2026. A review of R2's personnel record revealed R2 had been hired as an assistant caregiver on October 27, 2025. A review of R2's personnel record revealed a form titled "Employee Orientation." However, the form was blank. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a patient's medical record included documentation of an identification of the patient's need for an opioid before the opioid was administered and documentation of the effect of the opioid administered, for one of two sampled residents. Findings include: 1. A review of the facility's policies and procedures revealed a "pain medication" policy, which stated, "Staff members who are authorized to administer pain mediation: 1. Must be an employee of Family Loving Kare. 2. Must be a Certified Care Giver. 3. Must have signed off on acknowledgement of SOP for Pain Management. 4. Must have demonstrated successfully the skill set to administer medications safely utilizing the 6 rights of Medication Administration. 5. Must assess all residents for pain when taking daily vital signs at the beginning of their shift and as needed throughout their shift. 6. Must assess by using the guide as mentioned on page 1, "General Principles of Pain Assessment." 7. Must refer to the Resident's specific Care Plan to determine the course of action for Pain Relief. 8. Must document in QuickMar if Medication was provided an provide a pain value. 9. Must document in QuickMar 1 hour post administration if Medication was successful in providing relief." 2. A review of R1's medical record revealed a service plan, dated December 1, 2025, for personal care services including medication administration. 3. A review of R1's medical record revealed a list of medication orders, dated December 11, 2025, which include the following opioids: "Methadone HCL 10 MG/ML CONC, Give one bottle (11.5 equal to 115mg) Morphine oral solution by mouth every morning...Schedule Daily at 08:00."; and "Oxycodone HCL 5 MG Tablet, take 1 tablet by mouth daily as needed for pain." 4. A review of R1's medical record revealed a medication administration record (MAR) dated November 2025. The MAR documented the following: Methadone had been documented as administered to R1 daily at 8:00 AM. However, documentation of R1's need for the opioid medication and monitoring of the effect of the opioid were not available for review. Oxycodone had been documented as administered on nine days during November, 2025. However, R1's pain value at the time of administration had not been documented. Instead, the documentation included the statements, "Pain 3-7," "Pain 7+," "LBP," and, "leg pain." 5. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's service plan was signed and dated by the medical practitioner or behavioral health practitioner who reviewed the service plan, for one of one sampled residents who required behavioral care. Findings include: 1. A review of R1's medical record revealed a service plan, updated December 1, 2025, for personal care including behavioral care. However, the service plan was not signed and dated by the medical practitioner or behavioral health practitioner who reviewed the service plan. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation, 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 two sampled residents. Findings include: 1. During an environmental inspection of the facility, at approximately 10:30 AM, the Compliance Officer observed R1 was alone in R1's bedroom. Upon entering the bedroom, the Compliance Officer observed R1 was sitting in a recliner with a tray table in front of R1. On the tray table, the Compliance Officer observed a clear plastic cup containing approximately 10 tablets, and a bottle of liquid methadone. 2. A review of R1's medical record revealed a service plan, dated December 1, 2025, for personal care services including medication administration. The service plan stated the following: "Opioid Use Disorder - Managed by Methadone HCL 10mg/1ml oral concentrate 11.5mL - 115mg PO daily. Staff to monitor s/s of opiate overdose. [R1] is transported to [a behavioral health outpatient clinic] every other Wednesday via transportation provided by [ALTCS plan]. [R1] receives Wednesday dose of Methadone from [a behavioral health outpatient center] and is given 13 days' worth of Methadone to bring home. Staff to count and lock up Methadone when [R1] arrives back home." "Medication: Always stored in locked cabinet. Administration: takes with water Management: Care Givers and manager order medications through Pharmacy." 3. A review of R1's medical record revealed a list of medication orders, signed and dated December 11, 2025. This list included the following orders: "Methadone 10MG/ML Conc - give one bottle (11.5 equal to 115mg) Morphine oral solution by mouth every morning (Bottles are pre measured and packaged by [a behavioral health outpatient clinic). Schedule: Daily at 08:00."; "Amlodipine Besylate 10 MG TAB, Take 1 tablet by mouth daily for HTN **hold for SBP less than 110**. Schedule: Daily at 08:00."; "Clonidine HCL 0.1 MG Tablet, take 1 tablet by mouth every 12 hours for HTN **hold for SBP less than 110**. Schedule: Daily at 08:00, Daily at 20:00"; and "Propranolol 40 MG Tablet, Take 1 tablet by mouth every afternoon for HTN **Hold if SBP less than 110 or Pulse less than 60** Schedule: Daily at 17:00." 4. A review of R1's medical record revealed a medication administration record (MAR) dated November 2025. The MAR indicated all morning medications were administered at 8 AM. The MAR indicated methadone had been administered at 8 AM on every day in November 2025, including every other Wednesday when the medication was not administered by the facility. The MAR indicated Amlodipine had been administered on every day in November 2025 and not been held at any time. The MAR included vitals at 6:00 AM and 6:00 PM each day and did not include vitals at 8:00 AM each day. 5. In an interview, E1 reported the staff use the 6:00 AM blood pressure readings for the medication parameters at 8:00 AM. 6. A review of R1's November 2025 MAR reveal

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were established and implemented for inventorying controlled substances. Findings include: 1. A review of the facility's policies and procedures revealed a medication policy which stated: "Controlled medication and how to document it. All controlled medications will be locked up in the medication cabinet. The Controlled medications will be in a separate basket or bin or storage container from the other resident's scheduled medications. There will be a log called the Narc Log. In this log the oncoming employee will do a medication count and write that in the appropriate Column and then sign taking full responsibility of that medication and the count. The off going employee will also sign agreeing to the count and relinquishing the medications to the oncoming employee. No controlled medication will be stored by a resident at our facility. All if any errors happen all employees are subject to random drug test if management deems it necessary. (sic)" 2. A review of R1's medical record revealed a service plan, dated December 1, 2025, for personal care services including medication administration. 3. A review of R1's medical record revealed a list of medication orders, dated December 11, 2025, which include the following opioids: "Methadone HCL 10 MG/ML CONC, Give one bottle (11.5 equal to 115mg) Morphine oral solution by mouth every morning...Schedule Daily at 08:00."; and "Oxycodone HCL 5 MG Tablet, take 1 tablet by mouth daily as needed for pain." 4. A review of the facility work schedule revealed the facility worked on two shifts per day, with shift changes at 7 AM and 7 PM. 5. A review of R1's medical record revealed an electronic log titled "$(Shift Change) History Log," This log included the date and time, if there was an issue, the filter for controlled medications, and the names of both personnel who counted the medications. The log was dated between November 23, 2025 and December 17, 2025, and included only 22 entries. However, the log did not include a count. Additionally, the log skipped the following entries: November 26, 2025 at 7 PM; November 27, 2025 at 7 AM; November 27, 2025 at 7 PM; November 28, 2025 at 7 AM; November 28, 2025 at 7 PM; November 29, 2025 at 7 AM; November 29, 2025 at 7 PM; November 30, 2025 at 7 AM; November 30, 2025 at 7 PM; December 1, 2025 at 7 AM; December 3, 2025 at 7 AM; December 3, 2025 at 7 PM; December 4, 2025 at 7 AM; December 4, 2025 at 7 PM; December 5, 2025 at 7 AM; December 5, 2025 at 7 PM; December 6, 2025 at 7 PM: December 10, 2025 at 7 PM; December 11, 2025 at 7 AM; December 11, 2025 at 7 PM: December 12, 2025 at 7 AM; December 12, 2025 at 7 PM:' December 12, 2025 at 7 AM; December 12, 2025 at 7 PM: December 13, 2025 at 7 AM; December 13, 2025 at 7 PM; December 14, 2025 at 7 AM; December 14, 2025 at 7 PM; and December 15, 2025 at 7 AM. 6. In an interview, the Compliance Officer asked how t

Based on documentation review and interview, the manager failed to ensure an incident report was generated when a resident had an accident, emergency, or injury resulting in the resident needing medical services. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. A review of R1's medical record revealed a medication administration record (MAR) dated November 2025. The MAR included twice daily vital documentation. The vitals record included the following records: On November 5, 2025 at 6:00 PM, R1's blood pressure was documented to have been 191/81; On November 9, 2025 at 6:00 PM, R1's oxygen saturation percentage was documented to have been 70%; and On November 13, 2025 at 6:00 AM, R1's blood pressure was documented to have been 197/101 and R1's oxygen saturation percentage was documented to have been 73%. 2. During the on-site inspection, the Compliance Officer requested to review documentation of R1's hypertensive crisis per R9-10-819(D). However, no additional documentation was available for each incident. 3. In an interview, E1 reported E1 believed the high readings were being caused by a wrist cuff that was not being used any longer. However, E1 was not able to provide any documentation of a follow up blood pressure check with a different device or other documentation of the emergency and the actions taken at the time. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided..

Based on documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure to cover fall prevention and fall recovery. However, the policy did not include initial training and continued competency training in fall prevention and fall recovery. 2. A review of E1's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 3. In an interview, E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

Based on record review, documentation review, and interview, the manager failed to ensure caregivers had the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. Findings include: 1. Upon arriving at the facility, the Compliance Officer observed E3 was the only staff member present at the facility. The Compliance Officer observed three residents were present at the facility. Two residents were observed to be non-ambulatory and using ventilators and the third resident was mobile with a power chair and was using a nasal cannula for supplemental oxygen. 2. In an interview, E3 reported E3 was not a nurse. E3 reported the nurse, E1, usually arrives at around 10 a.m. each day. 3. A review of the facility work schedule revealed the work schedule did not include E1. 4. A review of R1's medical record revealed a service plan, dated August 7, 2023, for personal care services including, "Hypoxia - managed by vent LTV1150, 2lpm O2 550 volume, peep 5, respirations 15, inspiration time 1 sec. high pressure 45 low pressure 10: Resident oxygen saturation monitoring 24/7 via pulse oximeter to keep O2 sat above 92, staff to respond to alarms, assess the resident, suction appropriately, and provide ordered breathing treatments, [R1] continues to be on the vent 24/7 due to respiratory status, seems to be declining, immune system weakening, and energy level declining. Increase PEEP on the Vent seems to provide [R1] with more energy and not having to work to breath on [their] own." 5. In an interview, E1 reported E1 is a nurse. E1 reported E1 is on call at all times and is usually on-site from about 10 a.m. to about 5 p.m. during the week. E1 reported E1 lives about 15-20 minutes away and does have a bedroom at the facility to stay if needed. E1 reported the licensee is also nurse and also maintains a residence at the facility. E1 acknowledged two of the residents needed continuous nursing services due to requiring a ventilator and acknowledged a caregiver with the nursing qualification to provide continuous nursing services was not present at the facility when the Compliance Officer arrived at the facility.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a bathroom adjacent to the office was open and unlocked during the survey. Inside the bathroom, the Compliance Officer observed a cabinet below the sink did not have a lock. Inside the cabinet, the Compliance Officer observed a container of, "Clorox toilet bowl cleaner with bleach," and a spray can of, "Scrubbing Bubbles." 2. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the counter in the kitchen had a magnetic lock, however, the lock was not engaged and the Compliance Officer was able to open the cabinet without a magnet. Inside the cabinet, the Compliance Officer observed two containers of "Soft scrub." 3. During an environmental inspection of the facility, the Compliance Officer observed the door to the garage was not locked. Inside the garage, the Compliance Officer observed a container of, "Combat Max Roach Killing Gel," on a shelf. 4. During an environmental inspection of the facility, in a back room, the Compliance Officer observed five containers of paint stacked on the floor by the exit door. 5. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents.