From-r-hearts, LLC

Based on documentation review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery which included continued competency training in fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy titled “Policies and Procedures for Fall Prevention Yearly Review,” which stated all caregivers would review the Fall Prevention pamphlet in the policy and procedure notebook yearly, dating and signing it when complete. 2. A review of E2's personnel records revealed E2 had last reviewed and signed the Fall Prevention pamphlet on January 1, 2024. There was no further documentation indicating E2 had received continued fall prevention and fall recovery training since then. 3. In an exit interview, the findings were reviewed with E1. E1 acknowledged E2 had not completed the fall prevention and recovery training program since January 1, 2024.

Based on documentation review and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented and implemented tuberculosis (TB) infection control activities required in R9-10-113.A.2.a-f for two of two personnel sampled. Findings include: 1. A review of E1 and E2’s personnel records revealed annual training and education related to recognizing the signs and symptoms of TB, to include initial training per R9-10-113.A.1, was not available for review. 2. In an interview, E1 acknowledged the health care institution had not documented and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f.

Based on documentation review and interview, the manager failed to establish, document, and implement a quality management program that included a method to identify, document, and evaluate incidents. The deficient practice posed a risk as a quality management program establishes and documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management." This policy stated, "The manager shall ensure that all staff members are oriented to appropriate measures to identify, evaluate, and document all incidents. The manager will evaluate the data collected to identify specific concerns about the delivery of services related to resident care. The manager will evaluate and identify changes or actions necessary to prevent recurrence of the incident…” 2. The Compliance Officer requested the Quality Management report for 2024; however, it was not available for review. 3. During an interview, E1 acknowledged the facility did not have a quality management plan and had failed to establish, document, and implement a quality management plan to identify, collect, and evaluate the methods required in R9-10-804.1.a-e.

Based on documentation review and interview, the manager failed to ensure that documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings Include: 1. The Compliance Officer requested a copy of the employee’s schedules for the month of October 2025; however, no employee schedules were available for review. 2. In an exit interview, E1 reported E1 does not keep an employee schedule and did not have any documentation of a schedule for the entire year of 2025.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one of one resident sampled who received directed care services. Findings include: 1. A review of R2's medical record revealed a service plan updated July 1, 2025 for directed care services. However, no service plan update dated on or before October 1, 2025 was available for review. 2. In an exit interview, the findings were reviewed with E1. E1 reported E1 had written down that R2’s service plan was due November 1, 2025 and had made a mistake.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled who received medication administration. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a service plan, dated July 1, 2025, for directed care services including medication administration. 2. A review of R2's medical record revealed a medication list which included the following: - “Formoterol 12MCG/ Budesonide 0.5MG/ Glycopyrolate37.5MCG: Inhale contents of 1 vial via nebulizer 2 times a day 12 hours apart”. 3. A review of R2's medical record revealed an electronic Medication Administration Record (eMAR) dated November 2025. However, the MAR documented Formoterol was administered at 8am and 5pm between November 1, 2025 and November 4, 2025, and had not been administered 12 hours apart as ordered. 4. In an exit interview, E1 acknowledged medications had not been administered to R2 in compliance with a medication order. E1 stated R2 was usually asleep by 8pm which is why E1 administered the medication earlier than ordered. 5. This is a repeat deficiency from the compliance inspection conduced September 14, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. Findings include: 1. During a tour of the facility, the Compliance Officers observed an unlocked storage shed in the back yard. The yard was surrounded by a chain link fence approximately four feet high and easily climbable. The Compliance Officers were able to open the shed door with little effort. Inside the Compliance Officers observed several manila envelopes, loose papers and three ring binders containing medical records. 2. In an interview, E1 acknowledged the documents were former resident medical records and were stored unsecured, and therefore not protected from loss, damage, or unauthorized use.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted which included the requirements in R9-10-807(B)(1-2) for one of four resident records reviewed. Findings include: 1. A review of R1's medical record revealed a residency agreement which included an acceptance date in the first paragraph. 2. A review of R1's medical record revealed a document titled "Initial Assisted Living Evaluation," which included the requirements in R9-10-807(B)(1-2). However, this document was signed and dated five days after the date documented in R1's residency agreement and was signed by the facility manager. 3. In an interview, E1 acknowledged the Initial Assisted Living Evaluation was not signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant on or prior to acceptance.

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 two of four resident records reviewed. 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 no service plan was available for review. However, based on R1's date of acceptance, a completed service plan was required. 2. A review of R2's medical record revealed no service plan was available for review. However, based on R2's date of acceptance, a completed service plan was required. 3. In an interview, E1 acknowledged a service plan for R1 and R2 was not provided for review because one did not exist. E1 reported experiencing issues with the nurse E1 used for service planning.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which when initially developed and when updated, was signed and dated by: the resident or resident's representative; the manager, for two of four resident records reviewed. Findings include: 1. A review of R3's medical record revealed a service plan update, which noted no changes, dated April 8, 2023. The service plan update included the signature of a nurse and the facility manager, however did not include the required signature of the resident or resident's representative. 2. A review of R4's medical record revealed a service plan update, which noted no changes, dated April 8, 2023. The service plan update included the signature of a nurse, however did not include the required signatures of the resident or resident's representative and the facility's manager. 3. In an interview, E1 acknowledged the service plans were not signed as required by the resident or resident's representative and the manager. E1 reported notifying R3's and R4's representative by phone.

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 one of seven resident records reviewed. Findings include: 1. A review of R1's medical record revealed no signed medication orders. E1 contacted the pharmacy and was able to obtain signed medication orders dated September 14, 2023, which included an order for "Docusate Sodium (Dulcolax Stool Softener) 100MG Oral Capsule, Take 1 capsule (100 MG) by mouth daily as needed". 2. A review of R1's medical record revealed a Medication Administration Record (MAR) dated "Aug 2023" and "Sept 2023." The MAR revealed "Docusate - One by mouth daily", was administered daily at 8 AM from August 7, 2023 through September 14, 2023. 3. In an interview E1 acknowledged the Docusate had been administered as an ordered medication rather than as needed. E1 reported difficulties establishing communication with R1's medical provider. 4. A review of R2's medical record revealed a signed medication order dated August 15, 2023. for "metoprolol tartrate 25 mg oral tablet" to be taken, "PO (oral) q12." 5. A review of R2's medical record revealed a Medication Administration Record (MAR) dated "Aug 2023" and "Sept 2023." The MARs included a section for documenting administration of "metoprolol 25 mg - One by mouth 2x daily." The MARs documented Metoprolol, was administered at "8:00 AM" and "5 PM", less than twelve hours, on August 14, 2023 through September 13, 2023. 6. In an interview, E1 acknowledged medication administered to R1 and R2 had not been administered as ordered.

Based on observation and interview the manager failed to ensure food was stored free from spoilage and was safe for human consumption. Findings include: 1. During a tour of the facility, the Compliance Officer observed the following in the main refrigerator in the facility's kitchen: - a bottle of "Boar's Head Honey Mustard", with a "SELL BY" date of "NOV 30 2019"; - a bottle of "Honey Mustard Dipping Sauce", with a "BEST IF USED BY" date of "12/11/2019"; and - a bottle of "Southwest Hot Mustard", with a "BEST IF USED BY" date of "DEC 22 2020". 2. In an interview, E1 acknowledged the bottles of honey mustard were passed their sell by and best by dates. E1 further reported the mustards belonged to E1 and were not intended for resident consumption, though they were in the unsecured kitchen refrigerator and accessible to residents.

Based on observation, documentation review and interview, the manager failed to ensure that pets allowed in the facility were licensed consistent with local ordinances. Findings include: 1. The Compliance Officers observed four dogs, D1, D2, D3 and D4, were present in the facility throughout the inspection. 2. A review of facility documentation revealed documentation of current Pima County licensure for D1, D3 or D4 was not available for review. 3. In an interview, E1 acknowledged the three dogs were not licensed consistent with local ordinances.

Based on observation, documentation review and interview, the manager failed to ensure that dogs allowed in the facility were vaccinated against rabies. Findings include: 1. The Compliance Officers observed four dogs, D1, D2, D3 and D4, were present in the facility throughout the inspection. 2. A review of facility documentation revealed documentation of current vaccination against rabies for D2, D3 and D4 , however documentation of current vaccination against rabies for D1 was not available for review. 3. In an interview, E1 reported having an appointment scheduled for a mobile veterinarian to come to the facility and vaccinate D1 against rabies. E1 acknowledged D1 was not current with vaccination against rabies.