Give Love Assisted Living, LLC

Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included an annual assessment of the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. A review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that includes the information prescribed in A.R.S. § 36-420.04.A.1-9 for two out of two residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R1 and R2's medical records revealed there was a standardized form to be used if an emergency responder was contacted, however, both forms were missing the following information: pharmacy address; primary care doctor's name; HIPPA release form; and copy of DNR. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, and according to policies and procedures for one of the two employees sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E1's personnel record revealed no documentation of verification of E1's skills and knowledge. 2. A review of the facility's policies and procedures revealed a policy titled, "Verifying Caregiver's Skills and Knowledge" that stated "Before the caregiver provides physical health services or behavioral health services, his or her skills and knowledge are verified and documented. PROCEDURES: 1. The manager will interview and assess the caregiver and test on caregiver skills using an assessment sheet. 2. The manager will make effort to contact the previous employers to inquire about the caregiver's work background and attitude. 3. The manager will put the assessment sheet and information from previous employers in the employee's files." 3. A review of the facility's staff schedule revealed a documented schedule with E1 listed to work everyday for the entire month of September 2025. 4. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy, for two of two residents sampled. The deficient practice posed a potential TB exposure risk to all residents. 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 documentation of an assessment of risk of prior exposure to infection TB and a signs or symptoms screening; however, this documentation was completed more than seven days after R1's date of occupany, Additionally, R1's medical record revelaed documentation of a TB skin test, however the results of this test were not documented. 3. A review of R2's medical record revealed documentation of freedom from infection TB, however, this documentation was completed more than seven days after R2's date of acceptance. 4. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner or registered nurse for two of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1 and R2's medical records revealed no documentation, which included whether R1 and R2 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner or registered nurse. Based on R1 and R2's acceptance date, this documentation was required. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided

Based on observation and interview, the manager failed to ensure that a resident’s medical record was protected from loss, damage, or unauthorized use. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed there were binders of resident records with their names on each binder that were left out on the kitchen counter. 2. In an interview, E1 stated the resident records were always stored out in the open on the kitchen counter. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident’s medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia for two of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1 and R2's medical records revealed no documentation of notification of either resident of the availability of vaccination for flu and pneumonia. Based on R1 and R2's date of acceptance, this documentation was required. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of two residents sampled. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of R1's medical record revealed a service plan for directed care dated July 18, 2025. This service plan revealed no documentation of R1's weight. In addition, R1's medical record revealed no documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided. 3. This is a repeat deficiency from the inspection conducted on February 23, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure that 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 monitored 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. A review of the facility license revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officers observed the sliding door leading to the backyard of the facility had an alarm, however, the alarm did not make a sound whenever the door was opened. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for one of two residents sampled. 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 R1's medical record revealed a signed medication order dated November 2024. This order stated Finasteride 5 mg 1 tab by mouth once daily at bedtime. A discontinued order was not available. 2. A review of R1's September 2025 MAR did not include documentation Finasteride was administered. 3. A review of R1's medications revealed R1's medication organizer contained Finasteride in the slot labeled "morning". 4. In an interview, E3 reported Finasterinde was not administered to R1. The Compliance Officers asked E3 if E3 knew why the medication was in the medication organizer. E3 could not give an explanation, but E3 reiterated that the medication was not administered. 5. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed the posted menu was dated July 1-7, 2025. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed the most current disaster drills were conducted on August 12, 2024 and February 13, 2025. 2. In an interview, E3 reported the facility had one 24-hour shift. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident’s acceptance by the assisted living facility, for one of two residents sampled. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency. Findings Include: 1. A review of R1’s personnel record revealed no documentation of R1's emergency orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident’s acceptance by the assisted living facility. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were in a locked area and were 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 Officers (COs) observed all purpose car detailer cleaner, Pro-Tex truck bed cover protectant spray stored, and Invisible glass cleaner spray stored unlocked in R1's closet. 2. In an interview, E2 and E3 stated the toxic materials belonged to E2 and E3. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of the facility's policies and procedures revealed the most recent documented review was conducted on June 15, 2017. No additional documentation to indicate the policies and procedures were reviewed at least once every three years was available for review. 2. In an interview, E1 acknowledged there was no documentation to indicate the policies and procedures were reviewed at least once every three years.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated February 8, 2024. R1's service plan reflected R1 would be provided assistance with bathing three times per week. Further review of R1's medical record revealed a document titled "Activities of Daily Living" (ADLs). R1's ADL documentation reflected R1 was provided assistance with bathing twice weekly in February 2024. 2. In an interview, E1 reported R1 received bathing assistance twice weekly and acknowledged the ADL documentation did not reflect bathing services were provided to the R1 according to R1's service plan.

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving directed care services included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for two of two directed care residents sampled. Findings include: 1. A review of R1's medical record revealed a current written service plan for directed care services dated February 8, 2024. R1's service plan did not contain documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. A review of R2's medical record revealed a current written service plan for directed care services dated January 3, 2024. R2's service plan did not contain documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 3. In an interview, E1 reviewed R1's and R2's medical records and acknowledged the service plans did not include documentation of the residents' weights or documentation from a medical practitioner stating weighing the residents was contraindicated.