Hacienda De Caring Hands LLC

Based on record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E3's personnel file revealed E3 had been hired in October of 2024. However, documentation of ongoing competency training in fall prevention and fall recovery was not available for review. 2. In an exit interview with E1, the finding was reviewed and no additional information was provided. 3. This is a repeat deficiency from the compliance/complaint inspection conducted on January 17, 2025.

Based on record review and interview, the chief administrative officer failed to ensure tuberculosis infection control activities were implemented, including baseline screening of employees and annual training and education related to recognizing the signs and symptoms of tuberculosis, for two of two sampled employees. Findings include: 1. A review of E3's personnel file revealed E3 had been hired in October of 2024. However, documentation of initial or annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 2. A review of E4's personnel file revealed E4 had been hired as a caregiver in November of 2025. 3. A review of E4's personnel file revealed a baseline screening document; however, the screening form had been left blank, had not been signed by an occupational health provider, did not include answers to the risk assessment or symptom screen questions, and did not include documentation of a test for tuberculosis. 3. A review of E4's personnel file revealed a doctor's note stating E4 did not have active TB. However, this document would only be required if E4 had a negative symptom screen and a positive test for TB, of which E4 had neither available. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance and complaint inspection conducted on January 17, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver documented in a patient's medical record an identification of the patient's need for an opioid before the opioid was administered and the effect of the opioid administered, for one of two sampled residents. Findings include: 1. A review of the facility's policies and procedures, last reviewed by E1 on September 26, 2025, revealed a policy titled "Opioid Prescribing and Treatment." This policy stated, "The caregiver will ask the resident to rate the pain level before administering the medication. After the medication has taken effect, the caregiver will ask again. Both responses shall be documented in the Resident Medical Record." 2. A review of R2's medical record revealed a service plan, updated November 18, 2025, for personal care services including medication administration. The service plan did not indicate R2 had an end of life condition or treatment for an active malignancy. 3. A review of R2's medical record revealed a medication order, dated August 18, 2025, for, "Tramadol HCI 50mg Oral Tablet, 2 tab, PO TID." 4. A review of R2's medical record revealed a medication administration record (MAR) dated January 2026. The MAR indicated R2 had been administered Tramadol three times per day as ordered. However, documentation of R2's need for the opioid medication and documentation of the effect of the opioid medication were not available for review. 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 the manager provided current documentation of first aid training. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3's personnel record revealed E3 had been hired in October of 2024 as the facility manager. 2. A review of E3's personnel record revealed an American Heart Association, "Heartsaver First Aid CPR AED" certification with a marked expiration of June 2025. 3. A review of E3's personnel record revealed an American Heart Association, "BLS Provider" certification with an issue date of June 9, 2025 and marked expiration of June 2027. However, documentation of current first aid training certification was not available for review. 4. In a telephonic interview, E3 reported the American Heart Instructor had advised E3 the "BLS" certification included first aid and stated E3 had taken a course which included both CPR and First Aid training. However, additional documentation from this instructor was not available during the on-site inspection. 5. Online research at the American Heart Association (cpr.heart.org) website revealed the following "frequently asked question" (FAQ): "Q: Do the AHA’s BLS courses include first aid? A: No, first aid is not included in the AHA’s BLS courses. The AHA offers a variety of courses that will prepare you to respond to a first aid emergency, including Heartsaver First Aid, Heartsaver First Aid CPR AED, Heartsaver Pediatric First Aid CPR AED." 6. 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 medical record contained a medication order from a medical practitioner for each medication that is administered to the resident, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, updated July 28, 2025, for personal care services including medication administration. 2. A review of R1's medical record revealed a medication order, dated November 15, 2025, for "Lorazepam 2mg/ml Oral Concentrate, 0.25 ml PO Q4HR PRN." However, R1's medical record contained no more recent orders for Lorazepam. 3. A review of R1's medical record revealed a medication administration record (MAR) dated January 2026. The MAR included documentation of the administration of "Lorazepam 0.5mg take 1 tablet by mouth at bedtime," on each day in January 2026 at 8 PM. 4. A review of R2's medical record revealed a service plan, updated November 18, 2025, for personal care services including medication administration. 5. A review of R2's medical record revealed medication orders, dated August 18, 2025, for "Omeprazole 20mg Oral Tablet, half before breakfast, 1/2 tab, PO, QAM," and "Seroquel 25mg Oral Tablet, 1 tab / 2 tab, PO, 1 tab QAM, 2 tab QHS." R2's medical record contained no more recent orders for Omeprazole or Seroquel. 6. A review of R2's MAR for January 2026 revealed R2 had been administered, "Omeprazole 20 mg 100 mg Take 1 tablet by mouth TID", one time per day at 7:30 AM, and had been administered, "Seroquel 25mg take one tab PO Qam and at Noon, and 2 tablets at dinner time," at 8 AM, 12 PM and 5 PM. 7. A review of R2's medication box and multi-dose container revealed R2 had been administered one 20 milligram Omeprazole tablet each morning, as confirmed by the medication bottle label and the 'pre-poured' pills in the multi-dose container. 8. A review of R1's and R2's medication records revealed change orders for the aforementioned medications were not available for review. 9. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training. Findings include: 1. A review of E3's and E4's personnel records revealed documentation of initial training in fall prevention and fall recovery was not available for review. 2. In an interview, E1 acknowledged E3's and E4's personnel records did not include documentation of initial training in fall prevention and fall recovery.

Based on observation, interview, documentation review, and record review, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1. Upon arriving at the facility, the Compliance Officer observed E4 working at the facility alone. 2. The Compliance Officer observed a posting in the office designated caregivers to be accountable for the facility when the manager was not present. However, E4 was not designated. 3. In an interview, E1 acknowledged E4 had not designated to be accountable for the assisted living facility when the manager was not present.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a documented residency agreement. However, the residency agreement had not been signed and dated by the manager. 2. In an interview, E1 acknowledged the manager had not signed and dated the residency agreement for R2 before or at the time of R2's acceptance.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated September 23, 2024, for personal care services. The service plan did not include hospice services. 2. A review of R2's medical record revealed R2 enrolled with hospice services on November 6, 2024. 3. A review of R2's medical record revealed an updated service plan, dated on or before November 20, 2024, was not available for review. 4. In an interview, E1 acknowledged R2's service plan had not been updated within 14 calendar days after R2 had a significant change in condition requiring hospice services.

Based on record review, and interview, for one of two residents sampled, who received personal care services, the manager failed to ensure a written service plan was reviewed and updated at least once every six months. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 12, 2024, for personal care services. However, an updated service plan, dated on or before December 12, 2024, was not available for review. 2. In an interview, E1 acknowledged a current service plan had not been provided for R1.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0F or below. Findings include: 1. During a facility tour, the Compliance Officer observed the following items requiring refrigeration in the pantry: - two bottles of "Original 100% Pasteurized Orange Juice, No Pulp, Not from Concentrate." The bottles were labeled, "Keep Refrigerated." 2. In an interview, E1 acknowledged foods requiring refrigeration had not been maintained at 41\'b0F or below.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer accurate to plus or minus 3\'b0 F. Findings include: 1. During an environmental inspection of the facility, the Compliance Offices observed that there was a thermometer in the refrigerator in the kitchen. However, the thermometer read -20\'b0 F. 2. In an interview, E1 acknowledged the refrigerator did not contain an accurate thermometer.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers in a locked area and inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the laundry room had been left unlocked. On an open shelf above the washer and dryer, the Compliance Officer observed the following: - a spray can of glass cleaner; - A container of "Quick Shine Hardwood floor luster;" - a spray bottle of "Hop's Perfect Stainless." 2. In an interview, E1 acknowledged poisonous or toxic materials had not been maintained in a locked area and inaccessible to residents.

Based on observation, record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of two employees sampled. 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 the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. The Compliance Officer observed E3 was working alone as a caregiver during the on-site inspection. 4. A review of E3's personnel record revealed E3 had been hired as a caregiver in March of 2024. E3's personnel record included a single TST. However, an assessment of E3's risks of prior exposure to TB and a determination if E3 had signs and symptoms of TB, (Baseline Screening) and a second-step TST were not available for review.. 5. In an interview, E1 acknowledged E3 had not provided documentation of evidence of freedom from infectious TB upon hire as required by R9-10-113.

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed both doors to the office were open and unlocked throughout the on-site survey. Inside the office, the Compliance Officer observed a cabinet containing medi-sets for all residents which had a lock. However, the cabinet was found to have been left unlocked during the on-site inspection. 2. In an interview, E1 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area. This is a repeat deficiency from the on-site complaint inspection conducted on October 10, 2023

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed both doors to the office were open and unlocked throughout the on-site survey. Inside the office, the Compliance Officer observed a medication organizer on a desk containing multiple doses of medication. 2. In an interview, E1 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled who received medication administration. Findings include: 1. A review of R1's and R2's medical record revealed a service plan which included medication administration. 2. A review of R1's and R2's medical record revealed orders for medications to be administered daily. 3. A review of R1's medical record revealed an undated Medication Administration Record (MAR) which was presumably for the month of October 2023. The MAR documented medication had been administered to R1 at 8 a.m .on October 2, 3, and 4, however, the MAR did not document the administration of medications at 8 a.m. on October 1st and did not document the administration of medication at 8 p.m. on October 1, 2, or October 3, 2023. The MAR documented the administration of medications at 5 pm as ordered. 4. A review of R1's medical record revealed an undated MAR which was presumably for the month of September 2023. The MAR included a line through all medications administered on September 24th through September 28th with no written explanation. 5. A review of R1's medical record revealed an unsigned flyer from R1's surgery center which state,d "Surgery date: 09/28/23. Take only these medications the morning of surgery: Carvedilol, Atorvatatin. Hold Metformin, Empagliflozin 3 days prior to surgery. Sacubitril." 6. In an interview, E1 reported R1 was going to have surgery and E1 spoke on the phone with R1's doctors, who advised to hold all medications prior to the inspection. E1 reported R1's transportation was too late on the day of the surgery, so R1 did not end up having the surgery. E1 acknowledged a written order to hold medications had not been obtained. 7. A review of R2's medical record revealed an undated MAR which was presumably for the month of October 2023. The MAR did not document the administration of medication to R2 at 8 p.m. on October 2 or October 3, 2023. 8. In an interview, E1 acknowledged the MAR's for R1 and R2 had not been completely filled out on each shift in October 2023 and acknowledged the pre-surgery medication hold for R1 in September had not been documented.

Based on documentation review, and interview, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe exploitation had occurred on the premises, the manager complied with all of the requirements of this rule, which posed a health and safety risk. Findings include: 1. A review of facility incident reports revealed no incident report regarding the alleged exploitation of R1. 2. A review of facility internal investigations revealed no documented internal investigation of the alleged exploitation of R1. E1 provided a folder which included a partially filled out bank fraud claim form and copies of three checks, a $100 check to a home health aide, a $200 check to an unknown individual, and $135 check to R1's responsible party, dated from June and July of 2023. 3. In an interview, E1 reported R1 had home health services through a third party provider contracted on R1's behalf by the Veteran's Administration. E1 reported the home health agency was providing three showers per week to R1. E1 reported in June 2023, R1 sent one of the home health aides to a store to buy some coffee and other personal items for R1. E1 reported this was unnecessary, as the facility would have assisted R1 to order items if requested, however, E1 reported E1 did not know at that time how R1 had paid for the items. E1 reported in late July or August, R1's responsible party, who also monitors R1's bank account, notified E1 of a suspicious check, written by R1 in July, 2023, for $200 to an unknown person. E1 reported E1 was currently assisting R1 to file a fraud claim with R1's bank to recover the $200, but a notary was required and had not yet been secured. E1 reported E1 did not know R1 had paid the aide with a $100 check to purchase items from the store and did not think R1 had received any change and the items would not have cost $100,so R1 also suspects the aide exploited R1. E1 reported when the check fraud was discovered, R1's responsible party took control of R1's check books to prevent any future occurrence of exploitation. 4. In an interview, E1 acknowledged documentation of the immediate notification of Adult Protective Services or local law enforcement of the suspected exploitation, per A.R.S. \'a7 46-454, had not been provided for review. E1 acknowledged documentation of the suspected exploitation, the action taken to stop the exploitation, and the documentation required by subsection (J)(2) were not available for review. E1 acknowledged the investigation of the suspected exploitation per subsection (J)(2) had not been provided and had not included, within five working days, documentation of the dates, times and a description of the suspected exploitation, a description of any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected exploitation, or the actions taken by the manager to prevent exploitation from occurring in the future.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a hospice document dated May 4, 2023. This document indicated the equipment which had been supplied to R1 by a hospice company had been picked up on May 4, 2023. 2. A review of R1's medical record revealed a service plan, dated January 31, 2023, for personal care services. The service plan stated R1 was receiving hospice services. 3. A review of R1's medical record revealed a service plan update, dated June 10, 2023, for personal care services. The update stated, "[R1] has been stable the past 6 months. [R1] is wheelchair bound. [R1] goes to the VA for [R1's] appointments. [R1] eats 100% of meals. [R1] prefers to stay in [R1's] room and watch TV. [R1] has good family support from [R1's family member] visits weekly. [R1] has [R1's] own cell phone." However, the service plan update was conducted more than 14 calendar days after R1 ended hospice services and failed to state R1 was no longer enrolled with hospice services at the time of the update. 4. In an interview, E1 acknowledged R1's service plan had not been updated within 14 calendar days after R1 stopped receiving hospice services. E1 was not sure when R1 had ended hospice services but agreed it would have been prior to the hospice equipment being picked up.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the manager for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated January 31, 2023 for personal care services. However, the service plan did not include a signature and date from the manager. 2. A review of R1's medical record revealed a service plan dated June 10, 2023 for personal care services. However, the service plan did not include a signature and date from the manager. 3. In an interview, E1 acknowledged R1's service plans did not include a signature and date from the manager.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed each resident had a current service plan describing the services which would be provided by the facility staff to each resident. 2. A review of R1's medical record revealed documentation of services provided to R1 during the month of October 2023 was not available for review. 3. A review of R2's medical record revealed an undated form titled, "Activities of Daily Living Record," (ADL) which was presumably intended to document the services provided to R2 during the month of October 2023. However, the form had only been filled out on October 1, 2023, and indicated R2 had eaten "110%" of breakfast, lunch, dinner, and snack on October 1, 2023. 4. A review of R2's medical record revealed an undated and unlabeled form titled, "Activities of Daily Living Record," which which was presumably intended to document the services provided to R2 during the month of October 2023. The form included three boxes for each day for the staff to initial on each shift indicating they had followed the resident's service plan. However, the form had not been filled out by any shift on October 3, 2023. 5. In an interview, E1 acknowledged the October, 2023 ADLs for each resident had not been completed on each shift. E1 reported an ADL for R1 for the month of October had not been started at the time of the inspection and had been overlooked.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, without the resident's primary care provider or other medical practitioner examining the resident at least once every six months throughout the duration of the resident's condition, reviewing the assisted living facility's scope of services, and signing and dating a determination stating the resident's needs were being met by the assisted living facility, for one of one resident sampled who was unable to ambulate. Findings include: 1. A review of R1's medical record revealed a current service plan dated June 10, 2023 for personal care services. The service plan stated "Functional status: Unable to ambulate." 2. A review of R1's medical record revealed a document titled, "Determination for Admission," which was signed and dated by a medical practitioner the day prior to R1's admission. The form stated R1 was confined to a chair or bed. 3. A review of R1's medical record revealed a document titled, "Determination for Residency to Continue at the Facility," dated at the time of R1's acceptance which included whether the resident's primary care provider or other medical practitioner examined the resident, reviewed the assisted living facility's scope of services, and signed and dated a determination stating the resident's needs could be met by the assisted living facility. However, subsequent documentation dated at least every six months was not available for review. Based on R1's acceptance date, this documentation was required. 4. In an interview, E1 acknowledged the aforementioned documentation was not available for review.