Happy Family Assisted Living LLC

Based on document review, record review, and interview, the health care institution failed to administer a training program that included initial training and continued competency training in fall prevention and fall recovery for one of two personnel sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Orientation and In-Service Training" that states, “Fall prevention and Recovery training is required upon hire and at least every 12 months thereafter.” 2. A review of E3’s personnel record revealed documentation of completed fall prevention and fall recovery training conducted on August 30, 2024. However, E3’s personnel record did not include documentation of additional training on fall prevention and fall recovery. 3. In an exit interview, the findings were reviewed with E1, no additional information was provided.

Based on documentation review, record review, and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section, for four of four residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of R1’s, R2’s, R3’s, and R4’s medical records revealed documentation of an EMS standardized form. However, the forms were not prefilled and were left blank. 3. In an interview, E1 acknowledged that the forms were left blank and did not have any information prefilled. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, interview, documentation review, and observation, the manager failed to ensure that an individual authorized to administer opioids identified the resident's need for an opioid before administering the opioid and monitored the resident's response to the opioid for residents who did not have an active malignancy or an end-of-life condition. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R3’s current service plan, dated October 2, 2025, revealed R3 received personal care and medication administration. The service plan did not indicate whether R3 was on hospice or receiving end-of-life care. 2. In an interview, E1 reported that all residents received medication administration, and there were no residents receiving hospice services. 3. A review of R3’s medication administration record (MAR) for the month of January 2026 revealed R3 received Tramadol 50 mg from January 1, 2026, to present day at 8 am. 4. A review of R3’s January 2026 MAR revealed the order for R3’s Tramadol 50 mg came on October 27, 2025. A review of R3’s signed medication orders revealed an order for Tramadol 50 mg "take one tablet by mouth twice daily as needed”. 5. A review of the facility’s policy and procedures revealed a policy titled, "Medications including Opioids and Narcotics” which stated, “3. Facility personnel will provide opioid medication based on doctor’s orders for regular administration (on a regular basis) and will identify and document the level of pain and/or the resident’s need for the opioid medication. If opioid medication is administered on a PRN basis, at the request of the resident, or upon determination of the pain level and/or need the caregiver will administer or assist the self- administration of the opioid based on the physician PRN written order.” 6. A review of R3’s medical records revealed no documentation of R3's pain level before administering Tramadol 50 mg. 7. The Compliance Officers observed R3’s Tramadol 50 mg pill bottle. The pill bottle was dispensed with 60 tablets, and approximately eight were in the bottle. 8. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for two of two personnel sampled. The deficient practice posed a risk if E2 and E3 were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states, "Each residential care institution, nursing care institution and home health agency 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, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 2. A review of the E3's personnel records revealed documentation of a valid fingerprint clearance card (FPCC). However, there was no documented verification of E3’s FPCC. 3. A review of E2's and E3's personnel records revealed no documentation verifying that they were not on the adult protective service registry. 4. In an exit interview findings were discussed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of four residents sampled. The deficient practice posed a TB exposure risk to 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 R4's medical record revealed no documentation of the individual’s freedom from infectious TB, a risk assessment of prior exposure to infectious TB or a determination if R4 had signs or symptoms of TB. A further look into R4’s medical records revealed signed orders dated December 24, 2025. These orders stated, “Tuberculin PPD Solution Step 2… ‘Document under the immunization Tab’” The immunization tab was unable to be viewed at the time of the inspection and R4’s TB results was not given to the Compliance Officers at the time of the inspection. Based on R4's date of acceptance, this documentation was required. 3. In an exit interview, the findings were reviewed with E1, 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 the assisted living facility, and if an individual was expected to receive supervisory care services, personal care services, or directed care services, the documentation included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for two of four 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 R4's medical record revealed there was no admitting documentation to indicate R4's expected level of care that included whether R4 required continuous medical services, continuous or intermittent nursing services, or restraints, and that was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan included the level of service the resident was expected to receive, for one of four residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R4's medical record revealed a current service plan dated December 25, 2025. The service plan did not include the level of service R4 received. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that, when updated, was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for one of four residents sampled. The deficient practice posed a health and safety risk if the required individual did not acknowledge the services that were to be provided. Findings include: 1. A review of R4’s medical record revealed a service plan dated December 25, 2025. This service plan indicated R4 received medication administration. However, this service plan did not include a signature and date by the manager and a nurse or medical practitioner. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that a resident’s medical record contained a medication order from a medical practitioner for each medication that was administered to the resident for one of four residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R4’s medical record revealed a service plan dated December 25, 2025. This service plan indicated R4 received medication administration. 2. A review of R4’s medication administration record (MAR) for January 2026 revealed Tamsulosin 0.4 mg was administered January 1, 2026 to present day at 8:00 am. 3. A review of R4’s medical record did not include an order for Tamsulosin 0.4 mg. 4. The Compliance Officers observed Tamsulosin 0.4 mg was prefilled in R4’s medication organizer. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for one of four residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R4's medical record revealed a current service plan dated December 25, 2025. This service plan indicated R4 received medication administration. 2. A review of R4’s medication administration record (MAR) for January 2026 revealed the following: - Furosemide 40 mg was administered January 1, 2026 to January 13, 2026 at 8:00 am and 6:00 pm; and - Amlodipine 2.5 mg was administered January 1, 2026 to January 19, 2026 at 12:00 pm. However, documentation of additional administrations, was not available. 3. A review of R4’s medical record revealed the following signed orders dated December 24, 2025: - Furosemide 40 mg tablet give 1 tablet by mouth two times a day, - Amlodipine 2.5 mg give 1 tablet by mouth in the afternoon. 4. In an interview, E1 reported Furosemide 40 mg and Amlodipine 2.5 mg were discontinued, however, discontinue orders were not available at the time of inspection. 5. The Compliance Officers observed Furosemide 40 mg and Amlodipine 2.5 mg in R4’s medication organizer. 6. In an exit interview, the findings were reviewed with E1 and no additional information was provided.