Happy Hearts Assisted Living

Based on documentation review, observation, and interview, the manager failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411, for one of two personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411 states, "A... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work..." 2. Review of E2’s personnel record revealed an expired fingerprint clearance card. The expiration date was December 2, 2025. 3. The Compliance Officer observed E2 working at the time of inspection and would occasionally go into a resident’s room without supervision from the other personnel. 4. Review of the Arizona Department of Public Safety (DPS) web portal at https://psp.azdps.gov/services/cardStatusRequest revealed an invalid fingerprint clearance card for E2. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. Review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed ambulatory residents. 3. The Compliance Officer observed a 500 caplets bottle of Acetaminophen 500 mg in R3’s bedroom drawer. 4. Review of the facility policies and procedures revealed a policy titled, “Part II- Receiving, Storing Medication” Which stated, “1. All Resident medications brought to the facility will be received by the Caregiver on duty who will then check contents of the medication.” 5. Review of the R3’s current service plan dated December 2025 revealed R3 received personal care services and medication administration. In the service plan, there is no mention of storing medication in R3’s bedroom. 6. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed ambulatory residents. 3. The Compliance Officer observed the garage door unlocked. When walking through the garage door the following toxic materials were observed: - A tub of Oxi Clean odor blasters - A spray can of Flying insect killer - A bottle of 511 H20+ Sealer - A squeeze bottle of Mapesil T plus silicone caulk. 4. Review of the facility policy and procedures revealed a policy titled, “Environmental and Physical Plant Safety, includes Pest Control Program,” which stated, “16. Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dining areas, and medications and inaccessible to residents,” 5. In an exit interview, the findings were reviewed with E3, and no additional information was provided. This is a repeat deficiency from the inspections conducted on January 31, 2023 and July 1, 2024.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for one of two residents sampled. The deficient practice posed a risk if services provided could not be verified. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed no signed medication order or verbal medication order for Hydrochlorothiazide 12.5 mg. 3. A review of R1's medical record revealed a medication administration record (MAR). However, Hydrochlorothiazide 12.5 mg was not listed on the MAR. 4. During an observation of R1's medication, Hydrochlorothiazide 12.5 mg was observed. 5. In an interview, E1 acknowledged R1's medical record did not contain a medication order from a medical practitioner for each medication that was administered.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of two residents reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 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. Review of R2's medical record revealed no documentation showing the pneumonia vaccination was offered or received. Based on R2's acceptance date, this documentation was required. 3. During an interview, E1 acknowledged R2's medical record did not include current documentation showing the pneumonia vaccination was offered or received.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were stored 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. The Compliance Officer observed ambulatory residents in the facility. 2. The Compliance Officer observed toxic materials stored in unlocked cabinets below the kitchen sink. The list provided was a sampled list of the toxic materials: - Clorox spray bottle - Lysol All Purpose Cleaner spray bottle - Lemon Pledge spray canister - Clorox wipes - Glass Cleaner spray canister - Lysol Lime & Rust Toilet Bowl Cleaner - Spic and Span Everyday spray bottle - Stainless Steel Cleaner & Polish spray canister 3. The Compliance Officer observed a spray bottle of Wax & Dry in the backyard of the facility. 4. The Compliance Officer observed a Glade spray canister in a resident bathroom. 5. A review of the facility's policy and procedures revealed a policy titled, "Environmental and Physical plant safety" that stated, "Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation areas, dining areas, and medications and are inaccessible to residents." 6. In an interview, E1 acknowledged poisonous or toxic materials were stored unlocked and were accessible to residents. This is a repeat deficiency from the compliance inspection conducted January 31, 2023.