Healing Hearts Assisted Living

Based on record review, documentation review and interview, the manager failed to ensure that a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. § 36-411(C).The deficient practice posed a risk if an employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411.C states: "C. Owners 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. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A review of E1’s, E2's, and E3’s personnel records, revealed an APS Central Registry check was not available for review. 3. An online review of the Arizona Department of Public Safety (DPS) web portal, at https://psp.azdps.gov/services/cardStatusRequest, revealed that E1, E2, and E3 were not on the APS Central registry. 4. In an interview, E1 acknowledged that the manager failed to ensure that a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. § 36-411(C).

Based on record review, documentation review, and interview, the manager failed to ensure that caregiver’s and assistant caregiver’s skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for one of three personnel records reviewed. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of E3’s personnel record revealed no verified skills and knowledge. 2. The Compliance Officer observed E3 was working in the facility during the on-site inspection conducted on August 5, 2025. 3. A review of the facility’s policies and procedures revealed a policy titled, “STAFFING AND WORK SCHEDULE”, which stated, “…EMPLOYEE RECORD KEEPING… 1. The manager shall ensure that for each employee or volunteer, a Personnel Record includes… c) Documentation of the individual’s qualifications, including skills, and knowledge applicable to the individual’s job duties…”. 4. A review of facility documentation revealed a document titled “Assistant Caregiver”, which detailed the job duties for an assistant caregiver. The tasks included preparing meals, preparing grocery lists, cleaning, and assisting the caregiver as needed. 5. In an exit interview, the findings were reviewed with E1. E1 acknowledged the file did not include verification of E3’s skills and knowledge, however, E1 believed the documentation was completed, though unable to be located during the inspection. This is a repeat deficiency from the on-site compliance inspection conducted on January 9, 2023.

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 two 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 and R2’s medical records revealed no initial service plans were available for review. However, based on R1's and R2’s dates of acceptance, completed service plans were required. 2. In an interview, E1 acknowledged service plans for R1 and R2 were not provided for review. E1 reported the service plans were not completed and reported issues with keeping a nurse contracted to complete service plans for the facility.

Based on record review and interview, the manager failed to ensure a resident, receiving directed care services, had a written service plan that was reviewed and updated at least once every three months, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a document titled HEALING HEARTS ASSISTED LIVING DETERMINATION FOR ADMISSION”. The document was signed by a medical provider and stated R2 required directed care services. 2. Further review revealed no service plan available for review. Based on R2’s date of admission, R2 required two service plan updates since admission. No initial or updated service plan was available for review. 3. In an interview, E1 acknowledged the medical record provided for R2 did not include a service plan update at least once every three months.

Based on documentation review and interview, the manager failed to ensure 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 the facility's work schedule revealed the facility had three shifts. 2. A review of facility documentation revealed a disaster drill conducted on each shift, in October 2024, January 2025, and July 2025. No disaster drills from April 2025 were provided for review. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat citation from the on-site complaint inspection conducted on June 6, 2024.

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 one of two sampled residents. 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 initial service plan was available for review. However, based on R1's date of acceptance, a completed service plan was required. 2. In an interview, E1 acknowledged a service plan for R1 was not provided for review. E1 reported the service plan was not completed and the nurse was working on it.

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 two of two resident records reviewed. 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 R1 was receiving medication administration. 2. A review of R1's medical record revealed a signed medication order dated April 11, 202, for the following medications: - "OLANZapine Oral Tablet 5 MG (Olanzapine)", "Give 0.5 tablet by mouth at bedtime ..." and - "trazodone HCI Oral Tablet 50 MG (Trazodone) HCI", "Give 1 tablet by mouth at bedtime". 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated May 2024. The MAR revealed the following medications administered from May 1, 2024 through May 23, 2024, with six exceptions noted when R1 was asleep, refused, or spit out medications: - "Olanzapine Dose: 5mg Give 1 tablet Qhs PO ..." and - "Trazodone Dose: 50mg Give 1 tablet BID PO ...". 4. A review of R2's medical record revealed R1 was receiving medication administration. 5. A review of R2's medical record revealed no signed medication orders. 6. A review of R2's medical record revealed a MAR dated June 2024. The MAR revealed the following medication s were administered from June 3 2024 through June 6, 2024: - Gabapentin 300MG; - Memantine 10MG; - Montelukast 10MG; - Donepezil 10MG; - Tamsulosin .4MG; - Trazodone 50MG; and - Cyanocobalamin 1000MG. 7. In an interview, E1 acknowledged medication administered to R1 and R2 had not been administered in compliance with signed medication orders, though E1 believed newer orders were received for R1, though was unable to provide documentation.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility's work schedule revealed the facility had three shifts. 2. A review of facility documentation revealed a disaster drills conducted on each shift, on February 21, 2024. No other disaster drills were provided for review. 3. In an interview, E1 acknowledged disaster drills were not conducted and documented on each shift at least once every three months.

Based on documentation review and interview, the manager failed to ensure an evacuation drill was conducted at least once every six months. Findings include: 1. A review of facility documentation revealed an evacuation drill conducted on October 2, 2023. 2. In an interview, E1 acknowledged an evacuation drill was not conducted at least once every six months.