Heavenly Assisted Living Facility

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of E1’s and E2’s personnel records revealed initial and/or current annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 2 . A review of facility documentation revealed an annual assessment of the health care institution's risk of exposure to infectious tuberculosis was not available for review. 3. In an interview, E1 acknowledged the health care institution had not documented, and implemented tuberculosis infection control activities as required in R9-10-113.A.2.a-f. Technical assistance was provided during the on-site compliance inspection conducted on May 22, 2024.

Based on observation and interview, the manager failed to ensure there was a current drug reference guide that was available for use by personnel members. Findings include: 1. During the environmental tour, the Compliance Officer observed that the facility provided medication administration services. 2. The Compliance Officer requested a current drug reference guide. However, the provided reference guide was published in 2012. 3. In an interview, E1 acknowledged that the facility did not have a current drug reference guide available for use by personnel members. Technical assistance for this rule was provided during the on-site compliance inspection conducted on May 22, 2024

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed E2 at the facility, providing services to residents, such as administering medications and operating a Hoyer lift. 2. A review of the facility's personnel schedule revealed E2 was not on the work schedule. The work schedule indicated E1 and E3 worked the 7AM to 7 PM shift, and revealed E1 and E4 worked the 7 PM to 7 AM shift, between March 16, 2025 and the day of the inspection. 3. In an interview, E1 reported E4 has not been employed by the facility for some time and reported the work schedule was not accurate. E1 reported E2 had just started working the day of the inspection. E1 acknowledged the facility failed to maintain documentation of the caregivers and assistant caregivers working each day, including the hours worked by each.

Based on observation, record review, and interview, the manager failed to maintain a personnel record for each employee which included the items required by this rule, for one of two personnel sampled. The deficient practice posed a risk as required information could not be verified for an employee. Findings include: 1 . The Compliance Officer observed E2 working in the facility as a caregiver, providing medication administration and operating a mechanical lift without supervision. 2. In an interview, E1 reported E2 had started working as a caregiver on the day of the on-site inspection. 3. A review of E2's personnel record revealed the following documentation was not available for review: E2's and contact telephone number; E2's starting date of employment; E2's skills and knowledge applicable to the E2's job duties, to include verification of E2's skills and knowledge; E2's completed orientation and in-service education required by policies and procedures, to include fall prevention and fall recovery training; E2's evidence of freedom from infectious tuberculosis, as E2's personnel record included a negative blood test from 2023 and did not include a risk assessment, symptom screen, or current test; Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C), to include documented good faith attempts to contact prior employers or verification of the current status of E2's fingerprint clearance card. 4. In an interview, E1 reported they thought they had some time after hiring a caregiver to get the personnel file together. E1 acknowledged E2's personnel record did not include all required documentation.

Based on record review and interview, the manager failed to ensure a written service plan included the level of service the resident is expected to receive, for one of two residents sampled. Findings include: 1 . A review of R2's medical record revealed a service plan dated January 5, 2025 for directed care services. However, a current service plan, dated on or before April 5, 2025 was not available for review. 2 . In an interview, E1 reported R2 was actually personal care, the service plan was not accurate, and a service plan update was not yet due. E1 acknowledged R2's service plan had not included the level of service the resident was expected to receive.

Based on record review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled 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: A review of R1's and R2's medical records revealed R1 and R2 received directed care services. During an environmental tour of the facility, the Compliance Officer observed the sliding back door to the patio and a rear exit door in a bathroom past the laundry room were equipped with an alarms to alert employees of egress; however, the alarms were not functional at the time of the inspection. In an interview, E1 reported the door alarms were wired to the home alarm system, and E1 would need to contact the alarm company to come out and service the alarms. E1 reported E1 would obtain additional alarms right after the survey if the alarm system could not be repaired immediately. E1 acknowledged that the facility provided directed care services and there was an uncontrolled means for a resident to exit or egress from the facility without alerting a caregiver.

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 one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. 1 . A review of R2's medical record revealed a service plan, dated January 5, 2025, for directed care services including medication administration. 2 . A review of R2's medical record review revealed a prescription dated February 21, 2025 for, "Quetiapine 25 mg tab, 1 tab po Q 2x day". 3 . Further review of R2's medical record revealed a medication administration record (MAR) sheet for April 2025 . The Mar included documentation of, "Quetiapine 25 mg tabs, take 1 tab by mouth QHS." However, the medication was documented to have been administered once a day instead of twice a day per the order, and the MAR did not include documentation of any medication administered between April 15 and April 21, the day of the on-site inspection. 4 . In an interview, E1 acknowledged R2's medical record did not contain accurate documentation of Quetiapine administration. This is a repeat deficiency from the on-site compliance inspection conducted on May 9, 2023 and the on-site compliance inspection conducted on May 22, 2024.

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 R1's medical record revealed a documented residency agreement. However, the residency agreement had been signed and dated by the manager seven days after R1's date of acceptance. 2. A review of R1's medical record revealed a medication administration record (MAR). The MAR documented medication had been administered to R1 for seven days before the date of the manager's signature on R1's residency agreement. 3. In an interview, E1 acknowledged the manager had not signed and dated the residency agreement for R1 before or at the time of R1's acceptance.

Based on observation and interview, the manager failed to ensure a current calendar of activities was posted. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a current calendar of activities was not posted in a location easily seen by residents. 2. In an interview, E1 acknowledged the current calendar of activities was not posted in an area designated for resident use.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated February 7, 2024, for personal care services, including medication administration. 2. A review of R1's medical record revealed a list of medication orders, dated April 1, 2024 , which included: - "Ferrous Sulfate 324mg: Give 1 tab by mouth every Monday, Wednesday, and Friday morning"; - "Fluticasone 50 mcg NAS Sp: Give 1-2 Sprays into each nostril every morning"; - "Colace 100 mg: Give 1 Capsule PO BID As needed for Constipation"; - "Senna 8.6 mg Tab Give 1 Tab by mouth BID PRN." 3. A review of R1's medical record revealed a medication administration record (MAR) dated May 2024. The MAR indicated the following: - "Ferrous Sulfate, 324 mg tab, Give 1 tab by mouth every Monday, Wednesday, and Friday morning," had been administered every day between May 1, 2024 and May 22, 2024; - "Fluticasone 50 mcg NAS SP, Give 1-2 Sprays in to each nostril every morning," had been marked as administered every day between May 1, 2024 and May 22, 2024, however, the amount provided had not been documented; - "Colace 100 MG, Give 1 Capsule PO BID as needed for constipation," had not been administered in May 2024; and - "Senna 8.6 mg Tab, 1 Tab PO BID PRN," had not been administered in May 2024. 4. The Compliance Officer observed a medication organizer for R1 contained the following: - Ferrous Sulfate was not present in R1's; - Colace was in every AM section; and - Senna was in every AM section. 5. In an interview, E1 acknowledged R1's orders, MAR, and medication organizer could not be reconciled and R1 had not been administered medication in compliance with a medication order. E1 reported R1's responsible party had just provided the new bottle of Ferrous Sulfate and it had not been added to the organizer yet, and reported R1 had been requesting the Colace and Senna every morning, which is why they had been added to the organizer even though they were not scheduled medications.

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 the door to the office had a lock. However, the key had been left in the lock, leaving the office accessible to residents. Inside the office, the Compliance Officer observed a cabinet containing medi-sets for all residents, medications on open shelving, and a refrigerator containing unsecured medications stored alongside food items. 2. In an interview, E1 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area used only for medication storage. This is a repeat deficiency from the on-site compliance inspection conducted on May 9, 2023

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. The deficient practice posed a potential residents' rights violation if residents were not treated with dignity, respect, or consideration. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a food menu was not posted conspicuously. 2. In an interview, E1 reported the menu had been moved into the office while the door the menu is normally posted on was painted. 3. The Compliance Officer observed the menu posted in the office, an area not designated for resident use, was dated May 11 through May 18, 2024. 4. In an interview, E1 acknowledged a food menu had not been conspicuously posted at least one calendar day before the first meal on the food menu was served. This is a repeat deficiency from the on-site compliance inspection conducted on May 9, 2023.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas 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 Officer observed a cabinet located in a bathroom adjacent to the laundry room had a lock, however, the cabinet was found to be unlocked during the inspection. Inside the cabinet, the Compliance Officer observed the following: - "Performance Plus Stainless Steel Cleaner;" - "Shout" laundry stain remover; - "Carbona Outdoor Cleaner;" - "Easy Off;" - "Miracle Spray for Electronics;" and -"Lemon-D Neutral Cleaner." 2. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on May 9, 2023.

Based on observation, documentation review, and interview, the manager failed to designate, in writing, a caregiver who was present on the facility's premises and accountable for the facility when the manager was not present. Findings include: 1. Upon arriving at the facility, the Compliance Officer observed the manager was not present. The Compliance Officer observed E2 and E3 were present at the facility. 2. A documentation review of the facility work schedule revealed three caregivers, E2, E3, and E4, had worked alone at the facility during the month of April 2023. 3. A documentation review of the facility's written designations revealed E2, E3, and E4 were not designated to be accountable for the facility when the manager was not present. 4. In an interview, E1 acknowledged E2, E3, and E4 had not been designated to be accountable for the facility when the manager was not present. Technical assistance for this rule was provided during the on-site compliance inspection conducted on May 18, 2022.

Based on record review, documentation review, and interview, the manager failed to ensure for two of two sampled personnel, before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification. Findings include: 1. A review of E2's personnel record revealed E2 was hired as a caregiver in May of 2020. 2. A review of the facility work schedule revealed E2 worked on the 7 a.m. to 7 p.m. shift on April 23, April 26, April 27, April 28, and April 29, 2023. 3. A review of E2's personnel file revealed an in-person CPR and First Aid card issued on April 24, 2021 with a marked expiration of April 2023. 4. A review of E3's personnel file revealed E3 was hired as a caregiver in January of 2021. 5. A review of the facility work schedule revealed E3 worked on the 7 a.m. to 7 p.m. shift on April 24, April 25, April 26, and April 27, 2023. 6. A review of E3's personnel file revealed an online CPR and First Aid card issued on January 31, 2021 which stated, "Valid for 2 years." 7. In an interview, E1 acknowledged E2's and E3's personnel files did not contain documentation of current first aid training and CPR training certification.

Based on documentation review and interview, the manager failed to establish and document a plan as part of the required policies and procedures to ensure the manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. Findings include: 1. A review of caregiver schedules revealed no manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. 2. A review of the facility's "Policy and Procedures Manual" with a last reviewed date of, "9/10/18/2019/2020/2021/22," revealed a policy titled, "Staffing and Work Schedule." However, the policy did not include a plan to ensure the manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. 3. In an interview, E1 acknowledged the policy and procedure manual provided for review did not include a plan to ensure the manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. This is a repeat deficiency from the on-site compliance inspection conducted on May 18, 2022.

Based on observation and interview, the manager failed to ensure a calendar of planned activities was prepared at least one week in advance of the date the activity was provided. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a calendar of planned activities dated April 15th through April 21st, 2023. However, a calendar of planned activities for the week of May 7th, 2023, was not posted. 2. In an interview, E1 acknowledged the facility had not posted a calendar of planned activities prepared at least one week in advance.

Based on observation 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 a bottle of "Phillips Milk of Magnesia," in an unlocked refrigerator in the kitchen. The medication was stored in the door of the refrigerator along with food items. 2. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on observation and interview, the manager failed to ensure 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 Officer observed a posted food menu, dated April 15, 2023 - April 21, 2023. 2. In an interview, E1 acknowledged a current menu had not been posted.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the hot water temperature measured at 125.7\'b0 F in a shared bathroom adjacent to the living room. 2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95 \'b0F and 120 \'b0F.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a shared bathroom located adjacent to the living room. The Compliance Officer observed a cabinet inside the bathroom was not locked and contained a spray bottle of "Sprayway Glass Cleaner." 2. In an interview, E1 reported the bathroom is used by staff and is kept locked. E1 reported the lock does not require a key and E1 unlocks the door with their fingernail. 3. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the kitchen sink did not have a lock. Inside the cabinet, the Compliance Officer observed a spray bottle of "Great Value Glass Cleaner," and a spray can of, "Walker Chemical Oven & BBQ Heavy Duty Foaming Oven Cleaner." 4. During an environmental inspection of the facility, the Compliance Officer observed a cabinet located in a bathroom adjacent to the laundry room had a lock, however, the cabinet was found to be unlocked during the inspection. Inside the cabinet, the Compliance Officer observed the following: - "Walker Chemical Blast Off Heavy Duty Toilet Bowl Cleaner;" - "Shout" laundry stain remover; and - "Chemcor Protector;" 5. During an environmental inspection of the facility, the Compliance Officer observed a spray bottle of, "Spectracide Weed and Grass Killer" on top of the pool fence and accessible to residents from the back patio. 6. During an environmental inspection of the facility, the Compliance Officer observed a bucket of, "Plus 3 Joint Compound," in the backyard near the outdoor kitchen. 7. During an environmental inspection of the facility, the Compliance Officer observed a plastic set of drawers in the backyard near the outdoor kitchen. The drawers did not have a lock. Inside the drawers, the Compliance Officer observed a spray bottle of, "Walker Chemical Oven & BBQ Heavy Duty Foaming Oven Cleaner," and a spray bottle of, "WD-40." 8. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents.