Legacy of Hearts Assisted Living LLC

Based on documentation review and interviews, the manager failed to ensure that personnel provided appropriate first aid in accordance with its certification training for first aid before the arrival of emergency medical services to a resident who is in distress and to a non-injured resident who has fallen, as required under Arizona Revised Statutes (A.R.S.) 36-420.B.1-3. Findings include: 1. A review of Department documentation revealed an intake report dated January 7, 2025, which included sworn testimony that stated, "Staff/facility insufficient to meet patient need for safety and wellbeing. Staff failed to recover [R1] per ARS 36-420. Inappropriate utilization of the 911 system. On Scene Narrative (Author): Care home staff member did not attempt to help [R3] up off the floor. R3 was not hurt and only wanted to be helped up. LT asked E2 why E2 did not help R3 up, and E2 stated that there was no other staff there to help. 2. In an interview, E1 acknowledged that first aid had not been provided before the arrival of emergency medical services for a noninjured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently.

Based on the documentation review and interview, the manager failed to ensure that a quality management plan was implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to manage services provided effectively. Findings include: 1. A review of the facility’s documents revealed no documentation of a quality management plan. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A review of department documentation revealed an intake report dated January 7, 2025, which revealed that 911 was called. 2. A review of R3's record revealed no documentation showing the date and time of the incident; the names of the individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future. 3. In an interview, E1 acknowledged that E1 and E2 did not include documentation showing the date and time of the incident; the names of the individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for one of three employees sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 or contracted work." 2. A review of E3's personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(A) was not available for review. 3. In an interview, E1 acknowledged the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(A) for E3.

Based on observation, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provides physical health services, for one of two caregivers sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs. Findings include: 1. The Compliance Officer observed E2 on the premises when the Compliance Officer arrived at the facility at approximately 9:25 AM. 2. A review of E2's personnel record revealed E2 was hired as an assistant caregiver. 3. A review of E2's personnel record revealed a form used to document verification of skills and knowledge, with multiple subjects to verify individually. However, the documentation was not completed for all subjects on the form. 4. In an interview, E1 acknowledged E2's skills and knowledge were not verified and documented before E2 provided physical health services.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation required by policies and procedures, for one of three personnel records sampled. The deficient practice posed a risk if the employee was unable to meet a resident's needs. Findings include: 1. A review of facility policies and procedures revealed a policy titled "Orientation, in-service training for employees." The policy stated "Ensure that new employees are provided with training on the items listed on the new employee orientation form before they begin their regular job duties...After reviewing all items with the employee, both the individual providing the training and the new employee should sign the bottom of the form." 2. A review of E2's personnel record revealed a document titled "Employee orientation form." However, the form was not initialed, signed or dated by E2. 3. In an interview, E1 acknowledged E2's orientation form was not signed by E2 to indicate E2's orientation was completed.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of all requirements in Arizona Administrative Code (A.A.C.) R9-10-806(C)(1), for one of three personnel sampled. The deficient practice posed a risk as the required information could not be verified for E3. Findings include: 1. A review of E3's personnel record revealed documentation of an Assisted Living Manager's certification as required per A.A.C. R9-10-806(C)(1)(c)(iv) and documentation of freedom from infectious tuberculosis as required per A.A.C. R9-10-806(C)(1)(c)(vi). However, documentation of all other requirements in A.A.C. R9-10-806(C)(1) was not available for review. 2. In an interview, E1 acknowledged E1 failed to ensure E3's personnel record included documentation of all requirements in A.A.C. R9-10-806(C)(1).

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 did not observe a posted current calendar of activities. 2. In an interview, E1 acknowledged the current calendar of activities was not posted.

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 services. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. In an interview, E1 reported all residents are provided with medication administration. 2. A review of R1's medical record revealed a medication administration record (MAR) for December 2023. Review of R1's December 2023 MAR, at 10:42 AM, revealed the MAR documented the following medications were administered at the following times on December 20, 2023: -"Acetaminophen" documented as administered at 12:00 PM and 6:00 PM; -"Carbamazepine" documented as administered at 8:00 PM; -"Symbicort" documented as administered at 5:00 PM; -"Gabapentin" documented as administered at 12:00 PM and 5:00 PM; and -"Mupirocin" documented as administered at 12:00 PM and 5:00 PM. 3. A review of R2's medical record revealed a MAR for December 2023. Review of R2's December 2023 MAR, at 10:44 AM, revealed the MAR documented "Trazadone" was administered at 8:00 PM on December 20, 2023. 4. In an interview, E1 reported E1 accidentally filled in the information for December 19, 2023 in the column for December 20, 2023. E1 acknowledged E1 failed to ensure a medication administered to a resident was accurately documented in the resident's medical record.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food or medication contained a thermometer, accurate to plus or minus 3 \'b0F, placed at the warmest part of the refrigerator. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a thermometer in the refrigerator in the kitchen. However, the thermometer was broken and not accurately measuring the temperature. 2. In an interview, E1 acknowledged the kitchen refrigerator did not contain a working thermometer accurate to plus or minus 3 \'b0F. Technical assistance regarding this rule was provided during the previous compliance inspection conducted on November 7, 2022.