Loving Arms Assisted Living, LLC

Based on record review, documentation review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for three of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Review of E2’s personnel records revealed E2 did not have annual TB training in identifying the signs and symptoms for the years 2024 and 2025 in their file at the time of the inspection. Based on E2’s hire date this documentation was required. E2 did have TB training for January 2023. 2. Review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 3. Review Of E1’s and E3’s personnel record revealed E1 and E2 did not have initial TB training. Based on E1’s and E3’s hire date this documentation was required. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

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 three 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(C)(1) states: "C. 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. Review of E3’s personnel record revealed E3’s references. However, E3’s references were not previous employers. The references were labeled as, “friend”. 3. In an interview, E1 acknowledged E3 did not have reference checks from previous employers and did not bring other documents to show previous employers were called and verified for E3. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, interview, and record review, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individual was not qualified to provide the required services. Findings include: 1. The facility was licensed at the Directed Care Level. 2. A review of A.R.S. § 36-401.A.49. revealed "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 3. The Compliance Officers observed E1 and E3 working at the time of the inspection. 4. The Compliance Officers observed E3 going into the residents’ rooms unsupervised. 5. In an interview, E1 was questioned as to why the Compliance Officers were unable to enter R2’s room. E1 reported at the time of the environmental inspection R2 was being changed by E3. 6. Review of E3’s personnel record revealed E3 was hired as an assistant caregiver. In E3’s personnel record there was no documentation of a caregiver certificate. 7. Electronic review of https://azcg.tmutest.com/ revealed no results for a caregiver certificate for E3. 8. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of three employees sampled. The deficient practice posed a potential 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) test is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. The Compliance Officers observed E3 working at the time of the inspection. 5. Review of E3’s personnel record revealed E3’s date of hire was September 2025. 6. Review of E3’s personnel record revealed E3’s first TB skin test was administered September 2025. Then E3’s second skin test was administered in October 2025. Based on E3’s hire date this second TB skin test was supposed to be done prior to providing services. 7. Review of the facility documentation of the employee work schedule revealed October 2025’s work schedule was missing. 8. In an interview, E1 acknowledged the October 2025 work schedule was missing and did not provide the requested documentation. 9. In an interview, E3 reported E3 was working assisting caregivers around September 15th or 16th of 2025. 10. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained for each employee as required for one of three employees sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. The Compliance Officers observed the E1 working at the time of the inspection. 2. The Compliance Officers observed E1 filling out documentation at the time of the environmental inspection. The Compliance officers requested the documents that E1 was working on and E1 handed the documents over to the Compliance Officers. The documents were blank except for E1’s name, position, date of hire, and caregiver license. 3. In an interview, E1 reported E1 was filling out E1’s personnel documentation. E1 reported E1 was waiting to receive E1’s employee file from E1’s previous job. E1 reported E1’s previous job would not give E1’s employee file to E1 and that is why E1’s personnel file is blank. The Compliance Officers asked if E1’s previous job was a sister facility or a part of E1’s current employer's LLC. E1 replied, “no”. 4. Review of E1’s personnel file revealed the documents were blank except for the hire date, position, and the caregiver certificate. Based on E1’s hire date this was required. 5. In an interview, E1 acknowledged E1’s personnel record was blank and was supposed to be filled out. 6. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one of two 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. Review of R2’s medical record revealed no documentation of R2’s TB test or signs and symptoms risk assessment questionnaire. Based on R2’s date of acceptance this was required. 3. In an interview, E1 acknowledged R2’s medical record did not have any TB tests or the signs and symptoms risk assessment questionnaire. 4. 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 there was a documented residency agreement with the assisted living facility that included the facility responsibilities for two of two sampled residents. Findings include: 1. Review of R1’s and R2’s medical records revealed residency agreements. However, the residency agreements did not include the facility’s responsibilities. 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 there was a documented residency agreement with the assisted living facility that included a list of the services available from the assisted living facility at an additional fee or charge for two of two sampled residents. Findings include: 1. Review of R1’s and R2’s medical records revealed residency agreements. However, the residency agreements did not include a list of the services available from the assisted living facility at an additional fee or charge. 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, for two of two sampled residents, a resident had a service plan which accurately included the amount, type, and frequency of assisted living services and ancillary services being provided to the resident. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. Review of R1’s current service plan was dated August 2025. This service plan did not have the frequency for the following services that were provided to the resident: - Dressing - Laundry - Maintenance of room Only “Dependent” was marked on the service plan. 2. Review of R2’s current service plan was dated October 2025. This service plan did not have the frequency for the following services that were provided to the resident: - Dressing - Laundry - Maintenance of room Only “Dependent” was marked on the service plan. 3. In an interview, E1 reported those services were provided to the residents and acknowledged the service plan did not have the frequency for the services mentioned above. 4. 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 medication administered to a resident was administered in compliance with a medication order for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1’s medical record revealed a service plan, dated August 2025 which revealed R1 received medication administration. 2. Review of R1’s medical record revealed a medication list that contained the following: - Lomotil Tablet 2.5- 0.025 mg - Lisinipril tablet 2.5 mg - Atorvasatin Calcium tablet 40 mg - Aspirin tablet 81 mg - Senna plus tablet 8.6- 50 mg - Ipratropium Albuterol solution 0.5-2.5 (3) mg/ 3ml - Trazadone tablet 50 mg - Acetaminophen extra strength 500 mg - Ondansetron tablet disintegrating 4 mg - Metformin tablet 500 mg - Atavan tablet 0.5 mg However there was no signature from a medical practitioner for these medications mentioned above. 3. Review of R1’s medical record revealed a medication administration record (MAR) for December 2025. This MAR revealed R1 was receiving the medications mentioned above from the start of December to present day. 4. In an interview, E1 called someone on the phone and asked for the medication orders. The person on the phone spoke to the Compliance Officers and asked what medications orders the Compliance Officers needed. The Compliance Officers told the person on the phone they will need signed medication orders for R1 and R2. E1 later reported the medication orders were going to be faxed. However, E1 did not provide the signed medication orders. The Compliance officers never saw the signed orders at the time of the inspection. 5. In an interview, E1 reported the medication that was documented on the MAR was administered to R1. 6. Review of R2’s medical record revealed a current service plan dated October 2025. This service plan revealed R2 received medication administration. 7. Review of R2’s medical record revealed a document titled “Medication Record for PRN, opioid, and controlled medications” which revealed Hydroco/APAP 325 mg was administered on December 25, 2025. However a medication order that was signed by a medical practitioner was not presented at the time of the inspection. 8. 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 Officers observed the following medication in a plastic bag on the kitchen counter: - A bottle of Tylenol pm - A bottle of Advil pm - A box of Advil 200 mg tablets - A bottle of Alieve 220 mg tablets - Non-drowsy Claritin 10 mg - A tube of Neosporin pain relief ointment 4. The Compliance Officers observed unlocked kitchen cabinets that contained medication for the seven residents in the facility. The following medications were observed in the cabinets: - Approximately five bottles of Polyethylene Glycol 3350 - A bottle of Lactulose Solution USP 10 g/ 15 mL - A bottle of Cetrizine Hydrochloride 10 mg - A blister pack of Hydrococo/APAP 5-325 mg 5. Review of the facility policy and procedures revealed a policy titled, “Medication Policy and Procedure” which stated, “A locked secured area is used for storage of medications, solutions, and prescriptions. This area is locked when not in use and is to be inaccessible to residents.” 6. In an interview, E1 reported a family member dropped off the plastic bag of medications the night before the inspection. E1 also acknowledged the plastic bag was left out until the morning of the inspection and the medications cabinets were unlocked. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance and complaint inspection on July 26, 2024.

Based on observation 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. The Compliance Officers observed an unlocked garage door. In the garage the Compliance Officers observed the following: - One 3.58 L of Clorox performance bleach - One bottle of Lysol Laundry sanitizer - One container of Wind Fresh + Oxi laundry detergent - One bottle of Fabuloso - One bottle of Fabric Softener ultra concentrated 2. In an interview, E1 acknowledged the door was supposed to be locked however it was not. 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 a medication administered to a resident was documented in the resident's medical record, for one of two sampled residents. The deficient practice posed a risk as medication could not be verified as administered against a medication order and the medical record inaccurately indicated a medication was administered. Findings include: 1. A review of the R1's medical record revealed an order dated July 24, 2024 for "Sulfa/Trimet 800 mg take one tablet by mouth for ten days." 2. A review of R1's July 2024 medication administration record (MAR) did not include Sulfa/Trimet 800 mg. 3. A review of R1's medical record revealed a medication order dated March 20, 2024 for "Amlodipine Besylate 2.5 MG 1 tablet ORAL 1 times a day." 4. A review of R1's medical record revealed a July 2024 MAR. The MAR indicated Amlodipine Besylate 2.5 MG was administered at 8 AM and 5 PM. 5. In an interview, E1 reported the medications were administered per the medication orders and acknowledged R1's medical record did not include accurate documentation the medications were administered.

Based on observation and interview, the manager failed to ensure 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. The Compliance Officer observed an unlocked kitchen cabinet. Upon looking inside, the Compliance Officer observed a tube Mupirocin Ointment USP 2%. 2. The Compliance Officer observed an unlocked mini refrigerator located in the hallway by the kitchen. Upon looking inside, the following medications were observed: - Humulin R U- 500 Kwikpen 500U/ ML - 500 units of prefilled insulin - Acetaminophen 650mg - Rivastigmine 9.5 mg 3. In an interview, E1 acknowledged medications were not stored in a locked room, closet, cabinet, or self-contained unit.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of five employees reviewed. 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 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... 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..." 2. Review of E4's personnel record revealed E4 worked as a facility caregiver and had a hire date of May 1, 2023. The personnel record revealed a fingerprint card issued on July 12, 2018. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E4's fitness to work in a residential care institution. 3. Review of the DPS fingerprint clearance card database on May 12, 2023, revealed E4's fingerprint clearance card was valid. 4. During an interview, E1 acknowledged documentation was not available showing E4's work references were obtained upon hire at this facility.

Based on record review, documentation review, and interview, the manager failed to ensure a residency agreement included the policy and procedure for a resident to terminate residency including terminating residency because services were not provided to the resident according to the resident's service plan, for two of two residents reviewed accepted by the assisted living home on or after October 1, 2013. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Review of R1's medical record revealed a residency agreement. However, this residency agreement did not include the policy and procedure for a resident to terminate residency including terminating residency because services were not provided to the resident according to the resident's service plan. Based on R1's acceptance date, this documentation was required. 2. Review of R2's medical record revealed a residency agreement. However, this residency agreement did not include the policy and procedure for a resident to terminate residency including terminating residency because services were not provided to the resident according to the resident's service plan. Based on R2's acceptance date, this documentation was required. 3. Review of the facility's policies and procedures revealed a policy titled "Termination of Residency (By Resident)" reviewed and signed by E2 February 22, 2022. This policy stated " ...The resident may terminate the agreement due to health reasons, such as admission to a hospital or the requirement for extended skilled nursing care. The resident may terminate the residency agreement because he or she needs services that the facility is either not licensed to provide or is licensed to provide but not able to provide. The residency agreement may be termination with a 30 day notice if the resident is not provided with the services as stated in the service plan..." 4. During an interview, E1 acknowledged R1's and R2's residency agreements did not include the policy and procedure for a resident to terminate residency including terminating residency because services were not provided to the resident according to the resident's service plan.

Based on record review, documentation review, and interview, the manager failed to ensure a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for one of two residents reviewed accepted by the assisted living facility on or after October 1, 2019. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Review of R2's medical record revealed a residency agreement. This residency agreement did not include the correct provisions allowing a manager to terminate residency of a resident. The residency agreement did not include the following terms for a 14 day termination: -The primary condition for which the individual needs assisted living services is a behavioral health issue; and -The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual. Based on R2's acceptance date, this documentation was required. 2. Rule review of R9-10-807(G) on or after October 1, 2019 and the facility's policy and procedure titled "Termination of Residency (By the Facility)" reviewed and signed by E2 February 22, 2022 stated: "A manager may terminate residency of a resident as follows: 1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility; 2. With a 14 calendar day written notice of termination of residency: a. For nonpayment of fees, charges or deposits; or b. Under any of the conditions in subsection (C); or 3. With a 30 calendar day written notice of termination of residency, for any other reason." Review of subsection (C) stated: "1. The individual requires continuous: a. Medical services; b. Nursing services unless the assisted living facility complies with A.R.S.36-401(C); or c. Behavioral Health Services; 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; 3. The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual; 4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 5. The individual requires restraints, including the use of bedrails." 3. During an interview, E1 acknowledged R2's residency agreement did not include the correct policy and procedure for an assisted living facility to terminate residency.

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 influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident 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 flu and pneumonia vaccinations were 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 flu and pneumonia vaccinations were offered or received.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed a current written service plan for personal care services dated March 8, 2023. This service plan stated "WC bound". 2. Review of R2's medical record revealed a written determination from R2's medical practitioner signed and dated March 2, 2022. However, documentation was not available stating R2's needs were met by the facility and R2's needs were within the facility's scope of services, at least once every six months. 3. During an interview, E1 reported R2 was unable to ambulate even with assistance since acceptance and E1 acknowledged R2's medical practitioner did not provide a written determination at least once every six months.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of one resident reviewed receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated May 4, 2023. This service plan revealed no documentation of R1's weight. In addition, R1's medical record revealed no documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. During an interview, E1 acknowledged R1's service plan did not include documentation of R1's weight and documentation was not available in R1's record from a medical practitioner stating weighing R1 was contraindicated.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area that allowed residents to be at least 30 feet away from the facility and 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: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the facility tour with E1, the surveyor observed the outside area, in the backyard, allowed residents to be a least 30 feet away from the facility. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not work. 3. During an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated May 4, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated May 8, 2023. This medication order stated "Discontinue: effective 5/8/23 - donepezil 5mg oral tablet; take 1 tab(s) orally once a day". 3. Review of R1's medical record revealed a May 2023 medication administration record (MAR). This MAR stated "Donepezil HCL 5mg Tablet 1 tab PO QD D.C 05-08-2023" indicated one tab was administered at 4pm May 1st - 7th. 4. During an observation of R1's medications, Donepezil 5mg was observed and one tab was observed prefilled in the "Evening" slot of R1's medication organizer. 5. During an interview, E1 reported the medication should have been discontinued and acknowledged R1's medication was not administered in compliance with the available medication order.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During the facility tour with E1, the Compliance Officer observed one large oxygen tank and two small oxygen tanks unsecured in R2's bedroom. 2. During an interview, E1 acknowledged oxygen tanks were not secured in an upright position.