Loving Hearts Assisted Living 3

Based on document review and interview the health care institution's chief administrative officer did not ensure that the health care institution had annually assessed the health care institution's risk of exposure to infectious tuberculosis Findings include: 1 . A review of facility documents revealed tuberculosis testing for residents and employees, however there was no assessment for the health care institution's risk of exposure to infectious tuberculosis. 2 . In an exit interview, E1 acknowledged that there was not an annual assessment for the health care institution's risk of exposure to infectious tuberculosis.

Based on record review and interview the manager failed to ensure that before or at the time of acceptance of an individual, the individual submit documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility. Findings include: 1 . A review of R2's records revealed no documentation to indicate if the resident required continuous medical services, continuous or intermittent nursing services or restraints dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant. 2 . In an exit interview, E1 acknowledged that before or at the time of acceptance of an individual, the individual did not submit documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility.

Based on document review and interview the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . A review of facility documents revealed disaster drills dated January 1, 2025 and April 1, 2025, however there was not an disaster drill conducted for July 2025 or October 2025. 2 . In an exit interview, E1 acknowledged that there was not a disaster drill conducted for employees on each shift at least once very three months.

Based on document review and interview the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1 . A review of facility documents revealed an evacuation drill dated January 1, 2025, however there was not an evacuation drill conducted for employees and residents after the January drill. 2 . In an exit interview, E1 acknowledged that there was not an evacuation drill for employees and residents conducted at least once every six months.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed two fire extinguishers mounted in the facility. Both fire extinguishers had inspection tags dated July 2021, more than one year prior to the on-site inspection. 2. In an interview, E1 acknowledged the fire extinguisher service tags indicated the fire extinguishers had not been serviced every 12 months.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of the facility's policies and procedures revealed a dated signature indicating the policy and procedure manual had been reviewed and approved by the manager was not available for review. 2. In an interview, E1 acknowledged the policy and procedure manual review had not been documented.

Based on document review, record review, and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the suspected abuse, neglect, or exploitation, and any action taken according to subsection (J)(1), failed to initiate an investigation of the suspected abuse, neglect, or exploitation and within five day after the report required in subsection (J)(2), document the dates, times, and description of the suspected abuse, neglect, or exploitation, a description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, neglect, or exploitation, and the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. The deficient practice posed a potential safety risk for residents and potential rights violation if alleged abuse, neglect, or exploitation was not reported as required. Findings include: 1. A review of the facility's policies and procedures, with no documented review date, revealed a policy titled "Abuse/Neglect/Exploitation," which did not comply with the requirements found in A.R.S.\'a7 46-454. This policy stated, "A manager shall ensure if there is a reasonable basis to believe that a resident is alleged or suspected to have occurred on or off the premises receiving services from Loving Hearts Assisted Living 3, caregiver the Manager shall follow the procedure below (sic): A Manager shall report the suspected abuse, neglect, or exploitation of the resident to a peace officer or an adult protective services worker 48 hours or the next working day if the 48 hours expire on weekend or holiday" 2. A review of R1's medical record documentation of an incident was not available for review. 3. A review of facility quality management documentation revealed documentation of an incident involving R1 was not available for review. 4. In an interview, E2 reported there was an incident about a week prior to the on-site inspection involving R1. E2 reported not knowing the exact date or time, but stated it was after dinner. E2 reported a resident called out for E2 to come and check on R1. E2 reported E2 came to the living room and R1 was standing at the door of R1's room, and was touching themselves inappropriately. E2 reported E2 told R1 to go back into R1's room and R1 complied. E2 initially denied any other resident had been involved, and then said the other resident who called E2 to come assist R1 had seen what R1 was doing. E2 stated E2 had not documented the incident. 5. In an interview, E1 reported E1 had not known about any incident until being advised during the inspection by E2. E1 reported Adult Protective Services (APS) had called E1 the day of the on-site inspection, but had only warned E1 that there was an in

Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of two employees sampled. 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E3's personnel record revealed E3 had been hired as a caregiver in March of 2024. However, E3's personnel record did not include the signature of an Occupational Health Provider on E3's baseline screening questionnaire and E3's personnel record included a single step negative skin test and did not include the required second step skin test. 4. In an interview, E1 acknowledged the personnel file provided for E3 had not included documentation of evidence of freedom from infectious TB as required by R9-10-113.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, and the manager, when initially developed and when updated, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan updated May 15, 2024. However, the service plan was not signed and dated by the resident or the resident's representative or the manager. 2. In an interview, E1 acknowledged the service plan provided for R2 did not include all required signatures.

Based on record review and interview, the manager failed to ensure a resident's representative was designated for a resident who was unable to direct self-care, for one of two sampled residents who received directed care services. Findings include: Arizona Revised Statutes (A.R.S.) 36-401(A)(16) states: "Directed care services" means "programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions." 1. A review of R2's medical record revealed R2 had signed all admissions documentation. R2's face sheet indicated R2's "Responsible Party/Relationship" was, "Self." 2. A review of R2's medical record revealed a service plan, updated May 15, 2024, for directed care services. Additionally, the service plan update was not signed by R2 or R2's representative. 3. A review of R2's medical record revealed no documentation of designation of a representative for R2. 4. In an interview, E1 acknowledged a resident's representative was not designated for a resident who was unable to direct self-care according to their service plan.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom or residential unit being used by a resident receiving directed care services. Findings include: 1. During a facility tour, the Compliance Officer observed R2 was in bed. The Compliance Officer observed a mechanical bell was placed on a table near the bed, out of R2's reach. R2 had a tray table with water in reach, however, the bell was not placed on the tray table. 2. In an interview, E2 reported R2 was not ambulatory and could not reach the bell on the table, E2 reported R2 just yells for assistance. 3. A review of R2's medical record revealed a service plan for directed care serviced, updated May 15, 2024. The service plan indicated R2 was, "bedbound," required, "1-2 persons assist for transfers and ambulation," and required a, "Call bell within reach." 4. In an interview, E1 acknowledged R2's call bell had not been placed within reach..

Based on observation, documentation review and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During the environmental tour, the Compliance Officer observed the facility provided medication administration services. 2. A review of facility documentation revealed a policy titled, "Medication Services," which stated, "Procedures: Ensure the Medication Administration section of the Policies and Procedures are reviewed and approved by a Medical Practitioner or nurse and every three years thereafter." However the medication services policy and procedure was not reviewed and signed by a medical practitioner, registered nurse, or pharmacist. 3. In an interview, E1 acknowledged the medication services policy and procedure was not reviewed and signed by a medical practitioner, registered nurse, or pharmacist.

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 sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication, and false or misleading information was provided to the department. Findings include: 1. A review of R1's medical record revealed a service plan was not available. 2. In an interview, E1 reported R1 was directed care and received medication administration. E1 reported R1 was sent to the facility by a hospital without any medications and they were able to get a doctor to order medications within 24 hours of admission. 3. A review of R1's medical record revealed a list of medication orders, dated June 15, 2024 , which included: - "Guaifenesin Oral Syrup, 100 MG/5ML, Take 15ml by mouth every 6 hours as needed (PRN) for cough;" - "Albuterol Sulfate Inhalation Nebulization Solution, Inhale one vial via nebulizer every 6 hours as needed for SOB," - "Lisinopril Oral Tablet 30 MG, Give one tablet by mouth daily"; - "MedroxyProgesterone Acetate Oral Tablet 5 MG, Give one tablet by mouth daily"; - "Sitagliptin Phosphate Oral Tablet 100 MG, Give one tablet by mouth daily"; - "Acetaminophen Oral Capsule 500 MG, Give one tablet by mouth three times a day for pain"; - "Loperamide HCI Oral Capsule 2 MG, Give 2 tablets by mouth daily as needed for diarrhea"; - Apixaban Oral Tablet 5 MG, Give 1 tablet by mouth twice a day"; - Metformin HCI Oral Tablet 1000 MG, Give one tablet by mouth daily"; and - Tamsulosin HCI Oral Capsule 0.4 MG, Give one tablet by mouth at bedtime." 4. After requesting R1's and R2's medication administration records (MAR's), the Compliance Officer observed E2 filling in previous day entries on the MAR and requested E2 stop attempting to correct the previously missed entries and provide it as-is. 5. A review of R1's medical record revealed a medication administration record (MAR) dated June 2024. The MAR indicated the following: - "Guaifenesin 15ml," had been administered every day from June 15, 2024 to June 24, 2024 at 7 AM, 1 PM and 7 PM instead of PRN as ordered; - "Albuterol Sulfate," had been administered twice every day from June 15, 2024 to June 24, however, PRN reason and the time of administration was not documented; - "Lisinopril 30 MG" had been administered once daily at 7 AM from June 15, 2024 to June 24, 2024 as ordered, and had not been administered on June 25, 2024 or June 26, 2024; - "MedroxyProgesterone Acetate 5 MG," had not been administered as ordered on any day in June 2024; - "Sitagliptin Phosphate 100 MG," had been administered once daily at 7 AM from June 15, 2024 to June 24, 2024 as ordered, and had not been administered on June 25, 2024 or June 26, 2024; - "Acetaminophen 500 MG," had been administered three times daily from June 15, 2024 to June 24, 2024 as ordered, and had not been administered on

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a separate locked area used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the following: - a refrigerator in the kitchen was accessible to residents. Inside the refrigerator, the Compliance Officer observed containers of Guaifenesin, Insulin, Lactulose, Lorazepam, Docusate Sodium, and Milk of Magnesia in the door, stored alongside food items; - a small metal box in the refrigerator had a lock, however, the key had been left in the lock. Inside the box, the Compliance Officer observed containers of Haloperidol, Ativan, Lorazepam, and, "Artificial Tears;" - a cabinet above the kitchen counter had a lock, however, the cabinet had been left unlocked. Inside the cabinet, the Compliance Officer observed five totes, each containing all of the medications for each resident; - a second cabinet above the kitchen counter had a lock, however, the cabinet had been left unlocked. Inside the cabinet, the Compliance Officer observed a container of 70% Isopropyl Alcohol and a tote containing medication for a former resident; - a third cabinet above the kitchen counter did not have a lock. Inside the cabinet, the Compliance Officer observed containers of, "Tums," "Hyland's Leg Cramps effective relief," "and, "Nervive Advance Nerve Relief"; - a fourth cabinet above the kitchen counter did not have a lock. Inside the cabinet, the Compliance Officer observed a container of Loperamide; - A cabinet below the kitchen counter did not have a lock. Inside the cabinet, the Compliance Officer observed containers of Ibuprofen, Aspirin, and, "Belbuca"; - A second cabinet below the kitchen counter did not have a lock. Inside the cabinet, the Compliance Officer observed filled multi-dose medication organizers for each resident. 2. In an interview, E1 acknowledged medication stored by the facility was not stored in a separate locked area used only for medication storage.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3\'b0 F, placed at the warmest part of the refrigerator. Findings include: 1. During the facility tour, the Compliance Officers observed a refrigerator in the kitchen. The refrigerator contained foods requiring refrigeration. However, refrigerator did not contain a thermometer. 2. In an interview, E1 acknowledged the refrigerator did not contain a thermometer placed at the warmest part of the refrigerator.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the 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. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the kitchen counter did not have a lock. Inside the cabinet, the Compliance Officer observed containers of, "Comet," "Windex," "Mop&Glo," "Great Value Glass Cleaner," "Fabuloso," and, "Weiman Stainless Steel Cleaner." 2. During an environmental inspection of the facility, the Compliance Officer observed a second cabinet below the kitchen counter did not have a lock. Inside the cabinet, the Compliance Officer observed containers of "Windex," "Great Value Multi-Purpose Cleaner," "Soft Scrub," "Great Value Bathroom Cleaner," a container with a glass cleaner label, however, the liquid inside was white and opaque, and two containers of, "Crossfire Bed Bug Concentrate." 3. In an interview, E1 acknowledged poisonous or toxic materials stored by the facility were not stored in a locked area inaccessible to residents.