Loving Hearts Assisted Living, LLC

Based on documentation review, observation, and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which 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 Department documentation revealed the facility was authorized to provide directed care services. 2) During the facility tour, the Compliance Officer observed a door leading to the backyard and a door leading outside to the side of the home. Both doors did not control or alert employees of the egress of a resident from the facility. 3) In an interview, E4 acknowledged there was not a means of exiting the facility that controlled or alerted employees of the egress of a resident.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for three of three residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1) Review of R1's medical record revealed R1 received medication administration. 2) Review of R1's medication administration record (MAR) for June 2025 revealed documentation that the following medications were administered at 8:00 PM on June 12, 2025 (the day of the inspection): -Albuterol 100/IPRATRO 20 CG; -Carbidopa 25/Levodopa 100 mg; and -Trazdone 50 mg. However, the MAR documentation was provided for the Compliance Officer at 1:55 PM. 3) Review of R2's MAR for June 2025 revealed documentation that the following medication was administered at 7:00 PM on June 12, 2025: -Trazodone 50 MG. However, the MAR documentation was provided for the Compliance Officer at 1:55 PM. 4) Review of R3's MAR for June 2025 revealed documentation that the following medications were administered at 7:00 PM on June 12, 2025: -Lorazepam 0.50mg; -Trazadone 100 mg tablet; -Seroquel Fumarate 25 MG; and -Mucas Relief tab 600 MG. However, the MAR documentation was provided for the Compliance Officer at 1:55 PM. 5) In an interview, E4 acknowledged R1's, R2's, and R3's medical records did not contain accurate documentation of medication administered to R1, R2, and R3.

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 inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1) During an environmental inspection of the facility, the Compliance Officer observed a container of Ajax bleach and Ajax dish soap in an unlocked cabinet under the kitchen sink. 2) In an interview, E4 acknowledged the toxic materials were not stored in a locked area and inaccessible to residents.

Based on observation, documentation review, and interview, the manager failed to ensure a pet was licensed consistent with local ordinances and vaccinated against rabies. The deficient practice posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1) During the facility tour, the Compliance Officer observed O1 on the premises. 2) In documentation review, the facility did not have documentation O1 was licensed following the local ordinance, which was required annually by Maricopa County. Further review revealed a document titled "Rabies Vaccination Certificate". However, the certificate had an expiration date of June 14, 2024. 3) In an interview, E4 acknowledged the facility did not have documentation O1 was licensed consistent with local ordinances and O1 rabies vaccination was expired.

Based on observation and interview, the manager failed to ensure a list of resident rights was conspicuously posted. Findings include: 1. The Compliance Officer observed a posting contained resident's rights. However, the resident's rights posted were not in compliance with the resident rights in subsection (C). 2. In an interview, E2 acknowledged the resident rights conspicuously posted were not in compliance with subsection (C).

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility; to include whether the resident required continuous medical services, continuous nursing services, intermittent nursing services or restraints, for two of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs if the resident needed a higher level of care. Findings include: 1. A review of R2's medical record revealed documentation to include R2 did not require continuous medical services, intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. However, the document was signed and dated four days after R2's date of admission. 2. A review of R3's medical record revealed documentation to include R3 did not require continuous medical services, intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. However, the document was signed and dated thirteen days after R3's date of admission. 3. In an interview, E2 acknowledged R2 and R3 did not submit documentation dated within 90 calendar days before the resident's date of admission to include whether the resident required continuous medical services, continuous nursing services, intermittent nursing services or restraints.

Based on record review and interview, the manager failed to ensure a resident's written service plan, when updated, was signed and dated by the resident or resident's representative, for one of three residents sampled. Findings include: 1. A review of R3's (admitted in 2021) medical record revealed a written service plan for personal care services dated in February 2023. However, the service plan was not signed and dated by R3 or R3's representative. 2. In an interview, E2 acknowledged R3's written service plans did not include a signature and date from the resident or resident's representative.

Based on record review and interview, the manager failed to ensure at the time of admission, a resident or resident's representative received a written copy of the requirements in subsection (B), and the resident rights in subsection (C), for three of three residents sampled. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed documentation of resident rights. However, the documentation was not in compliance with the requirements in subsection (B), and the resident rights in subsection (C). 2. In an interview, E2 acknowledged R1, R2 and R3, or their representatives, did not receive a written copy of the requirements in subsection (B), and the resident rights in subsection (C).

Based on documentation review and interview, the manager failed to ensure the disaster plan review included the time of the disaster plan review, a critique of the disaster plan review; and if applicable, recommendations for improvement. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed a disaster plan review dated in May 2023. However, the disaster plan review did not include documentation of the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. 2. In an interview, E2 acknowledged the disaster plan review did not include the above mentioned requirements.