Triple Hearts Assisted Living I LLC

Based on documentation review, interview, and record review, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9) for two of two sampled residents. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of R1's and R2's medical records revealed standardized emergency responder forms were not available for review. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities including providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution for three of three employees reviewed. The deficient practice posed a risk as the caregivers received no organized instruction or information related to TB surveillance. Findings include: 1. A 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." 2. A review of E1's, E2's, and E3's personnel records did not include documentation of initial training and education related to recognizing the signs and symptoms of TB. Based on E1's, E2's, and E3's hire dates, this training was required. 3. In an interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review, observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. § 36-425(I), when there was a change in the manager, and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. A review of Department documentation for the facility revealed that O1 was no longer the manager of the facility, effective October 2, 2025. 2. During the environmental inspection of the facility, the Compliance Officer observed E1's assisted living facility manager's license was posted in the facility. 3. In an interview, E2 reported E2 was not aware the Department had not been notified of these changes. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure the facility's policies and procedures for a quality management (QM) program were documented and implemented. The deficient practice posed a risk as a quality management program documents and tracks the necessary information required to effectively evaluate and manage services provided. Findings include: 1. A review of the facility's documentation revealed a document titled "Quality Management- Monthly Summary Form." However, the document was blank and no further documentation was provided for review. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of three employees reviewed. 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. A review of E1's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E1 had signs or symptoms of TB. Based on E1's hire date, this documentation was required. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

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, upon acceptance and every six months thereafter, that stated 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 two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a service plan dated October 24, 2025. The service plan stated the resident was "bed-bound." 2. A review of R1's medical record revealed a signed and dated determination dated December 11, 2024. However, additional documentation signed by R1's primary care provider every six months was not available for review. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a health and safety risk to residents and employees if the disaster plan was not up-to-date to adequately meet the needs of the residents during a disaster. Findings include: 1. In documentation review, the facility's disaster plan did not indicate the plan was reviewed at least once every 12 months, as required. 2. During an interview, E2 acknowledged the facility did not have documentation the disaster plan was reviewed at least once every 12 months. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation 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. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's disaster drill documentation revealed documentation of a drill conducted on November 11, 2024. However, documentation of additional drills was not available for review. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation 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 the facility's evacuation drill documentation revealed documentation of a drill conducted on November 11, 2024. However, documentation of additional drills was not available for review. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation and interview, the manager failed to ensure the swimming pool on the premises of the assisted living facility is locked when the swimming pool is not in use. The deficient practice posed a potential risk to the health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed an unlocked gate leading into the swimming pool. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of two sampled personnel. The deficient practice posed a risk if the employees were not qualified to provide the required services and the Department was provided false or misleading information. Findings include: 1. When the Compliance Officer arrived, E2 and E3 were observed working at the facility as caregivers. 2. A review of E3's personnel record revealed E3 was hired as a caregiver on December 01, 2024. The personnel record contained a caregiver training certificate from "Platinum Training Services LLC" (ALTP #0185) dated February 19, 2013. 3. In an interview, E3 stated that they first arrived in Arizona in 2021 and completed caregiver training at a caregiver school "Platinum Training Services LLC" in Goodyear that same year. E3 was unaware that their certification was issued in 2013. Additionally, E3 provided an Arizona identification card indicating an issue date of September 10, 2021, which aligns with their arrival in Arizona. 4. A review of the https://azcg.tmutest.com/search website revealed no documentation of a caregiver training certificate for E3. 5. In a telephonic interview, E4 reported E3's caregiver certificate was verified on the NCIA Board website for caregiver certification verification (https://nciaboard.az.gov/news/caregiver-certificate-verification). However, when questioned about the timeline of R3 being in Arizona, E4 acknowledged the caregiver certificate was false and the Department was provided false or misleading information. 6. In an interview, E2 and E3 reported E3 was working at the facility as a caregiver and acknowledged documentation was not available that showed documentation of completing a caregiver training program approved by the Department or the NCIA Board.

Based on observation, record review, and interview, the manager failed to ensure a personnel record was established and maintained, for one of two personnel records sampled. The deficient practice posed a risk to resident health and safety if the facility did not obtain documentation showing an employee met the requirements to provide services for the residents. Findings include: 1. Upon arrival at the facility, the Compliance Officer observed E2 working at the facility. 2. A personnel record was not available for review for E2. 3. In an interview, E1 reported they did not have a personnel record for E2 available for review. E1 reported E2 just recently started working at the facility. E1 and E3 acknowledged a personnel record was not established for E2.

Based on record review and interview, the manager failed to ensure a written service plan was available, for three of three residents sampled. The deficient practice posed a health and safety risk if the caregivers did not know the services the residents needed to receive. Findings include: 1. A review of R1's medical record revealed no documentation of a service plan. Based on R1's date of acceptance, a service plan was required. 2. A review of R2's medical record revealed no documentation of a service plan. Based on R2's date of acceptance, a service plan was required. 3. A review of R3's medical record revealed no documentation of a service plan. Based on R3's date of acceptance, a service plan was required. 4. In an interview, E1 and E3 acknowledged R1, R2, and R3's medical records did not contain a service plan.