Triple Hearts Assisted Living II LLC

Based on record review and interview, for two of three employees reviewed, 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. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of E3's personnel record (hired on August 23, 2025) did not include documentation of training and education related to recognizing the signs and symptoms of TB. 2. A review of E4's personnel record (hired on November 26, 2024) did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review, record review and interview, for two of three employees reviewed, the governing authority failed to make a documented good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in the facility. The deficient practice posed a safety risk to residents. Findings include: 1. A.R.S. § 36-411(C)(1) states, "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. A review of E3's personnel record did not include documentation of the facility's good-faith effort to contact E3's previous employers. 3. A review of E4's personnel record did not include documentation of the facility's good-faith effort to contact E4's previous employers. 4. In an interview, the finding was reviewed with E2 and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided health services for one of three personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. Upon arrival, the Compliance Officer observed E4 providing services to residents. 2. A review of E4's personnel record revealed a job title of "Assistant Caregiver". E4's personnel record did not contain documentation of E4's qualifications, including skills and knowledge applicable to the individual's job duties and E4's education and experience applicable to E4's job duties. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review, record review, and interview, for two of three personnel records reviewed, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of facility documentation revealed a policy titled "Employee New Orientation". The policy stated "1. ...Before providing assisted living services to a resident, a manager, caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the manager, caregiver, or assistant caregiver...L. The New Orientation Checklist will be used to document the orientation process..." 2. A review of E3's personnel record revealed a job title of "Caregiver" hired on August 23, 2025. E3's record revealed a document titled "Staff Orientation Acknowledgment". However, the document was not dated or signed as conducted by the manager. 3. A review of E4's personnel record revealed a job title of "Assistant Caregiver" hired on November 26, 2024. E4's documentation of orientation specific to the duties to be performed was not available for review. 4. 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 a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of three caregivers reviewed. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of August 23, 2025. The personnel record revealed a first aid and CPR card with an expiration date of October 2024. There was no other current documentation of first aid and CPR training in E3's personnel record. 2. 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 a resident had a written service plan that was developed with assistance and review from the resident or resident's representative, for one of two residents sampled. The deficient practice posed a risk if the resident or resident's representative were unable to participate in the development or review the service plan to provide essential information. Findings include: 1. A review of R1's medical record revealed a service plan dated August 6, 2025 for directed care services. The service plan revealed no signature of R1 or R1's representative indicating the service plan was developed with assistance and reviewed by the resident or the resident's representative. 2. In an 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 facility documentation revealed no documentation of disaster drills conducted within the last 12 months. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.