Bring-healing-home Personal Care LLC.

“Based on documentation review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training, for two of two personnel sampled. The deficient practice posed a health and safety risk for residents.  Findings include: 1. A review of E1's personnel record (hired September 4, 2023) revealed documentation of E1's completed training for fall prevention and fall recovery dated October 14, 2024. However, no further documentation of additional training was available for review. 2. A review of E2's personnel record (hired March 12, 2024) revealed documentation of E2's completed training for fall prevention and fall recovery dated October 14, 2024. However, no further documentation of additional training was available for review. 3. In an exit interview, the findings were reviewed with E1 over the phone and 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 two of three personnel records reviewed. 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 E1's personnel record revealed E1 worked as a caregiver and had a hire date of September 4, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 2. A review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of March 12. 2024. The personnel record 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 E1 over the phone and E2, and no additional information was provided.”

“Based on documentation review, record review, and interview, for two of two employees reviewed, the governing authority failed to ensure compliance with A.R.S. § 36-411. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. Findings Include:  1. A.R.S. § 36-411 states: C. Each residential care institution, nursing care institution, and home health agency shall make documented, good-faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459.” 2. A review of E1's personnel record (hired on September 4, 2023) did not include documentation of verification that E1 was not on the adult protective services registry. 3. A review of E2's personnel record (hired on March 12, 2024) did not include documentation of verification that E2 was not on the adult protective services registry. 4. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided.”

“Based on documentation review and interview, and record review, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was incomplete documentation identifying the staff present each day to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a personnel schedule that was dated June 2024. However, no additional documentation of the caregivers working each day since June 2024 was available for review. 2. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure a manager provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of two employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of March 12, 2024. The personnel record revealed a first aid and CPR card with an expiration date of March 2026. There was no other current documentation of first aid and CPR training in E2's record. 2. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of three 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. A review of R1's medical record revealed no documentation of a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3. A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided. This is a repeat deficiency from the inspection conducted on April 14, 2025.”

“Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services and once every three months for a resident receiving directed care services for two of three residents sampled. The deficient practice posed a risk if a resident's service plan was not updated as required to reinforce and clarify services, and a caregiver was not aware of the services to be provided for a resident. Findings include: 1. A review of R2's medical record revealed a service plan for personal care services dated December 26, 2024. However, documentation of a service plan after December 26, 2024, was not available for review. 2. A review of R3's medical record revealed a service plan for directed care services dated September 5, 2025. However, documentation of a service plan after September 5, 2025, was not available for review. 3. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for three of three residents reviewed. The deficient practice posed a health and safety risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed a document titled "Activities of Daily Living." However, the document was blank at the time of inspection. 2. In an interview, E2 stated all services were provided in accordance with R1's, R2's, and R3's service plans. 3. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided.”

“Based on observation, interview, and record review, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for two of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order and the Department was provided false and misleading information. Findings include: 1. Upon arrival at the facility, the Compliance Officer requested the facility's medical administration records (MARs) for R1 and R2. The Compliance officer observed E2 writing in R1's and R2's MAR for April 2026 through May 5, 2026. 2. In an interview, E2 reported E2 had administered medication to R1 and R2 according to the medication order. E2 reported E2 had not correctly documented any medication administered to R1 and R2 in April 2026 or May 2026. E2 acknowledged E2 was backdating the MAR from April 2026 to May 5, 2026. 3. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility 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 could access the medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a kitchen refrigerator where an unlocked medication storage box contained Morphine Sulfate Oral Solution 100 mg per 5 mL. 2. During an environmental inspection of the facility, the Compliance Officer observed an open cabinet in the kitchen that contained residents' medication boxes. The cabinet door contained a lock, but it was unlocked at the time of the inspection. 3. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided. This is a repeat deficiency from the inspection conducted on April 14, 2025.”

“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 personnel schedule revealed there were two shifts. 2. A review of the facility's disaster drills revealed documentation of a disaster drill during the day shift and night shift on August 1, 2025. However, documentation of additional drills was not available for review. 3. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided. This is a repeat deficiency from the inspection conducted on April 14, 2025.”

“Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months and included all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. A review of facility documentation revealed documentation of an evacuation drill conducted on August 2, 2025; however, no documentation of additional drills was available for review. 2. In an exit interview, the findings were reviewed with E1 over the phone and E2, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two 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) A review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3) A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 4) In an interview, E1 acknowledged R1's and R2's medical records did not include documentation of a risk assessment of prior exposure to infectious TB or a determination if they had signs or symptoms of TB.”

“Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility 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 could access the medication. Findings include: 1) During an environmental inspection of the facility with E1, the Compliance Officer observed a box labeled "Trulicty; 1.5 mg/once weekly" located in the door of the unlocked refrigerator. 2) In an interview, E1 acknowledged the medication was not locked as required.”

“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 personnel schedule revealed there were two shifts. 2) A review of the facility's disaster drills revealed documentation of a disaster drill conducted during the day shift on November 1, 2024. However, no additional documentation of disaster drills was available for review. 3) In an interview, E1 acknowledged disaster drills were not conducted on each shift once every three months.”