Abe's Touching Hearts Al.

“Based on documentation review, 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 physical health services or behavioral health services, and according to policies and procedures, for two of three personnel sampled. The deficient practice posed a risk if personnel were unable to meet a resident's needs. Findings include: 1. A review of the facility's policies and procedures revealed a policy reviewed on February 1, 2026, and titled "Skills and Knowledge Verification". This policy stated, "The manager shall verify the caregiver's skill and knowledge through direct observation and shall document verification on the 'Employee Skills & Knowledge Verification Record' Form." 2. During an environmental inspection, the Compliance Officer observed E2 providing services to residents. 3. A review of the facility's schedule revealed E2 had worked five 24-hour shifts in May 2026 and that E3 had worked 27 12-hour shifts in May 2026. 3. A review of E2 and E3's records revealed no documented verification of E2 and E3's skills and knowledge. Based on E2 and E3's dates of hire, this documentation was needed. 4. In an interview with E3, E3 confirmed that E2 and E3's skills and knowledge had not been verified and documented before providing physical health services. 5. In an exit interview, the findings were reviewed with E3, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a caregiver or assistant caregiver documented the services provided in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical records revealed a service plan, dated January 20, 2026, which indicated R1 needed assistance with oral care twice per day or as needed, dressing twice per day or as needed, and perineal care once per day and as needed. 2. In an interview, E3 reported that R1 received assistance with oral care twice per day, dressing twice per day or as needed, and perineal care once per day and as needed during May 2026 and June 2026. 3. A review of R1's medical records revealed two documents titled "Activities of Daily Living" for May 2026 and June 2026. The documents indicated R1 received assistance with oral care once per day and dressing once per day. 4. A review of R2's medical records revealed a service plan, dated February 16, 2026, which indicated R2 needed assistance with perineal care once per day and as needed. 5. In an interview with E3, E3 reported that R2 received assistance with perineal care once per day and as needed during May 2026 and June 2026. 6. A review of R2's medical records revealed two documents titled "Activities of Daily Living" for May 2026 and June 2026. However, the two documents did not indicate that R2 received assistance with perineal care once per day and as needed during May 2026 and June 2026. 7. In an exit interview, the findings were reviewed with E3, and no additional information was provided.”

“Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area that allows the resident to be at least 30 feet away from the facility that is secure, and monitored 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. A review of the facility's documentation revealed the facility was licensed to provide directed care services. 2. During the environmental inspection, the Compliance Officer observed E3 arrive at the facility and turn on the alarm on the back door leading to the secure backyard that allowed a resident to be at least 30 feet away from the facility. 3. During an environmental inspection, the Compliance Officer observed an ambulatory resident open the aforementioned back door, and the alarm did not sound. 4. In an interview with E2 and E3, E3 instructed E2 to keep the alarm on the back door turned on. E2 and E3 reported that the alarm is turned off when residents are taken into the backyard while supervised. However, it does not always get turned back on. 5. In an exit interview, the findings were discussed with E3, and no additional information was provided.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of five employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work... C. Owners shall make documented, good faith efforts to:...2. Verify the current status of a person's fingerprint clearance card..." 2. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of November 14, 2022. The personnel record revealed a fingerprint clearance card issued May 30, 2017. However, the record did not contain documentation that showed the card was verified with DPS. 3. Review of the Department of Public Safety (DPS) fingerprint clearance card database on November 6, 2023, revealed E2's fingerprint clearance card was valid. 4. In an interview, E1 acknowledged documentation was not available that showed E2's fingerprint clearance card was verified with DPS upon hire.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated October 30, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated October 25, 2023. These medication orders stated the following: "Ondansetron HCL 4mg tablet, Sig: 1 tablet orally every 6 hours" "Quetiapine Fumarate 25mg Tablet, Sig: 1 tablet at bedtime" 3. Review of R1's medical record revealed a November 2023 medication administration record (MAR). This MAR stated the following: "Ondansetron HCL 4mg tab 1 tab q6h PO" and indicated the medication was administered at 8am, 1pm, 5pm, and 9pm, not every six hours per the medication order. "Quetiapine 25mg Fumarate 1 tab BID PO" and indicated the medication was administered at 8am and 5pm, not at bedtime per the medication order. 4. During an observation of R1's medications, the following was observed: Ondansetron HCL 4mg was observed Quetiapine 25mg was observed 5. In an interview, E1 reported the medications were administered per the MAR and acknowledged R1's medications were not administered in compliance with the available medication orders.”

“Based on record review, observation, and interview, 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. Findings include: 1. Review of R1's medical record revealed a current written service plan dated October 30, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated October 25, 2023. These medication orders stated the following: "Ondansetron HCL 4mg tablet, Sig: 1 tablet orally every 6 hours" "Pantoprazole Sodium 40mg tablet delayed release, Sig: 1 tablet orally twice a day" "Quetiapine Fumarate 25mg Tablet, Sig: 1 tablet at bedtime" "Metformin HCL 1000mg tablet, Sig: 1 tablet with a meal orally twice a day" "Donepezil HCL 5mg Tablet, Sig: 1 tablet at bedtime orally once a day" "Atorvastatin Calcium 40mg tablet, Sig: 1 tablet orally at bedtime" In addition, R1's medical record revealed a signed medication order dated October 28, 2023. This medication order stated "Pyridium 100 BID". 3. Review of R1's medical record revealed a November 2023 medication administration record (MAR). This MAR stated the following: "Ondansetron HCL 4mg tab 1 tab q6h PO" however, did not include the initials of the individual administering this medication at 1pm, 5pm, and 9pm November 3rd-present. "Pantoprazole Sodium 40mg 1 tab BID PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd-present. "Quetiapine 25mg Fumarate 1 tab BID PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd. "Metformin HCL 1000mg 1 tab BID PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd. "Donepezil HCL 5mg 1 tab PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd. "Atorvastatin Calcium 40mg 1 tab HS PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd. "Phenazopyridine PO 1 tab 100mg" however, did not include the initials of the individual administering this medication at 5pm November 3rd-4th. 4. During an observation of R1's medications, the following was observed: Ondansetron HCL 4mg was observed Pantoprazole Sodium 40mg was observed Quetiapine 25mg was observed Metformin HCL 1000mg was observed Donepezil HCL 5mg was observed Atorvastatin Calcium 40mg was observed Phenazopyridine 100mg was observed 5. Review of R2's medical record revealed a current written service plan dated May 16, 2023. This service plan indicated R2 received medication administration. 6. Review of R2's medical record revealed signed medication orders dated October 3, 2023. These medication orders stated the following: "Famotidine 20mg 1 tab q 12 h po" "Eliquis 5mg 1 tab bid po" 7. Review of R2's medical record revealed a November 2023 MAR. This MAR stated the following: "Famotidine 20mg tab 1 tab q 12 h po" however, did not include the initials of the individual administering this medication at 5pm November 3rd. "Eliquis 5mg tab 1 tab bid po" however, did not include the initials of the individual administering this medication at 8pm November 3rd. 8. During an observation of R2's medications, the following was observed: Famotidine 20mg was observed Eliquis 5mg was observed 9. In an interview, E1 reported the medications were administered per the medication orders and acknowledged R1's and R2's medical record did not include documentation the medications were administered.”

“Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed an opened jar of Smucker's strawberry jam, an opened bottle of Kikkoman soy sauce, and an opened bottle of Sweet Baby Ray's barbecue sauce in the kitchen pantry. These containers stated "Refrigerate after opening". 2. In an interview, E1 and E2 acknowledged the foods were stored in the pantry and required refrigeration.”

“Based on observation and interview, the manager failed to ensure an evacuation path was conspicuously posted on each hallway of each floor of the assisted living facility. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed the hallway on the west side of the facility did not have a posted evacuation path. 2. In an interview, E1 acknowledged the evacuation path was not posted on each hallway of the assisted living facility.”

“Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. The deficient practice posed a health and safety risk to the residents if a fire extinguisher was needed and did not work properly. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed a rechargeable fire extinguisher. This fire extinguisher had a receipt attached that showed a purchase date of October 21, 2021. 2. In an interview, E1 acknowledged the rechargeable fire extinguisher was not serviced at least once every 12 months.”

“Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed four small oxygen tanks unsecured in the hallway. 2. In an interview, E1 acknowledged oxygen tanks were not secured.”

“Based on documentation review, observation, and interview, the manager failed to ensure a dog was licensed with Maricopa County. The deficient posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1. Review of the Maricopa County Animal Care and Control website stated "all dogs three months of age and older are required to have a license..." 2. During an environmental inspection of the facility with E2, O1 was observed. O1 appeared to be older than three months of age. 3. Documentation of a license with Maricopa County was not available for O1. 4. In an interview, E1 acknowledged documentation was not available that showed O1 had a current Maricopa County license.”