Loving Arms Assisted Living, LLC.

“Based on record review, documentation review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for three of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Review of E2’s personnel records revealed E2 did not have annual TB training in identifying the signs and symptoms for the years 2024 and 2025 in their file at the time of the inspection. Based on E2’s hire date this documentation was required. E2 did have TB training for January 2023. 2.  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." 3. Review Of E1’s and E3’s personnel record revealed E1 and E2 did not have initial TB training. Based on E1’s and E3’s hire date this documentation was required.  4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, observation, and interview, the manager failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411, for one of three personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population.   Findings include:   1. A.R.S. § 36-411(C)(1) states: "C. 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. Review of E3’s personnel record revealed E3’s references. However, E3’s references were not previous employers. The references were labeled as, “friend”.  3. In an interview, E1 acknowledged E3 did not have reference checks from previous employers and did not bring other documents to show previous employers were called and verified for E3.  4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, observation, interview, and record review, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individual was not qualified to provide the required services.   Findings include: 1. The facility was licensed at the Directed Care Level. 2. A review of A.R.S. § 36-401.A.49. revealed "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 3. The Compliance Officers observed E1 and E3 working at the time of the inspection. 4. The Compliance Officers observed E3 going into the residents’ rooms unsupervised.  5. In an interview, E1 was questioned as to why the Compliance Officers were unable to enter R2’s room. E1 reported at the time of the environmental inspection R2 was being changed by E3.  6. Review of E3’s personnel record revealed E3 was hired as an assistant caregiver. In E3’s personnel record there was no documentation of a caregiver certificate.  7. Electronic review of https://azcg.tmutest.com/ revealed no results for a caregiver certificate for E3.  8. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, observation, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of three employees sampled. 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) test is used to test health care personnel upon hire (preplacement), two-step testing should be used."  3. The Compliance Officers observed E3 working at the time of the inspection. 5. Review of E3’s personnel record revealed E3’s date of hire was September 2025.  6. Review of E3’s personnel record revealed E3’s first TB skin test was administered September 2025. Then E3’s second skin test was administered in October 2025. Based on E3’s hire date this second TB skin test was supposed to be done prior to providing services.  7. Review of the facility documentation of the employee work schedule revealed October 2025’s work schedule was missing.  8. In an interview, E1 acknowledged the October 2025 work schedule was missing and did not provide the requested documentation. 9. In an interview, E3 reported E3 was working assisting caregivers around September 15th or 16th of 2025.  10. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained for each employee as required for one of three employees sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. The Compliance Officers observed the E1 working at the time of the inspection. 2. The Compliance Officers observed E1 filling out documentation at the time of the environmental inspection. The Compliance officers requested the documents that E1 was working on and E1 handed the documents over to the Compliance Officers. The documents were blank except for E1’s name, position, date of hire, and caregiver license.  3. In an interview, E1 reported E1 was filling out E1’s personnel documentation. E1 reported E1 was waiting to receive E1’s employee file from E1’s previous job. E1 reported E1’s previous job would not give E1’s employee file to E1 and that is why E1’s personnel file is blank. The Compliance Officers asked if E1’s previous job was a sister facility or a part of E1’s current employer's LLC. E1 replied, “no”.  4. Review of E1’s personnel file revealed the documents were blank except for the hire date, position, and the caregiver certificate. Based on E1’s hire date this was required. 5. In an interview, E1 acknowledged E1’s personnel record was blank and was supposed to be filled out.  6. In an exit interview, the findings were reviewed with E3, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one 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. Review of R2’s medical record revealed no documentation of R2’s TB test or signs and symptoms risk assessment questionnaire. Based on R2’s date of acceptance this was required. 3. In an interview, E1 acknowledged R2’s medical record did not have any TB tests or the signs and symptoms risk assessment questionnaire.  4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included the facility responsibilities for two of two sampled residents. Findings include: 1. Review of R1’s and R2’s medical records revealed residency agreements. However, the residency agreements did not include the facility’s responsibilities.  2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included a list of the services available from the assisted living facility at an additional fee or charge for two of two sampled residents. Findings include: 1. Review of R1’s and R2’s medical records revealed residency agreements. However, the residency agreements did not include a list of the services available from the assisted living facility at an additional fee or charge. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure, for two of two sampled residents, a resident had a service plan which accurately included the amount, type, and frequency of assisted living services and ancillary services being provided to the resident. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. Review of R1’s current service plan was dated August 2025. This service plan did not have the frequency for the following services that were provided to the resident: - Dressing - Laundry - Maintenance of room Only “Dependent” was marked on the service plan. 2. Review of R2’s current service plan was dated October 2025. This service plan did not have the frequency for the following services that were provided to the resident: - Dressing - Laundry - Maintenance of room Only “Dependent” was marked on the service plan. 3. In an interview, E1 reported those services were provided to the residents and acknowledged the service plan did not have the frequency for the services mentioned above.  4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for two of two residents sampled. 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 service plan, dated August 2025 which revealed R1 received medication administration.  2. Review of R1’s medical record revealed a medication list that contained the following: - Lomotil Tablet 2.5- 0.025 mg - Lisinipril tablet 2.5 mg - Atorvasatin Calcium tablet 40 mg - Aspirin tablet 81 mg  - Senna plus tablet 8.6- 50 mg - Ipratropium Albuterol solution 0.5-2.5 (3) mg/ 3ml - Trazadone tablet 50 mg - Acetaminophen extra strength 500 mg - Ondansetron tablet disintegrating 4 mg - Metformin tablet 500 mg - Atavan tablet 0.5 mg However there was no signature from a medical practitioner for these medications mentioned above. 3. Review of R1’s medical record revealed a medication administration record (MAR) for December 2025. This MAR revealed R1 was receiving the medications mentioned above from the start of December to present day.  4. In an interview, E1 called someone on the phone and asked for the medication orders. The person on the phone spoke to the Compliance Officers and asked what medications orders the Compliance Officers needed. The Compliance Officers told the person on the phone they will need signed medication orders for R1 and R2. E1 later reported the medication orders were going to be faxed. However, E1 did not provide the signed medication orders. The Compliance officers never saw the signed orders at the time of the inspection.  5. In an interview, E1 reported the medication that was documented on the MAR was administered to R1. 6. Review of R2’s medical record revealed a current service plan dated October 2025. This service plan revealed R2 received medication administration. 7. Review of R2’s medical record revealed a document titled “Medication Record for PRN, opioid, and controlled medications” which revealed Hydroco/APAP 325 mg was administered on December 25, 2025. However a medication order that was signed by a medical practitioner was not presented at the time of the inspection.  8. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. Review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed ambulatory residents.  3. The Compliance Officers observed the following medication in a plastic bag on the kitchen counter: - A bottle of Tylenol pm - A bottle of Advil pm - A box of Advil 200 mg tablets - A bottle of Alieve 220 mg tablets - Non-drowsy Claritin 10 mg - A tube of Neosporin pain relief ointment 4. The Compliance Officers observed unlocked kitchen cabinets that contained medication for the seven residents in the facility. The following medications were observed in the cabinets: - Approximately five bottles of Polyethylene Glycol 3350 - A bottle of Lactulose Solution USP 10 g/ 15 mL - A bottle of Cetrizine Hydrochloride 10 mg - A blister pack of Hydrococo/APAP 5-325 mg 5. Review of the facility policy and procedures revealed a policy titled, “Medication Policy and Procedure” which stated, “A locked secured area is used for storage of medications, solutions, and prescriptions. This area is locked when not in use and is to be inaccessible to residents.”  6. In an interview, E1 reported a family member dropped off the plastic bag of medications the night before the inspection. E1 also acknowledged the plastic bag was left out until the morning of the inspection and the medications cabinets were unlocked.  7.  In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance and complaint inspection on July 26, 2024.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed an unlocked garage door. In the garage the Compliance Officers observed the following: - One 3.58 L of Clorox performance bleach - One bottle of Lysol Laundry sanitizer - One container of Wind Fresh + Oxi laundry detergent - One bottle of Fabuloso - One bottle of Fabric Softener ultra concentrated 2. In an interview, E1 acknowledged the door was supposed to be locked however it was not. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two sampled residents. The deficient practice posed a risk as medication could not be verified as administered against a medication order and the medical record inaccurately indicated a medication was administered. Findings include: 1. A review of the R1's medical record revealed an order dated July 24, 2024 for "Sulfa/Trimet 800 mg take one tablet by mouth for ten days." 2. A review of R1's July 2024 medication administration record (MAR) did not include Sulfa/Trimet 800 mg. 3. A review of R1's medical record revealed a medication order dated March 20, 2024 for "Amlodipine Besylate 2.5 MG 1 tablet ORAL 1 times a day." 4. A review of R1's medical record revealed a July 2024 MAR. The MAR indicated Amlodipine Besylate 2.5 MG was administered at 8 AM and 5 PM. 5. In an interview, E1 reported the medications were administered per the medication orders and acknowledged R1's medical record did not include accurate documentation the medications were administered.”

“Based on observation and interview, the manager failed to ensure medication 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 were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed an unlocked kitchen cabinet. Upon looking inside, the Compliance Officer observed a tube Mupirocin Ointment USP 2%. 2. The Compliance Officer observed an unlocked mini refrigerator located in the hallway by the kitchen. Upon looking inside, the following medications were observed: - Humulin R U- 500 Kwikpen 500U/ ML - 500 units of prefilled insulin - Acetaminophen 650mg - Rivastigmine 9.5 mg 3. In an interview, E1 acknowledged medications were not stored in a locked room, closet, cabinet, or self-contained unit.”