Hacienda de Caring Hands LLC.

“Based on record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery.  The deficient practice posed a health and safety risk for residents.  Findings include: 1. A review of E3's personnel file revealed E3 had been hired in October of 2024. However, documentation of ongoing competency training in fall prevention and fall recovery was not available for review. 2. In an exit interview with E1, the finding was reviewed and no additional information was provided. 3. This is a repeat deficiency from the compliance/complaint inspection conducted on January 17, 2025.”

“Based on record review and interview, the chief administrative officer failed to ensure tuberculosis infection control activities were implemented, including baseline screening of employees and annual training and education related to recognizing the signs and symptoms of tuberculosis, for two of two sampled employees. Findings include: 1. A review of E3's personnel file revealed E3 had been hired in October of 2024. However, documentation of initial or annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 2. A review of E4's personnel file revealed E4 had been hired as a caregiver in November of 2025. 3. A review of E4's personnel file revealed a baseline screening document; however, the screening form had been left blank, had not been signed by an occupational health provider, did not include answers to the risk assessment or symptom screen questions, and did not include documentation of a test for tuberculosis. 3. A review of E4's personnel file revealed a doctor's note stating E4 did not have active TB. However, this document would only be required if E4 had a negative symptom screen and a positive test for TB, of which E4 had neither available. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance and complaint inspection conducted on January 17, 2025.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver documented in a patient's medical record an identification of the patient's need for an opioid before the opioid was administered and the effect of the opioid administered, for one of two sampled residents. Findings include: 1. A review of the facility's policies and procedures, last reviewed by E1 on September 26, 2025, revealed a policy titled "Opioid Prescribing and Treatment." This policy stated, "The caregiver will ask the resident to rate the pain level before administering the medication. After the medication has taken effect, the caregiver will ask again. Both responses shall be documented in the Resident Medical Record." 2. A review of R2's medical record revealed a service plan, updated November 18, 2025, for personal care services including medication administration. The service plan did not indicate R2 had an end of life condition or treatment for an active malignancy. 3. A review of R2's medical record revealed a medication order, dated August 18, 2025, for, "Tramadol HCI 50mg Oral Tablet, 2 tab, PO TID." 4. A review of R2's medical record revealed a medication administration record (MAR) dated January 2026. The MAR indicated R2 had been administered Tramadol three times per day as ordered. However, documentation of R2's need for the opioid medication and documentation of the effect of the opioid medication were not available for review. 5. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure the manager provided current documentation of first aid training. 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 E3's personnel record revealed E3 had been hired in October of 2024 as the facility manager. 2. A review of E3's personnel record revealed an American Heart Association, "Heartsaver First Aid CPR AED" certification with a marked expiration of June 2025. 3. A review of E3's personnel record revealed an American Heart Association, "BLS Provider" certification with an issue date of June 9, 2025 and marked expiration of June 2027. However, documentation of current first aid training certification was not available for review. 4. In a telephonic interview, E3 reported the American Heart Instructor had advised E3 the "BLS" certification included first aid and stated E3 had taken a course which included both CPR and First Aid training. However, additional documentation from this instructor was not available during the on-site inspection. 5. Online research at the American Heart Association (cpr.heart.org) website revealed the following "frequently asked question" (FAQ): "Q: Do the AHA’s BLS courses include first aid? A: No, first aid is not included in the AHA’s BLS courses. The AHA offers a variety of courses that will prepare you to respond to a first aid emergency, including Heartsaver First Aid, Heartsaver First Aid CPR AED, Heartsaver Pediatric First Aid CPR AED." 6. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication that is administered to the resident, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, updated July 28, 2025, for personal care services including medication administration. 2. A review of R1's medical record revealed a medication order, dated November 15, 2025, for "Lorazepam 2mg/ml Oral Concentrate, 0.25 ml PO Q4HR PRN." However, R1's medical record contained no more recent orders for Lorazepam. 3. A review of R1's medical record revealed a medication administration record (MAR) dated January 2026. The MAR included documentation of the administration of "Lorazepam 0.5mg take 1 tablet by mouth at bedtime," on each day in January 2026 at 8 PM. 4. A review of R2's medical record revealed a service plan, updated November 18, 2025, for personal care services including medication administration. 5. A review of R2's medical record revealed medication orders, dated August 18, 2025, for "Omeprazole 20mg Oral Tablet, half before breakfast, 1/2 tab, PO, QAM," and "Seroquel 25mg Oral Tablet, 1 tab / 2 tab, PO, 1 tab QAM, 2 tab QHS." R2's medical record contained no more recent orders for Omeprazole or Seroquel. 6. A review of R2's MAR for January 2026 revealed R2 had been administered, "Omeprazole 20 mg 100 mg Take 1 tablet by mouth TID", one time per day at 7:30 AM, and had been administered, "Seroquel 25mg take one tab PO Qam and at Noon, and 2 tablets at dinner time," at 8 AM, 12 PM and 5 PM. 7. A review of R2's medication box and multi-dose container revealed R2 had been administered one 20 milligram Omeprazole tablet each morning, as confirmed by the medication bottle label and the 'pre-poured' pills in the multi-dose container. 8. A review of R1's and R2's medication records revealed change orders for the aforementioned medications were not available for review. 9. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.”

“B. A manager: 3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is: b. Present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises.”

“D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 10. The manager's signature and date signed.”

“A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): a. No later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition; and”

“A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: ii. At least once every six months for a resident receiving personal care services, and”

“C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; and”

“C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 5. A refrigerator used by an assisted living facility to store food or medication contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator;”

“A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;”

“Based on documentation review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training. Findings include: 1. A review of E3's and E4's personnel records revealed documentation of initial training in fall prevention and fall recovery was not available for review. 2. In an interview, E1 acknowledged E3's and E4's personnel records did not include documentation of initial training in fall prevention and fall recovery.”

“Based on observation, interview, documentation review, and record review, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1. Upon arriving at the facility, the Compliance Officer observed E4 working at the facility alone. 2. The Compliance Officer observed a posting in the office designated caregivers to be accountable for the facility when the manager was not present. However, E4 was not designated. 3. In an interview, E1 acknowledged E4 had not designated to be accountable for the assisted living facility when the manager was not present.”

“Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a documented residency agreement. However, the residency agreement had not been signed and dated by the manager. 2. In an interview, E1 acknowledged the manager had not signed and dated the residency agreement for R2 before or at the time of R2's acceptance.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated September 23, 2024, for personal care services. The service plan did not include hospice services. 2. A review of R2's medical record revealed R2 enrolled with hospice services on November 6, 2024. 3. A review of R2's medical record revealed an updated service plan, dated on or before November 20, 2024, was not available for review. 4. In an interview, E1 acknowledged R2's service plan had not been updated within 14 calendar days after R2 had a significant change in condition requiring hospice services.”

“Based on record review, and interview, for one of two residents sampled, who received personal care services, the manager failed to ensure a written service plan was reviewed and updated at least once every six months. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 12, 2024, for personal care services. However, an updated service plan, dated on or before December 12, 2024, was not available for review. 2. In an interview, E1 acknowledged a current service plan had not been provided for R1.”

“Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0F or below. Findings include: 1. During a facility tour, the Compliance Officer observed the following items requiring refrigeration in the pantry: - two bottles of "Original 100% Pasteurized Orange Juice, No Pulp, Not from Concentrate." The bottles were labeled, "Keep Refrigerated." 2. In an interview, E1 acknowledged foods requiring refrigeration had not been maintained at 41\'b0F or below.”

“Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer accurate to plus or minus 3\'b0 F. Findings include: 1. During an environmental inspection of the facility, the Compliance Offices observed that there was a thermometer in the refrigerator in the kitchen. However, the thermometer read -20\'b0 F. 2. In an interview, E1 acknowledged the refrigerator did not contain an accurate thermometer.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers in a locked area and inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the laundry room had been left unlocked. On an open shelf above the washer and dryer, the Compliance Officer observed the following: - a spray can of glass cleaner; - A container of "Quick Shine Hardwood floor luster;" - a spray bottle of "Hop's Perfect Stainless." 2. In an interview, E1 acknowledged poisonous or toxic materials had not been maintained in a locked area and inaccessible to residents.”

“Based on observation, record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence 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, and as specified in R9-10-113, for one of two employees sampled. 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 the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. The Compliance Officer observed E3 was working alone as a caregiver during the on-site inspection. 4. A review of E3's personnel record revealed E3 had been hired as a caregiver in March of 2024. E3's personnel record included a single TST. However, an assessment of E3's risks of prior exposure to TB and a determination if E3 had signs and symptoms of TB, (Baseline Screening) and a second-step TST were not available for review.. 5. In an interview, E1 acknowledged E3 had not provided documentation of evidence of freedom from infectious TB upon hire as required by R9-10-113.”

“Based on observation, record review, and interview, the manager failed to ensure that 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. During an environmental inspection of the facility, the Compliance Officer observed both doors to the office were open and unlocked throughout the on-site survey. Inside the office, the Compliance Officer observed a cabinet containing medi-sets for all residents which had a lock. However, the cabinet was found to have been left unlocked during the on-site inspection. 2. In an interview, E1 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area. This is a repeat deficiency from the on-site complaint inspection conducted on October 10, 2023”