Heavenly Assisted Living Facility.

“Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of E1’s and E2’s personnel records revealed initial and/or current annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 2 . A review of facility documentation revealed an annual assessment of the health care institution's risk of exposure to infectious tuberculosis was not available for review. 3. In an interview, E1 acknowledged the health care institution had not documented, and implemented tuberculosis infection control activities as required in R9-10-113.A.2.a-f. Technical assistance was provided during the on-site compliance inspection conducted on May 22, 2024.”

“Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings include:  1. During an environmental tour of the facility, the Compliance Officer observed E2 at the facility, providing services to residents, such as administering medications and operating a Hoyer lift.  2. A review of the facility's personnel schedule revealed E2 was not on the work schedule. The work schedule indicated E1 and E3 worked the 7AM to 7 PM shift, and revealed E1 and E4 worked the 7 PM to 7 AM shift, between March 16, 2025 and the day of the inspection. 3. In an interview, E1 reported E4 has not been employed by the facility for some time and reported the work schedule was not accurate. E1 reported E2 had just started working the day of the inspection. E1 acknowledged the facility failed to maintain documentation of the caregivers and assistant caregivers working each day, including the hours worked by each.”

“Based on observation, record review, and interview, the manager failed to maintain a personnel record for each employee which included the items required by this rule, for one of two personnel sampled. The deficient practice posed a risk as required information could not be verified for an employee. Findings include: 1 . The Compliance Officer observed E2 working in the facility as a caregiver, providing medication administration and operating a mechanical lift without supervision. 2. In an interview, E1 reported E2 had started working as a caregiver on the day of the on-site inspection. 3. A review of E2's personnel record revealed the following documentation was not available for review: E2's and contact telephone number; E2's starting date of employment; E2's skills and knowledge applicable to the E2's job duties, to include verification of E2's skills and knowledge; E2's completed orientation and in-service education required by policies and procedures, to include fall prevention and fall recovery training; E2's evidence of freedom from infectious tuberculosis, as E2's personnel record included a negative blood test from 2023 and did not include a risk assessment, symptom screen, or current test; Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C), to include documented good faith attempts to contact prior employers or verification of the current status of E2's fingerprint clearance card. 4. In an interview, E1 reported they thought they had some time after hiring a caregiver to get the personnel file together. E1 acknowledged E2's personnel record did not include all required documentation.”

“Based on record review and interview, the manager failed to ensure a written service plan included the level of service the resident is expected to receive, for one of two residents sampled. Findings include: 1 . A review of R2's medical record revealed a service plan dated January 5, 2025 for directed care services. However, a current service plan, dated on or before April 5, 2025 was not available for review. 2 . In an interview, E1 reported R2 was actually personal care, the service plan was not accurate, and a service plan update was not yet due. E1 acknowledged R2's service plan had not included the level of service the resident was expected to receive.”

“Based on record review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled 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:  A review of R1's and R2's medical records revealed R1 and R2 received directed care services.  During an environmental tour of the facility, the Compliance Officer observed the sliding back door to the patio and a rear exit door in a bathroom past the laundry room were equipped with an alarms to alert employees of egress; however, the alarms were not functional at the time of the inspection.  In an interview, E1 reported the door alarms were wired to the home alarm system, and E1 would need to contact the alarm company to come out and service the alarms. E1 reported E1 would obtain additional alarms right after the survey if the alarm system could not be repaired immediately. E1 acknowledged that the facility provided directed care services and there was an uncontrolled means for a resident to exit or egress from the facility without alerting a caregiver.”

“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 residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. 1 . A review of R2's medical record revealed a service plan, dated January 5, 2025, for directed care services including medication administration. 2 . A review of R2's medical record review revealed a prescription dated February 21, 2025 for, "Quetiapine 25 mg tab, 1 tab po Q 2x day". 3 . Further review of R2's medical record revealed a medication administration record (MAR) sheet for April 2025 . The Mar included documentation of, "Quetiapine 25 mg tabs, take 1 tab by mouth QHS." However, the medication was documented to have been administered once a day instead of twice a day per the order, and the MAR did not include documentation of any medication administered between April 15 and April 21, the day of the on-site inspection. 4 . In an interview, E1 acknowledged R2's medical record did not contain accurate documentation of Quetiapine administration. This is a repeat deficiency from the on-site compliance inspection conducted on May 9, 2023 and the on-site compliance inspection conducted on May 22, 2024.”

“Based on observation and interview, the manager failed to ensure there was a current drug reference guide that was available for use by personnel members. Findings include: 1. During the environmental tour, the Compliance Officer observed that the facility provided medication administration services. 2. The Compliance Officer requested a current drug reference guide. However, the provided reference guide was published in 2012. 3. In an interview, E1 acknowledged that the facility did not have a current drug reference guide available for use by personnel members. Technical assistance for this rule was provided during the on-site compliance inspection conducted on May 22, 2024”

“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 R1's medical record revealed a documented residency agreement. However, the residency agreement had been signed and dated by the manager seven days after R1's date of acceptance. 2. A review of R1's medical record revealed a medication administration record (MAR). The MAR documented medication had been administered to R1 for seven days before the date of the manager's signature on R1's residency agreement. 3. In an interview, E1 acknowledged the manager had not signed and dated the residency agreement for R1 before or at the time of R1's acceptance.”

“Based on observation and interview, the manager failed to ensure a current calendar of activities was posted. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a current calendar of activities was not posted in a location easily seen by residents. 2. In an interview, E1 acknowledged the current calendar of activities was not posted in an area designated for resident use.”

“Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated February 7, 2024, for personal care services, including medication administration. 2. A review of R1's medical record revealed a list of medication orders, dated April 1, 2024 , which included: - "Ferrous Sulfate 324mg: Give 1 tab by mouth every Monday, Wednesday, and Friday morning"; - "Fluticasone 50 mcg NAS Sp: Give 1-2 Sprays into each nostril every morning"; - "Colace 100 mg: Give 1 Capsule PO BID As needed for Constipation"; - "Senna 8.6 mg Tab Give 1 Tab by mouth BID PRN." 3. A review of R1's medical record revealed a medication administration record (MAR) dated May 2024. The MAR indicated the following: - "Ferrous Sulfate, 324 mg tab, Give 1 tab by mouth every Monday, Wednesday, and Friday morning," had been administered every day between May 1, 2024 and May 22, 2024; - "Fluticasone 50 mcg NAS SP, Give 1-2 Sprays in to each nostril every morning," had been marked as administered every day between May 1, 2024 and May 22, 2024, however, the amount provided had not been documented; - "Colace 100 MG, Give 1 Capsule PO BID as needed for constipation," had not been administered in May 2024; and - "Senna 8.6 mg Tab, 1 Tab PO BID PRN," had not been administered in May 2024. 4. The Compliance Officer observed a medication organizer for R1 contained the following: - Ferrous Sulfate was not present in R1's; - Colace was in every AM section; and - Senna was in every AM section. 5. In an interview, E1 acknowledged R1's orders, MAR, and medication organizer could not be reconciled and R1 had not been administered medication in compliance with a medication order. E1 reported R1's responsible party had just provided the new bottle of Ferrous Sulfate and it had not been added to the organizer yet, and reported R1 had been requesting the Colace and Senna every morning, which is why they had been added to the organizer even though they were not scheduled medications.”

“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 the door to the office had a lock. However, the key had been left in the lock, leaving the office accessible to residents. Inside the office, the Compliance Officer observed a cabinet containing medi-sets for all residents, medications on open shelving, and a refrigerator containing unsecured medications stored alongside food items. 2. In an interview, E1 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area used only for medication storage. This is a repeat deficiency from the on-site compliance inspection conducted on May 9, 2023”

“Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. The deficient practice posed a potential residents' rights violation if residents were not treated with dignity, respect, or consideration. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a food menu was not posted conspicuously. 2. In an interview, E1 reported the menu had been moved into the office while the door the menu is normally posted on was painted. 3. The Compliance Officer observed the menu posted in the office, an area not designated for resident use, was dated May 11 through May 18, 2024. 4. In an interview, E1 acknowledged a food menu had not been conspicuously posted at least one calendar day before the first meal on the food menu was served. This is a repeat deficiency from the on-site compliance inspection conducted on May 9, 2023.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet located in a bathroom adjacent to the laundry room had a lock, however, the cabinet was found to be unlocked during the inspection. Inside the cabinet, the Compliance Officer observed the following: - "Performance Plus Stainless Steel Cleaner;" - "Shout" laundry stain remover; - "Carbona Outdoor Cleaner;" - "Easy Off;" - "Miracle Spray for Electronics;" and -"Lemon-D Neutral Cleaner." 2. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on May 9, 2023.”