Heritage Oaks Assisted Living LLC.

“Based on record review and interview, the assisted living center failed to maintain a copy of documentation provided to an emergency responder for two years after the date of an emergency, for one of one sampled residents for whom an emergency responder had been contacted on their behalf by the facility. ARS 36-420.04(A-B) states: "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives. B. The assisted living center or assisted living home must notify the resident's authorized representative that the resident was transported to a hospital and provide the name and location of the hospital." Findings include: A review of R1's medical record revealed a medication administration record (MAR) dated March 2026. The MAR documented medications had not been administered to R1 between March 11, 2026, at 8 PM and March 15, 2026, at 5 PM, for the reason, "Resident in the hospital." In an interview, E1 reported R1 has a cardiac condition and was sent to the hospital on March 11, 2026, via emergency medical services (EMS). During the on-site inspection, the Compliance Officer requested to review an incident report, EMS responder packet, progress notes, or hospital discharge information regarding R1's hospitalization; however, no documentation was available for review. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“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 four sampled residents. Findings include: A review of the facility's policies and procedures, last reviewed by E1 and E2 on January 22, 2025, revealed a medication policy. This policy stated, "Prior to administering the opioid, the caregiver or manager will identify and record the resident's pain using either a 1-10 scale if the resident is supervisory or personal level of care. The Personal Care Level Indicator: Ask resident to rate their pain 0 = none to 10 = worse pain ever. The Directed Care Level record the indicator that fits resident has 1 - moaning 2 - crying 3 - restless 4 - crying/screaming 5 - frowning/grimacing 6 - resident specific. i) One hour after administration the caregiver or manager will identify and record the resident's pain using either a 1-10 scale if the resident is supervisory or personal level."  A review of R4's medical record revealed a service plan, dated February 3, 2026, for personal care services including medication administration. The service plan did not indicate that R4 had an end-of-life condition or was receiving treatment for an active malignancy. A review of R4's medical record revealed a medication order, dated January 31, 2026, for "Hydrocodone - Acetaminophen Oral Tablet 5-325 MG, Take 1 tablet orally at bedtime daily for chronic pain syndrome ***Increase Acetaminophen maximum daily dose to 4000 mg***." A review of R4's medical record revealed a medication administration record (MAR) dated March 2026. The MAR indicated R4 had been administered Hydrocodone every day as ordered. However, documentation of R4's need for the opioid medication and documentation of the effect of the opioid medication were not available for review. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of four sampled personnel. The deficient practice posed a risk if E5 was a danger to a vulnerable population. Findings include: A review of E5's personnel record revealed E5 had been hired in December 2024 as a caregiver. E5's personnel record included an employment record listing previous employers. However, documentation of good-faith attempts to contact previous employers was not available for review. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided. This is an uncorrected deficiency from the on-site compliance and complaint inspection conducted on April 14, 2025.”

“Based on 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, before or within seven calendar days after the resident's date of occupancy, for three of four sampled residents. Findings include: A review of R1's medical record revealed baseline screening, to include an assessment of R1's risk of prior exposure to TB, and a determination if R1 had symptoms of TB, was not available for review. R1's medical record included a negative TB test. Based on R1's date of occupancy, completed TB baseline screening was required. A review of R2's medical record revealed baseline screening, to include an assessment of R2's risk of prior exposure to TB, and a determination if R2 had symptoms of TB, was not available for review. R2's medical record included a negative TB test. Based on R2's date of occupancy, completed TB baseline screening was required. A review of R3's medical record revealed baseline screening, to include an assessment of R3's risk of prior exposure to TB, and a determination if R3 had symptoms of TB, was not available for review. R3's medical record included a baseline screening form; however, the form had not been signed by an occupational health provider, medical practitioner, or public health agency. R3's medical record included a negative TB test. Based on R3's date of occupancy, completed TB baseline screening was required. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of four sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: A review of R1's medical record revealed a service plan, dated November 13, 2025, for personal care services including medication administration. A review of R1's medical record revealed a signed list of medication orders, dated February 20, 2026, which included the order, "Metoprolol Tartrate Oral Tablet 50 MG, Give 1 tab by mouth every 12 hours, hold for SBP < 110 or HR < 60." A review of R1's medical record revealed a Medication Administration Record (MAR), dated March 2026. The MAR documented the administration of Metoprolol to R1 and included the following: Documentation of blood pressure and heart rate prior to administration was not available on March 15, 2026, and March 16, 2026, at 8:00 PM, March 17, 2026, at 8:00 AM and 8:00 PM, March 18, 2026, at 8:00 AM and 8:00 PM, March 19, 2026, at 8:00 AM and 8:00 PM, and March 20, 2026, at 8:00 AM; On March 20, 2026, at 8:00 PM, R1's blood pressure was 102/64; however, the medication was not held; On March 22, 2026, at 8::00 PM, R1's blood pressure was 157/110; however, the medication was held; On March 26, 2026, at 8:00 AM, R1's blood pressure was 87/71; however, the medication was not held; and On March 28, 2026, at 8:00 AM, R1's blood pressure was 107/88; however, the medication was not held. In an exit interview with E1 and E2, the findings were reviewed, and no additional information was provided. This is a repeat deficiency from the on-site compliance inspection conducted on January 30, 2023, and the on-site compliance and complaint inspection conducted on April 14, 2025.”

“Based on record review and interview, when a resident had an emergency that resulted in the resident needing emergency services, the manager failed to ensure a caregiver or an assistant caregiver documented the incident as required. Finding include: A review of R1's medical record revealed a medication administration record (MAR) dated March 2026. The MAR documented medications had not been administered to R1 between March 11, 2026, at 8 PM and March 15, 2026, at 5 PM, for the noted reason, "Resident in the hospital." In an interview, E1 reported R1 had a cardiac condition and was sent to the hospital on March 11, 2026, via emergency medical services (EMS). During the on-site inspection, the Compliance Officer requested to review an incident report, EMS responder packet, progress notes, or hospital discharge information regarding R1's hospitalization; however, no documentation was available for review. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“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 (TB) infection control activities required in R9-10-113.A.2.a-f.     Findings include:     1. A review of E1’s and E4’s personnel records revealed annual training and education related to recognizing the signs and symptoms of TB, to include initial training per R9-10-113.A.1, was not available for review.   2. A review of R1’s medical record revealed documentation of baseline screening to include a risk assessment, symptom screening, and a negative TB test, dated within seven days after R1’s date of acceptance, was not available for review.   3. A review of R2’s medical record revealed a negative TB test dated 19 days prior to R2’s date of admission. However, documentation of a complete baseline screening to include a risk assessment and symptom screen were not available for review.   4. In an interview, E1 and E2 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 for this rule during the on-site compliance and complaint inspection conducted on January 3, 2024.”

“Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for four of four personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population.      A.R.S. § 36-411 states:   "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.   B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section.   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. Verify the current status of a person's fingerprint clearance card.   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.   D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service.   E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked.   F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.   G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety.   H. For the purposes of this section:   1. "Direct supportive services":   (a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including:   (i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair.   (ii) Assistance with self-administration of medication.   (iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room.   (iv) Transportation services, including van services.   (b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution.   2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised.   3. "Home health services" has the same meaning prescribed in section 36-151."     Findings include:   1. A review of E1’s personnel record revealed E1 had been hired in August of of 2020, and was a manager.   2. A review of E1's personnel record revealed documentation of an Adult Protective Services registry check was not available for review.   3. A review of E3's personnel record revealed E3 had been hired as an assistant caregiver in December of 2024.   4. A review of E3's personnel record revealed documented attempts to contact E3's prior employers was not available for review. 5. A review of E3's personnel record revealed documentation of an Adult Protective Services registry check was not available for review.   6. A review of E4’s personnel record revealed E4 had been hired as a caregiver in February of 2023.   7. A review of E4's personnel record revealed an employment record covering August of 2022 through E4's hire date. However, E4's fingerprint clearance card had been issued in 2018, leaving a more than six month period of time between 2018 and August of 2022 during which E4's employment record did not document E4 had been employed by any employer.   8. A review of E5’s personnel record revealed E5 had been hired as a caregiver in October of 2023.  9. A review of E5's personnel record revealed documentation of an Adult Protective Services registry check was not available for review.   10. In an interview, E1 and E2 acknowledged the personnel records provided for E1, E3, E4, and E5 did not include documentation of compliance with all sections of ARS § 36-411.”

“Based on documentation 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:  1. A review of the facility's license revealed the facility was licensed to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed an exit door from the kitchen had a door alarm magnet, but was missing the door alarm entirely. The Compliance Officer observed when the door was opened, an alarm did not sound. 3. During an environmental tour of the facility, the Compliance Officer observed an exit door from the living room had a door alarm, but was missing the magnet. The Compliance Officer observed when the door was opened, an alarm did not sound. 4. In an interview, E1 and E2 acknowledged the facility provided directed care services, and did not have a means to control or alert employees of the egress of a resident from the facility on all exits.”

“Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a mediation order, for one of two sampled residents. Findings include: A review of R2's medical record revealed a service plan, dated November 11, 2024, for personal care services including medication administration. A review of R2's medical record revealed a Medication Administration Record (MAR) dated March 2025. For the medication, "Memantine HCI Oral Tablet 5 MG, Give 5 mg by mouth at bedtime for dementia," the MAR indicated the following: On March 20, 2025, the medication had not been administered due to, "Medication not Available"; On March 21, 2025, the medication had not been administered due to, "Medication not Available"; On March 22, 2025, the medication had not been administered due to, "Medication not Available"; On March 23, 2025, the medication had not been administered due to, "Medication not Available"; On March 24, 2025, the medication had not been administered due to, "Medication not Available"; On March 25, 2025, the medication had not been administered due to, "Medication not Available"; On March 26, 2025, the medication had not been administered due to, "Medication not Available"; On March 27, 2025, the medication had not been administered due to, "Medication not Available"; On March 28, 2025, the medication had not been administered due to, "Medication not Available"; On March 29, 2025, the medication had been marked as administered; On March 30, 2025, the medication had not been administered due to, "Medication not Available"; and On March 31, 2025, the medication had not been administered due to, "Medication not Available". A review of R2's medical record revealed an order from a medical practitioner ordering the medication to be held until filled, discontinued, or changed was not available for review. A review of R2's medical record revealed a termination notice stating the facility was not able to meet R2's needs for ordered medication was not available for review. In an interview, E1 acknowledged the medication had not been administered on March 29, 2025 as it was not yet available on that date. In an interview, E1 and E2 acknowledged R2 had not been administered Memantine between March 20 and March 31 due to the medication not being available.”

“Based on documentation review, record review, and interview, the health care institution 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 one of four personnel sampled.   Findings include:    1.    A review of E3's personnel record revealed documentation of completed initial training on fall prevention and fall recovery was not available for review. 2.    In an interview, E1 and E2 acknowledged the personnel record provided for E3’s had not included documentation of initial training in fall prevention and fall recovery training.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated August 16, 2023, for personal care services. The service plan stated the following service would be provided to R2: - "Constipation: 1) Monitor bowel movements daily. 2) Include high fiber foods, such as beans, whole grains, fresh fruit and vegetables in diet daily. 3) Offer fluids in between meals 4) Give PRN medication, as ordered, for constipation if no bowel movement. 4) If [R2] has any of the following call Doctor: distended abdomen, abdominal pain, vomiting or no bowel movement for 3 days." 2. A review of R2's electronic medical record revealed a, "Care Tracking Sheet," dated December 2023, which documented the services provided to R2. However, documentation of bowel movements were not available for review. 3. A review of facility documentation revealed a log titled, "BM Tracking Sheet," which documented the bowel movements and assistance provided to all residents at the facility between December 9, 2023 and January 1, 2024. However, documentation of R2's bowel movements were not available for review. 4. In an interview, E2 reported the service plan for R2 may need to be updated because R2 was independent of toileting and could report bowel movements to staff if required but did not regularly receive assistance with toileting. E1 and E2 acknowledged documentation of services provided to R2 did not include documentation of bowel movements as required by R2's service plan. Technical assistance for this rule was provided during the onsite compliance inspection conducted on January 30, 2023.”