CARING HEARTS SENIOR CARE LLC

INSP-0158671

Complete

Date: 8/28/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-09-23

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00103083 conducted on August 28, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

A.R.S. § 36-420.01.A. 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.

Evidence/Findings:

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "Fall Prevention and Recovery Training." The P&P stated, "The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery.” The P&P continued, “The established care home will provide and deliver training for employees on Fall Prevention and Fall Recovery.” 2. A review of E2's personnel record revealed E2 was hired as a housekeeper. However, the review revealed no documentation of training regarding fall prevention and fall recovery. 3. In an interview, E1 reported E1 thought E2 did not need the training since E2 was a housekeeper, stating, “That’s why I didn’t do it.”

Permanent Solution:

Upon the exit interview; the manager was made aware of the deficiency, and the manager immediately removed employee E2 from the work schedule until E2 completed the Fall Prevention and Fall Recovery training and documented. E2’s Fall Prevention and Fall Recovery was verified by the manager on 8.29.2025 and the verification form was completed and placed in E2’s personnel file.

Person Responsible:

Andreea Velciu, Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-113.A.2.a-f. Tuberculosis Screening A. 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, baseline 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); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on documentation review, record 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 to individuals employed by the health care institution, for one of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.” The webpage stated: “The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting…Initial TB training should be provided before the HCW starts working.” 2. A review of E2’s personnel record revealed E2 was hired as a housekeeper. However, the review revealed no documentation demonstrating E2 received training and education related to recognizing the signs and symptoms of TB. 3. In an interview, E1 reported E1 thought E2 did not need the TB training since E2 was a housekeeper, stating, “That’s why I didn’t do it.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on October 18, 2023.

Permanent Solution:

Upon the exit interview; the manager was made aware of the deficiency, and the manager immediately removed employee E2 from the schedule until E2 completed the TB training and education related to recognizing the signs and symptoms of TB. E2’s TB training and education was verified by the manager on 8.30.2025 and the verification form was completed and placed in E2’s personnel file.

Person Responsible:

Andreea Velciu, Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident’s date of occupancy, and 2. As specified in R9-10-113

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure 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 Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-ii) 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…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 [and] ii. Determining if the individual has signs or symptoms of tuberculosis.” 2. A review of R2's medical record revealed R2 was admitted to the facility more than seven days before the date of the inspection. However, the review revealed no documentation assessing risks of prior exposure to infectious tuberculosis and determining if R2 had signs or symptoms of TB. 3. In an interview, when the Compliance Officer asked if the facility had the aforementioned documentation for R2, E1 stated, “I don’t have it” and “I forgot to do it.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on October 18, 2023.

Permanent Solution:

Upon identification of the deficiency, the Manager immediately reviewed R2’s admission documentation and confirmed that the resident did not have the TB Assessment done prior to the date of move-in. The Manager called R2’s PCP to come out and do a TB assessment and screening on R2. No signs or symptoms of infectious TB were identified and the PCP of R2 signed the TB assessment and screening document and was filed away in the resident’s file.

Person Responsible:

Andreea Velciu, Manager

Deficiency #4

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander; 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on documentation review, observation, and interview, the manager failed to ensure 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 monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk as the facility was unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed a door leading from the facility to the backyard. The Compliance Officer observed the door had an alert installed. However, upon opening the door, the Compliance Officer heard no alert. 3. In an interview, E1 reported the alert on the door triggered a sounding device plugged into an outlet in the dining room. 4. The Compliance Officer observed the sounding device was not plugged in. 5. In an interview, E1 reported a caregiver working the overnight shift likely unplugged it to go outside and forget to plug it back in.

Permanent Solution:

During the onsite inspection, the manager immediately plugged back into the outlet the sounding device and was double checked that it was properly connected, operational, and audible. Immediately following the inspection, the manager verified all door exit alarms throughout the residential assisted living home were also properly connected, operational, and audible. All residents were accounted for, and no incidents of unsafe egress were identified.

Person Responsible:

Andreea Velciu, Manager

INSP-0063611

Complete

Date: 10/18/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2023-11-07

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00196993 conducted on October 18, 2023:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
a. Is administered by an individual under direction of a medical practitioner,

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication was administered to a resident under the direction of a medical practitioner, for one of two residents reviewed. The deficient practice posed a risk as medication administration was being completed by individuals who had not been approved by a qualified individual to provide medication administration services.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated September 29, 2023. This service plan indicated R1 received medication administration. Review of R1's medical record revealed medications were administered by facility caregivers. However, documentation from a medical practitioner stating a manager or caregiver could administer medications was not available.

2. Review of E1 and E3's personnel records revealed no documentation from a medical practitioner stating medications could be administered by a manager or caregiver or that E1 and E3 were nurses.

3. In an interview, E1 acknowledged the facility caregivers provided medication administration services to R1 without designation and authorization by a medical practitioner to administer medications to the resident.

Deficiency #2

Rule/Regulation Violated:

D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver:
2. Documents the following:
f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistance caregiver documented the action taken to prevent the accident, emergency, or injury from occurring in the future, for one of two residents who required medical services after an accident, emergency, or injury. The deficient practice posed a risk as the facility did not document preventative measures to protect the health and safety of residents.

Findings include:

1. A review of facility documentation revealed an incident report (dated September 12, 2023). The report stated "Resident was feeling weak and thinking possible stroke... called 911 and the paramedics took [R2] to .... Hospital." However, documentation of any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review.

2. In an interview, E1 reported R2 was monitored for three days.

3. A review of facility documentation revealed an incident report (dated October 2, 2023). The report stated "blood discharge from genital area ... Resident Taken to Hospital." However, documentation of any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review.

4. In an interview, E1 reported R2 returned to facility with a catheter and antibiotics.

Facility Information

Inspection History

INSP-0158671

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0063611

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings: