WE CARE RECOVERY LLC

<p>Based on record review, documentation review and interview, the manager failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for one of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents.</p><p><br></p><p><br></p><p>Findings Include:</p><p><br></p><p><br></p><p>1. A review of E2’s personnel record revealed E2's most current fall prevention and recovery training available was completed on October 15, 2023. No other fall prevention and recovery training beyond that date was available.</p><p><br></p><p><br></p><p>2. A review of the facility's policies and procedures revealed a document titled, "Fall Prevention and Fall Recovery" with the following verbiage, "This facility shall develop an initial training, conduct, and administer continued competency Training for all staff in Fall Prevention and Fall Recovery Program at least once every 12 months."</p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>

<p>Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that includes the information prescribed in A.R.S. § 36-420.04.A.1-9 for two out of two residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed no documentation of a standardized form to provide to emergency responders that included the following: </p><ul><li>The name, address and telephone number of the resident's current pharmacy;</li><li> The name and contact information for the resident's primary care physician and power of attorney or authorized representative;</li><li>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;</li><li>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;</li><li>A list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered; and</li><li>A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive.</li></ul><p><br></p><p><br></p><p>2. <span style="background-color: rgb(255, 255, 255);">A review of R2's medical record revealed no documentation of a standardized form to provide to emergency responders that included the following: </span></p><ul><li>The name, address and telephone number of the resident's current pharmacy;</li><li>The name and contact information for the resident's primary care physician and power of attorney or authorized representative;</li><li>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;</li><li> 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; and</li><li>a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered.</li></ul><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>

<p>Based on documentation review and interview, the health care institution failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a TB exposure risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of the facility's documentation revealed no facility risk assessment for infectious tuberculosis was documented and available during the inspection.</p><p><br></p><p><br></p><p>2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure that policies and procedures were established, documented, and implemented to protect the health and safety of a resident, that covered job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk as there was no policy and procedure to reinforce and clarify the health care institution’s standards. </p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">1. A review of the facility's policies and procedures revealed a policy titled "Staffing, hiring, orientation, and in-service training". This policy stated "Upon being hired by the facility the applicant must:... Verification of qualifications, knowledge, and skills to perform the duties of the job hired for." Another document that was found in their policies and procedures titled, " Roles and Responsibilities of A Manager" stated "Responsibilities and duties of the manager shall include, but not be limited to: 12. Ensuring that staff have the necessary qualifications, skills, training and/or experience to deliver the services and care required by the residents it serves." There was no verbiage found in the facility's policies and procedures that determined how the facility would verify staff's skills and knowledge.</span></p><p><br></p><p><br></p><p>2. A review of E3's personnel record revealed there was no documentation of verification of skills and knowledge.</p><p><br></p><p><br></p><p>3. A review of the facility's staff schedule revealed E3 worked shifts during the month of September 2025. E3 was also observed by the Compliance Officers to be working and giving care to residents during the day of the inspection, October 7, 2025.</p><p><br></p><p><br></p><p>4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two caregivers sampled. The deficient practice posed a potential TB exposure risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>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)..."</p><p><br></p><p><br></p><p>2. A review of E3's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E3 had signs or symptoms of TB. Based on E3's hire date, this documentation was required. </p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>

<p>Based on record review and interview, the manager failed to ensure that a resident's service plan included the level of service the resident was expected to receive for one of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1’s medical record revealed a service plan that did not include the level of service the resident was expected to receive.</p><p><br></p><p><br></p><p>2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. </p>

<p>Based on record review and interview, the manager failed to ensure that a caregiver documented the services provided in the resident’s medical record. The deficient practice posed a risk as services could not be verified as provided against a service plan.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed a service plan dated April 21, 2025. This service plan stated the following services were needed:</p><ul><li>Reposition every 2 hours during day; at least once at night.</li><li>Diaper change every 2-3 hours and PRN.</li><li>Assist with feeding as needed.</li><li>Encourage fluids and monitor intake.</li><li>Daily skin checks of sacral area, heels, shoulders."</li></ul><p>However, documentation was not available showing these services were provided.</p><p><br></p><p><br></p><p>2. A review of R2's medical record revealed a service plan dated for February 1, 2025. <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">This service plan stated the following services were needed:</span></p><ul><li>Bathing: Requires assistance.</li><li>Dressing: Requires assistance with lower body dressing</li></ul><p>However, documentation was not available showing these services were provided.</p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. </p>

<p>Based on observation, record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon acceptance and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental inspection of the facility with E2, the Compliance Officer observed R2 was wheelchair bound due to being an amputee.</p><p><br></p><p><br></p><p>2. A review of R2's medical record revealed a document titled, "Determination for Residency to Continue in the Facility" that stated R2 was unable to ambulate even with assistance and was confined to a bed or chair. The document was signed by a doctor and dated January 29, 2025. However, documentation was not available that stated R2's needs could be met by the facility and R2's needs were within the facility's scope of services, at least once every six months.</p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>

<p>Based on observation 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 could access the medication.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental inspection of the facility, the Compliance Officers (COs) observed an unlocked mini refrigerator in the kitchen/office area of the facility that contained the following:</p><ul><li>a bag of syringes for Lorazepam 2mg;</li><li>bottle of Geri-Tussin DM Cough Suppressant 16 fl oz;</li><li>box of Lorazepam droppers 2mg;</li><li>Lantus glargine insulin injections; and</li><li>Admelog insulin lispro injections.</li></ul><p><br></p><p><br></p><p>2. During an environmental inspection of the facility, the COs observed the following products unlocked throughout the facility:</p><ul><li>Medline Remedy Zinc Oxide Skin protectant ointment in kitchen/office area;</li><li>Medline Remedy A&D skin protectant ointment in kitchen/office area;</li><li>We Care Dyna Shield skin protectant ointment, Medline Remedy A&D skin protectant ointment in bathroom of R2;</li><li>Medline Remedy Zinc Oxide Skin protectant ointment and Medline Remedy A&D skin protectant ointment in an unlocked hallway closet;</li><li>We Care Vitamin A&D ointment and Medline Remedy Antifungal Ointment and a specimen cup with a white substance inside with the words "Flagyl" written on it, wound cleanser spray, and Therahoney gel in the bedroom of R3; and</li><li>Medline Remedy Zinc Oxide Skin protectant ointment and Medline Remedy A&D skin protectant ointment in in the bedroom of R1.</li></ul><p><br></p><p><br></p><p>3. In an interview, E1 and E2 reported the caregivers administer medication to all residents.</p><p><br></p><p><br></p><p>4. In an exit interview, the findings were reviewed with E1 and no additional information was provided. </p>

<p>Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of the facility’s documentation revealed several documents titled "Disaster Drill Record," however, the documents were all left blank.</p><p><br></p><p><br></p><p>2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. </p>

<p>Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a risk to the physical health and safety of a resident.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental inspection of the facility with E1, the Compliance Officer(CO) used a thermometer to test the hot water temperature of the water coming out of the kitchen faucet. The CO observed the hot water temperature rising above 130º F on the thermometer.</p><p><br></p><p><br></p><p>2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>