Triple Hearts Assisted Living I LLC

Cited requirement:A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document 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 expe…

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-113.A.1-2. 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: 1. Are consistent with recommendations in 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, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 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 exp…

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-803.A.7. Administration A. A governing authority shall: 7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager;

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-804.1.a-e. Quality Management A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to residents; c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority;

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.8.a-b. Personnel A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-814.B.1-2. Personal Care Services B. A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: 1. The condition is a result of a short-term illness or injury; or 2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: a. The resident or resident’s representative requests that the resident be accepted by or remain in the assisted living facility; b. The resident’s primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident’s condition; ii. Reviews the assisted living facility’s scope of services; and iii. Signs and dates a determination stating that the resident’s needs can be met by the assisted living facility within the assisted living facility’s scope of services and, for retention of a resident, are being met by the assisted living facility; and c. The resident’s service plan…

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.A.2. Emergency and Safety Standards A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.A.4. Emergency and Safety Standards A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.A.5.a. Emergency and Safety Standards A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-821.F.1.a-f. Physical Plant Standards F. If there is a swimming pool on the premises of the assisted living facility, a manager shall ensure that: 1. Unless the assisted living facility has documentation of having received an exception from the Department before October 1, 2013, the swimming pool is enclosed by a wall or fence that: a. Is at least five feet in height as measured on the exterior of the wall or fence; b. Has no vertical openings greater that four inches across; c. Has no horizontal openings, except as described in subsection (F)(1)(e); d. Is not chain-link; e. Does not have a space between the ground and the bottom fence rail that exceeds four inches in height; and f. Has a self-closing, self-latching gate that: i. Opens away from the swimming pool, ii. Has a latch located at least 54 inches from the ground, and iii. Is locked when the swimming pool is not in use;

Provider-listed correction date: Dec 5, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.1.a-b. Personnel A. A manager shall ensure that: 1. A caregiver: a. Is 18 years of age or older; and b. Provides documentation of: i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Admin- istrators and Assisted Living Facility Manag- ers; ii. For supervisory care services, employment as a manager or caregiver of a supervisory care home before November 1, 1998; iii. For supervisory care services or personal care services, employment as a manager or care- giver of a supportive residential living center before November 1, 1998; or iv. For supervisory care services, personal care services, or directed services, one of the follow- ing: (1) A nursing care institution administrator’s license issued by the Board of Examiners; (2) A nurse’s license issued to the individual under A.R.S. Title 32, Chapter 15; (3) Documentation of employment as a man- ager or caregiver of an unclassified resi- dential care institution before November 1, 1998; or (4) Documentation of sponsorship of or employment as a caregiver in an adult fos- ter care home before November 1, 1998;

Provider-listed correction date: Apr 3, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual's name, date of birth, and contact telephone number; b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties; ii. The individual's education and experience applicable to the individual's job duties; iii. The individual's completed orientation and in-service education required by policies and procedures; iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or policies and procedures; and ix. Do…

Correction information is not available in the records reviewed.

Cited requirement:A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 calendar days after the resident's date of acceptance; 2. Is developed with assistance and review from: a. The resident or resident's representative, b. The manager, and c. Any individual requested by the resident or the resident's representative; 3. Includes the following: a. A description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; b. The level of service the resident is expected to receive; c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication; d. For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner; e. For a resident who requires behavioral care: i. Any of the following that is necessary to provide assistance with the resident's psychosocial interactions to manage the resident's behavior: (1) The psychosocial interactions or behaviors for which…

Correction information is not available in the records reviewed.