Ccc B&b LLC Carehome.

“Based on record review, documentation review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, to include initial training and continued competency training, for three of three 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. Findings Include: 1. A review of E2 and E3’s personnel records revealed current training on Fall prevention. However, there was no documentation of Fall Recovery training. 2. In an interview, E1 acknowledged that E2 and E3 did not have the required Fall Recovery training. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on November 27, 2023.”

“Based on interview and documentation review, the manager failed to provide a written document with all required information to the emergency responder (EMS). The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R2's record contained an incident report dated March 16, 2026, for an unwitnessed fall that resulted in a call to 911 for medical services. 2. In an interview, when the Compliance Officer requested a copy of the documentation given to EMS in compliance with this statute, E1 reported that some paperwork was provided to EMS, but copies were not made. E1 reported not to be aware of all the requirements of this statute. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, interview, and observation, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) 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…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)." 2. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC).” 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel. 4. A review of E3’s personnel record revealed E3 was hired as a caregiver in 2023. The review revealed a single negative TST. However, a second TST was not available for review. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure that; if the assisted living facility was authorized to provide directed care services, an elopement drill for employees was conducted every six months on each shift and document the date, time, and description of each drill. Findings include: 1. A review of the facility's license revealed that the facility was licensed to provide Directed Care services. 2. A documentation review revealed the last elopement drill was conducted on June 17, 2025. 3. In an interview, E1 acknowledged that the manager failed to ensure an elopement drill for employees was conducted every six months on each shift and to document the date, time, and description of each drill. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the administrator failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. The deficient practice posed a risk if facility staff were 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 documented fall prevention and fall recovery training program. However, the fall prevention and fall recovery training program did not include initial training and continued competency training. 2. A review E4's and E5's personnel records revealed no documented evidence to indicate E4 and E5 completed fall prevention and fall recovery training. 3. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program failed to address initial and continued compentency training, and there was no documentation to indicate E4 and E5 completed fall prevention and fall recovery training.”

“Based on documentation review, record review, and interview, the manager failed to ensure a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of five sampled caregivers. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility work schedules dated November 27, 2023 through December 3, 2023, reflected E3 was scheduled to work the following times and dates: -Monday, November 27, 2023 from 6:30 AM to 5:00 PM; -Tuesday, November 28, 2023 from 1:30 PM to 3:00 PM; -Wednesday, November 29, 2023 from 8:45 AM to 5:00 PM; and -Thursday, November 3, 2023 from 8:00 AM to 5:00 PM. 2. A review of E3's personnel record revealed no documentation of CPR or first aid training. 3. In an interview, E1 acknowledged E3's personnel record did not include documentation of current CPR and first aid training.”

“Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed an undated document titled "Pre Admission Determination". The document reflected R1 did not require continuous medical services, continuous or intermittent nursing services, or restraints. However, the document was not signed or dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E1 acknowledged R1's "Pre-Admission Determination" was not signed or dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. This is a repeat citation from the previous compliance inspection conducted on September 26, 2022.”

“Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2's medical record a service plan dated October 25, 2023. R2's service plan reflected R2 required assistance with bathing twice weekly, skin care twice weekly, night checks every one to two hours, and "occasional" peri-care. 2. A review of R2's medical record revealed an activities of daily living (ADL) sheet dated November 2023. The ADL sheet did not reflect R2 was provided assistance with skin care twice weekly, "occasional" peri-care, or night checks every one to two hours as stated in R2's service plan. 3. In an interview, E1 reported R2 received the services according to R2's service plan, however the services were not documented.”