Beatitudes Campus of Care.

“Based on documentation review, record review, and interview, the governing authority failed to 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. The deficient practice posed a risk if a staff member was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed an untitled policy to minimize the likelihood of falls and steps for staff to take in the event of a resident fall. The documentation included multiple internet sources regarding fall prevention and fall recovery; however, it did not include a fall prevention and fall recovery training program that contained initial training and continued training competency. 2. A review of personnel records for E1, E3, E4, and E5 revealed a document titled, "Caregiver Competency Check" which showed fall prevention training was completed. 3. In an interview, E2 acknowledged the facility did not have a developed and administered training program for all staff regarding fall prevention and fall recovery program that included initial and continued competency training for all staff available for review.”

“Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings include: 1. A review of facility documentation revealed no documentation of a policy to address how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. 2. In an interview, E2 acknowledged the facility did not have a policy and procedure available for review of how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. E2 reported that the facility did not have a hard copy or electronic copy that could be accessed for review at the time of inspection.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for three of five personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 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)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of facility documentation titled, "Policy and Procedure: Tubercolosis (TB) Two-Step Testing Implementation" dated November 30, 2023 revealed that a policy was implemented for all new hire employees to undergo two-step TB testing and existing employees would be subject to the two-step TB testing proptocol on their anniversary date, starting on November 30, 2023. 4. A review of E3's personnel record revealed no documentation of a two step TB test conducted on or before the date E3 began providing services at or on behalf of the assisted living facility. 5. A review of E4's personnel record revealed no documentation of a two step TB test conducted on or before the date E4 began providing services at or on behalf of the assisted living facility. 6. A review of E5's personnel record revealed no documentation of a two step TB test conducted on or before the date E5 began providing services at or on behalf of the assisted living facility. 7. In an interview, E2 acknowledged documentation of evidence of freedom from infectious TB was not dated within 12 months before the dates E3, E4, and E5 began providing services at or on behalf of the health care institution as specified in R9-10-113.”

“Based on record review and interview, the manager failed to ensure that 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 R9-10-113, for four of ten residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of R6's, R7's, R8's, and R10's medical records revealed no evidence of freedom of TB before or within seven calendar days after R6's, R7's, R8's, and R10's dates of occupancy. 2. In an interview, E2 acknowledged R6's, R7's, R8's, and R10's medical records did not contain evidence that TB testing or screening was conducted before or within seven calendar days after R6's, R7's, R8's, and R10's dates of occupancy.”

“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 assisted living facility and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of ten sampled residents. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R6's medical record revealed documentation indicating whether residents 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; however, the document was dated after R6's date of acceptance. 2. In an interview, E2 acknowledged R6 documentation was not dated within 90 calendar days before R6 was accepted by the assisted living facility.”

“Based on documentation review, observation, record review, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication. The deficient practice posed a health risk to a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Saliba's Disposal of Medications." This document stated "Medications awaiting disposal by the ALF are documented on the Medication Disposition Record and stored in a locked, secure area designated for that purpose until disposal. Documentation includes: date, resident's name, name and strength of medication, quantity of medication, and reason for disposal (discontinued, expired, resident no longer in ALF)." 2. The Compliance Officer observed Atorvastatin 20 mg in R5's medication storage bin. A review of R5's medical record revealed a discontinue order for Atorvastatin 20 mg. A review of R5's medication administration record (MAR) revealed Atorvastatin 20 mg was not administered to R5 in the months of October 2024 and November 2024; however, the medication was not discarded per the facility policy and procedure. 3. During an interview, E2 acknowledged the facility did not discard R5's discontinued medication per the facility's policy and procedure.”

“Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed the facility's disaster plan was reviewed on March 26, 2020. However, no additional documentation of a review was available. 2. In an interview, E2 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.”

“Based on record review and interview, the manager failed to ensure that a resident receives orientation to the exits from the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility for seven of ten sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R2's, R3's, R4's, R6's, R7's, R9's, and R10's medical records revealed documentation of the resident's orientation to exits from the assisted living facility was not conducted within 24 hours of the residents' dates of acceptance to the assisted living facility. 2. In an interview, E2 acknowledged R2's, R3's, R4's, R6's, R7's, R9's, and R10's medical records did not contain documentation of orientation to exits from the assisted living facility within 24 hours of the residents' dates of acceptance to the assisted living facility.”

“Based on documentation review and interview, the manager failed to ensure a pest control program compliant with Arizona Administrative Code (A.A.C.) R3-8-201(C)(4) was implemented. Findings include: 1. A.A.C. R3-8-201(C)(4) states: "4. An individual may not provide pest management services at a...health care institution...unless the individual is a certified applicator in the certification category for which services are being provided." 2. A review of facility documentation revealed no documentation was available at the time of inspection to reflect pest control service was conducted by a certified applicator. 3. In an interview, E2 reported documentation for a pest control program was not available for review.”

“Based on document review and interview, the manager failed to report the suspected abuse, neglect, or exploitation of a resident according to A.R.S. \'a7 46-454. The deficient practice posed a potential safety risk to residents. Findings include: 1. The Compliance Officer reviewed all documents regarding a sexual abuse allegation involving R1, which was reported to facility staff on July 22, 2024. Document review established that the sexual abuse allegations were not reported to Adult Protective Services and a police report was not initiated. The manager reported the allegations to an ombudsman. 2. In an interview, E1 and E2 confirmed that Adult Protective Services was not notified and a police report was not filed in regards to the incident which occurred on July 22, 2024.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for two of two sampled caregivers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed staffing schedules for the previous 12 months. The schedules revealed E2 and E3 were scheduled to work at the facility as caregivers on multiple shifts throughout November 2023. 2. A review of E2's and E3's personnel records revealed no documented verification of E2's and E3's skills and knowledge available for review at the time of the inspection. 3. In an interview, E1 acknowledged E2's and E3's personnel records did not contain documented verification of E2's and E3's skills and knowledge at the time of the inspection. This is a repeat/uncorrected deficiency from the complaint inspection conducted on April 3, 2024.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's and assistant caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for five of five caregivers and assistant caregivers reviewed. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Personnel." The policy stated, "It shall be the policy of The Provider to maintain personnel files for each team member, which will contain the following: ... 2. Documentation of: Employee qualifications, knowledge, and skills as required for the position; Employee orientation, Essential Functions skills check ..." 2. A review of E3's personnel record revealed a hire date of March 4, 2022. E3's record revealed no documentation indicating E3's skills and knowledge were verified. 3. A review of E4's personnel record revealed a hire date of November 3, 2022. E4's record revealed no documentation indicating E4's skills and knowledge were verified. 4. A review of E5's personnel record revealed a hire date of February 27, 2024. E5's record revealed no documentation indicating E5's skills and knowledge were verified. 5. A review of E6's personnel record revealed a hire date of February 22, 2024. E6's record revealed no documentation indicating E6's skills and knowledge were verified. 6. A review of E7's personnel record revealed a hire date of April 26, 2023. E7's record revealed no documentation indicating E7's skills and knowledge were verified. 7. In an interview, E1 acknowledged documentation was not available showing E3's, E4's, E5's, E6's, and E7's skills and knowledge were verified and documented. E1 reported the facility recently started completing a competency form for new hires.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of five personnel sampled. The deficient practice posed a risk if E7 was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Personnel." The policy stated, "It shall be the policy of The Provider to maintain personnel files for each team member, which will contain the following: ... 2. Documentation of: ... Current training in CPR and first aid ..." 2. A review of E7's personnel record revealed current documentation of E7's CPR/First Aid training from the "National CPR Foundation" issued April 22, 2023 and valid for two years. However, the CPR training did not include a hands-on demonstration of techniques as required. 3. In an email exchange, a representative from the "National CPR Foundation," stated, "Our courses are online only." 4. In an interview, E1 acknowledged E7's personnel record did not include current CPR training with hands-on demonstration as required.”

“Based on record review and interview, the manager failed to ensure a resident's medication was administered in compliance with a medication order for one of three residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a signed medication list that included the following medications: -Atorvastatin 20 milligrams (mg), 1 tablet by mouth at 1:30 PM; -Gabapentin 300 mg, 2 capsules by mouth twice daily; -Simethicone 125 mg, 1 tablet by mouth once daily; -Lumigan 0.01% eye drops (Bimatoprost), 1 drop both eyes every night; and -Trazodone 50 mg, 1 tablet by mouth at bedtime. 2. A review of R1's medical record revealed a Medication Administration Record (MAR) dated March 2024. The MAR revealed R1 did not receive Trazodone as prescribed on the following dates, with the following reasons noted: -March 2, 2024-March 11, 2024: Not available. 3. A review of R1's medical record revealed a MAR dated March 2024. The MAR revealed R1 did not receive Lumigan (Bimatoprost) 0.01% eye drops as prescribed on the following dates, with the following reasons noted: -March 2, 2024-March 8, 2024: Not available; -March 9, 2024-March 15, 2024: Not available; -March 17, 2024-March 20, 2024: Not available; and -March 25, 2024-March 31, 2024: Not available. 4. A review of R1's medical record revealed a MAR dated March 2024. The MAR revealed R1 did not receive Atorvastatin as prescribed on the following dates, with the following reasons noted: -March 1, 2024, March 28, 2024, and March 29, 2024: Not available. 5. A review of R1's medical record revealed a MAR dated March 2024. The MAR revealed R1 did not receive Gabapentin as prescribed on the following dates, with the following reasons noted: -March 1, 2024, March 28, 2024, and March 29, 2024: Not available. 6. A review of R1's medical record revealed a MAR dated March 2024. The MAR revealed R1 did not receive Simethicone as prescribed on the following dates, with the following reasons noted: -March 4, 2024-March 6, 2024: Held (for unknown reason); -March 7, 2024-March 8, 2024: Not available; and -March 1, 2024-March 613 2024: Held (for unknown reason). 7. In an interview, E1 and E2 acknowledged R1 did not receive medication administration for the aforementioned medications in compliance with a medication order. E1 reported having problems with R1's pharmacy but could not provide any additional information.”

“Based on documentation review, record 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 in fall prevention and fall recovery. 1. A review of facility documentation revealed a PowerPoint presentation print-out titled "Fall Reduction Program." The documentation included training topics such as "Responding to a fall" and "Recovery of a fall." The document included steps for fall prevention and fall recovery for staff. 2. A review of E3's and E5's personnel records revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged the facility had not administered a training program for all staff regarding fall prevention and fall recovery.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan was developed with assistance and review from the resident or resident's representative, for one of ten residents sampled. Findings include: 1. A review of R4's medical record revealed a service plan dated June 19, 2023 for directed care services. The service plan did not contain the signature of R4's representative to indicate the service plan was developed with assistance and review by R4's representative. 2. A review of R5's medical record revealed a service plan dated June 19, 2023 for directed care services. The service plan did not contain the signature of R5's representative to show the service plan was developed with assistance and review by R5's representative. 3. In an interview, E1 acknowledged the service plans for R4 and R5 were not signed by R4's and R5's representatives to indicate the service plans were developed with assistance and review from R4's and R5's representatives.”

“Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for three of ten residents sampled. Findings include: 1. A review of R1's medical record revealed a current written service plan dated June 19, 2023 for directed care services. The service plan stated "Bathing...Resident requires stand-by assistance for showers twice weekly..." 2. A review of R2's medical record revealed a current written service plan dated August 2, 2023 for directed care services. The service plan stated "Bathing...Resident requires mininmal assistance for showers twice weekly..." 3. A review of R3's medical record revealed a current written service plan dated August 2, 2023 for directed care services. The service plan stated "Bathing...Resident requires mininmal assistance for showers twice weekly..." 4. A review of R1's, R2's, and R3's activities of daily living (ADL) documentation for September 2023 revealed documentation of bathing was not included on R1, R2, and R3's ADLs. 5. In an interview, E1 acknowledged the aforementioned service was not documented as provided on R1's, R2's and R3's ADLs. This is a repeat citation from the complaint inspection conducted on March 30, 2023.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of ten residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed the following medication orders: -"Allopurinol 100 mg (milligrams) tablet 1 tab by mouth once daily" dated July 18, 2023; -"Brimonidine 0.2% eye drops both eyes twice daily" dated July 7, 2023; and -"Carvedidol 6.25 MG Tablet 1 tab by mouth twice daily" dated July 7, 2023. 2. A review of R1's medication administration record (MAR) dated September 2023 revealed caregivers' initials to indicate caregivers had administered the following medications on the following dates and times: -"Allopurinol 100 mg tablet" on September 1-14 and 16-18, 2023 at 8:00 AM; -"Brimonidine 0/2% eye drops" on September 1-14 and 16-18, 2023 at 4:00 PM; and -"Carvedilol 6.25 mg tablet" on September 1-14 and 16-18, 2023 at 4:00 PM. However, documentation of the aforementioned medications adminstered to R1 on September 15, 2023 was not available for review. 3. In an interview, E1 reported the aforementioned medications were administered to R1 on September 15, 2023, however, the administration was not documented. E1 acknowledged R1's medication administration record did not include documentation of medication administered to R1 on September 15, 2023.”