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.