Beebes Assisted Living LLC

Based on documentation review, interview, and record review,the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was 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 an undated policy and procedure titled "ARS 36-40.01: HEALTH CARE INSTITUTIONS; FALL PREVENTION AND FALL RECOVERY; TRAINING PROGRAMS (ref: SB1373)." The policy and procedure stated: "A. All staff will have an initial training that will be included during orientation...C. After orientation, all staff will be required to have an ongoing training that will cover fall prevention and fall recovery at least once every 12 months...Completion of training will be documented in their personnel file." 2. A review of E1's personnel record revealed documentation of initial training in fall prevention and fall recovery dated January 25, 2022, but no such training every 12 months thereafter. 3. A review of E2's personnel record revealed E2 was hired as a caregiver. The review revealed documentation of initial training in fall prevention and fall recovery dated October 20, 2023, over two years after E2's hire date. 4. A review of E4's personnel record revealed E4 was hired as a caregiver more than one year before the date of the inspection. The review revealed no documentation of initial training in fall prevention and fall recovery or such training every 12 months thereafter. 5. In an interview, E1 confirmed training in fall prevention and fall recovery was to be done every year. E1 reported E4's personnel record was incomplete. This is a repeat citation from the compliance inspection conducted on November 8, 2022.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for four of four personnel members sampled. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population, or was unqualified to work in a residential care institution. Findings include: 1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A.R.S. \'a7 36-411(C)(1)-(2) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card." 3. A review of facility documentation revealed a policy and procedure titled "Staffing and record keeping" dated June 1, 2020. The policy and procedure stated: "1. The facility manager shall insure [sic] that a personnel record for each employee or volunteer: a. Includes...iii. Documentation of...compliance with the requirements in A.R.S. \'a7 36-411(A) and (C) [DPS fingerprinting clearance requirements]" (brackets in original text). 4. A review of E1's personnel record revealed a photocopy of E1's fingerprint clearance card. However, the photocopy indicated the card expired on December 13, 2023. 5. A review of the Arizona Department of Public Safety (DPS) fingerprint clearance card verification website revealed E1's fingerprint clearance card expired on December 13, 2023. The review revealed E1 did not have a current valid fingerprint clearance card and did not have one for more than two months prior to the inspection. 6. A review of E2's personnel record revealed a current fingerprint clearance card for E2 issued on November 27, 2023. 7. A

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 and according to policies and procedures, for two of four caregivers sampled. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Staffing and record keeping" dated June 1, 2020. The policy and procedure stated: "1. The facility manager shall insure [sic] that a personnel record for each employee or volunteer: a. Includes...iii. Documentation of...The individual's qualifications, including skills, and knowledge applicable to the individual's job duties." 2. A review of the personnel records of E3 and E4 revealed E3 and E4 were hired as caregivers. However, the review revealed no documentation of E3's or E4's skills and knowledge. 3. A review of facility documentation revealed a series of personnel schedules dated between May 2023 and February 2024. The schedules revealed E3 provided physical health services as a caregiver on a regular basis between May 2023 and February 2024 and E4 provided physical health services as a caregiver on several shifts in August 2023 and February 2024. 4. In an interview, E1 reported E4's personnel record was incomplete. E1 acknowledged E3's and E4's skills and knowledge were not verified and documented before E3 and E4 provided physical health services.

Based on documentation review, record review, and interview, the manager failed to ensure an employee 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 four personnel members sampled. The deficient practice posed a potential TB exposure risk to residents and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Staffing and record keeping" dated June 1, 2020. The policy and procedure stated: "1. The facility manager shall insure [sic] that a personnel record for each employee or volunteer: a. Includes...iii. Documentation of...Evidence of freedom from infectious tuberculosis." 2. A review of E2's personnel record revealed documentation of a tuberculin skin test (TST) dated as administered on October 11, 2023, and read on October 13, 2023. However, the document contained evidence of white corrective fluid in the following fields: -The "Patient's Name"; -The patient's "Date of Birth"; -The "Wheal Size"; -The "Date/Time" the TST was administered; -The earliest time and date the TST could be read; -The latest time and date the TST could be read; -The "Time Read"; and -The "Date" the TST was signed as read. The review revealed all aforementioned fields contained E2's information written over the white corrective fluid except for "Time Read" which was blank. 3. A review of E3's personnel record revealed documentation of a TST dated as administered on February 18, 2023, and read on February 20, 2023, nearly eight months before E2's TST. A comparison between E2's TST and E3's TST revealed E2's TST was a copied and edited version of E3's TST. The review revealed the following fields were identical between the two TSTs: -The checked box for "TB Test Placed at Minute Clinic"; -The circle around the "Location" the TST was placed; -The "Provider Signature"; -The circle around "pm" for the earliest time and date the TST could be read; -The circle around "pm" for the latest time and date the TST could be read; -The checked box for "PPD Read at Minute Clinic"; -The "Induration [of] 0 mm"; -The checked box for "Local Skin Reaction: No"; -The checked box for "Results: Negative"; and -The "Provider Signature" and credentials. 4. A review of facility documentation revealed a series of personnel schedules dated between May 2023 and February 2024. The schedules revealed E2 provided physical health services as a caregiver on a regular basis between May 2023 and February 2024. 5. In an interview, E1 stated E2's TST documentation looked "fine." When the Compliance Officer asked E1 and E2 to contact the TST provider to verify E2's TST, E1 and E2 refused to do so.

Based on documentation review, record review, and interview, the manager failed to ensure a 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 four personnel members sampled. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "First Aid and CPR training" dated June 1, 2020. The policy and procedure stated: "4. Each employee or volunteer will present proof of training in CPR and first aid in the form of an unexpired card...7. The time frame in retraining is determined by the expiration date shown on the card or 24 months whichever occurs first. The employee or volunteer will be reminded in a timely manner of an expiring card as a condition of employment." 2. A review of E3's personnel records revealed E3 was hired as a caregiver. The review revealed a photocopy of E3's previous first aid and CPR training certification dated as expired in January 2024 as well as a printout of E3's current first aid and CPR certification dated as issued on February 20, 2024. However, the review revealed E3 did not have current documentation of first aid and CPR training certification for approximately 20 days. 3. A review of facility documentation revealed two conflicting personnel schedules dated February 2024. The first schedule indicated E3 worked on February 3-4, 7-8, 11-12, and 14-16, 2024, while the second schedule indicated E3 worked on February 3-4, 7, 14-15, and 18-19, 2024. Both schedules indicated E3 worked without current documentation of first aid and CPR training certification. 4. In an interview, E1 acknowledged E3 provided assisted living services with expired first aid and CPR training certification.

Based on observation, interview, and documentation review, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked room with the door open. The Compliance Officer observed the door had a lock installed but the door was not locked at the time of the observation. Inside the room, the Compliance Officer observed unprotected resident records, including documentation of assisted living services provided to residents on a white board and documentation of medication administered to residents accessible in a cabinet. 2. In an interview, when the Compliance Officer informed E1 the shower schedules on the white board were part of a resident's medical record, E1 stated that was "kind of extreme." E1 reported this rule had never been brought up to E1 during an inspection. 3. A review of Department documentation revealed a Department Compliance Officer told E1 during the previous inspection conducted on November 8, 2022, that shower and medication administration schedules were part of a resident's medical record and needed to be protected from loss, damage, or unauthorized use. The review revealed E1 closed and locked the door after being informed. Technical assistance was provided on this rule during the compliance inspection conducted on November 8, 2022.