Beehive Homes

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officers observed the following in an unlocked kitchen cabinet: - Three bottles of Polyethylene Glycol 3350; and - One bottle of milk of magnesia. 2. In an interview, E1 acknowledged the unlocked medications in the kitchen cabinet. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, 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 E2’s personnel record revealed no documentation of initial fall prevention and fall recovery training. Based on E2’s hire date, this was required. 2. 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 assisted living home failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A. Findings include: 1. A.R.S. 36-420.04.A states, "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 experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of facility documentation did not include a standardized form that included the aforementioned information for each resident of the facility. 3. A review of R1's and R2's medical records revealed all required information, however, a standardized form with all aforementioned information was not available for review. 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 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 two sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(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: 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 E2’s personnel record revealed E2 was hired as a caregiver. The review revealed one TST dated as read before E2 began providing services at the facility. No other TST documentation was available for review at the time of inspection. 5. A review of the facility work schedule revealed E2 worked on Wednesdays, Thursdays, Fridays, and Saturdays for the entire month of August 2025. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver provided current documentation of first aid training training for one of two employees sampled. The deficient practice posed a risk if an employee was unable to meet the needs of residents. Findings include: 1. A review of E2’s personnel record revealed a basic life support card issued July 2024. However, E2’s personnel record did not include documentation of first aid training. Based on E2’s date of hire, this was required. 2. In an interview. E1 acknowledged E2 did not have a valid first aid card. 3. A review of the facility work schedule revealed E2 worked on Wednesdays, Thursdays, Fridays, and Saturdays for the entire month of August 2025. 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 manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a TB exposure 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 R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3. A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse, 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 no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1’s acceptance date, this documentation was required. 2. 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 manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of two residents sampled. The deficient practice posed a risk as required information could not be verified for the sampled resident. Findings include: 1. A.R.S. § 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: 1. If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider." 2. The surveyor requested R3's medical record for review. However, R3's medical records were unavailable for review at the time of the survey. 3. In an interview, E1 reported R3's medical record was given to the hospital when R3 was admitted. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon acceptance and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, 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 R2's medical record revealed a service plan dated September 8, 2025. The service plan stated the resident was "non-ambulatory." 2. A review of R2's medical record revealed a signed and dated determination dated November 28, 2024. However, additional documentation signed by R2's primary care provider every six months was not available for review. 3. 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 the health care institution established, documented, and implemented tuberculosis infection control activities that include the information found in subsections a. through f. of this rule. Findings include: 1. Review of facility documentation failed to reveal information indicating that the health care institution had established and documented tuberculosis infection control documentation and activities that include subsections a. through f. of this rule . 2. During an interview, E4 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E4 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E4 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a quality management plan is established, documented and implemented that includes the frequency of submitting a documented report to the governing authority. Findings include: 1. The facility quality management plan did not include the frequency of submitting a documented report to the governing authority. 2. During an interview, E4 acknowledged the required documentation was not included in the facility quality management plan. 3. During an interview, E4 stated, "We do create a report and give it to the owner quarterly."

Based on documentation review and interview, the manager failed to ensure that a quality management plan is established, documented and implemented that includes the frequency of submitting a documented report to the governing authority. Findings include: 1. The facility quality management plan did not include the frequency of submitting a documented report to the governing authority. 2. During an interview, E4 acknowledged the required documentation was not included in the facility quality management plan. 3. During an interview, E4 stated, "We do create a report and give it to the owner quarterly."

Based on record review and interview, the manager failed to ensure that one of one personnel record, for personnel who work more than eight hours per week, contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. Findings include: 1. The record for E1 contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the 12 months prior to E1's start date was found in the record. Based on the employee's date of hire this documentation was required. 2. During an interview, E4 acknowledged that the employees worked more than eight hours per week and the documentation did not reflect that the employee records contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.

Based on record review and interview, the manager failed to ensure that one of one personnel record, for personnel who work more than eight hours per week, contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. Findings include: 1. The record for E1 contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the 12 months prior to E1's start date was found in the record. Based on the employee's date of hire this documentation was required. 2. During an interview, E4 acknowledged that the employees worked more than eight hours per week and the documentation did not reflect that the employee records contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.

Based on record review and interview the manager failed to ensure that a record for four of four volunteers included all the information required in sub-sections a. through c. of this rule. Findings include: 1. During an interview, E4 indicated that O1, O2, O3, and O4 regularly volunteer at the facility. 2. No volunteer records were available for review. 3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on record review and interview the manager failed to ensure that a record for four of four volunteers included all the information required in sub-sections a. through c. of this rule. Findings include: 1. During an interview, E4 indicated that O1, O2, O3, and O4 regularly volunteer at the facility. 2. No volunteer records were available for review. 3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on record review and interview for two of two sample resident records, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident remain in the facility; a signed and dated statement from a medical practitioner indicating that the resident's needs were being met by the facility as per their scope of services and at least once every six months throughout the duration of the resident's condition. Findings include: 1. During an interview, E4 indicated that R1 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 2. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the medical practitioner that the resident's needs were being met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required. 3. During an interview, E4 indicated that R2 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 4. The last determination of residency signed by a medical practitioner indicating that the resident's needs were being met as per the facility's scope of services, was dated January 2, 2023. Based on the resident's date of acceptance this documentation was required. 5. During an interview, E4 acknowledged that the required documentation was not in the records.

Based on record review and interview for two of two sample resident records, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident remain in the facility; a signed and dated statement from a medical practitioner indicating that the resident's needs were being met by the facility as per their scope of services and at least once every six months throughout the duration of the resident's condition. Findings include: 1. During an interview, E4 indicated that R1 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 2. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the medical practitioner that the resident's needs were being met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required. 3. During an interview, E4 indicated that R2 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 4. The last determination of residency signed by a medical practitioner indicating that the resident's needs were being met as per the facility's scope of services, was dated January 2, 2023. Based on the resident's date of acceptance this documentation was required. 5. During an interview, E4 acknowledged that the required documentation was not in the records.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that include the information found in subsections a. through f. of this rule. Findings include: 1. Review of facility documentation failed to reveal information indicating that the health care institution had established and documented tuberculosis infection control documentation and activities that include subsections a. through f. of this rule . 2. During an interview, E4 acknowledged that the required documentation was not available for review.