Beehive Homes of Sierra Vista

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedures revealed documentation indicating that the policies and procedures were last reviewed on February 22, 2020. 2. In an exit interview, the findings were reviewed with E1. E1 acknowledged that the policies and procedures were not reviewed at least once every three years.

Based on documentation review and interview, the manager failed to ensure employees who were expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis as specified in R9-10-113, on or before the date the individual began providing services at the assisted living facility for two out of two personnel sampled. Findings Include: 1. A review of E1 and E2’s personnel records revealed there were no TB baseline screenings available for review. 2. In an exit interview, the findings were reviewed with E1. E1 acknowledged they had not provided evidence of freedom from infectious TB as specified in R9-10-113 and did not have TB screenings available for review. E1 stated E1 was confused regarding when a TB screening was necessary.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a documented residency agreement. However, the residency agreement did not include the date or the manager's signature. 2. In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on observation, record review, and interview, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a health and safety risk to the resident. Findings include: 1. R9-10-101.199 defines "Restraint" as any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. 2. During the facility tour the Compliance Officer observed R3 lying in bed with two sets of long bed rails on each side of R3's hospital bed. The bed rails were in the up potion. 3. In an interview, the Compliance Officer asked E6 if R3 was able to move the bed rails up and down. E6 reported no R3 is bedbound and unable to get up out of bed. 4. A review of R3's medical record revealed a determination of residency signed and dated December 28, 2023 by R3's physician. In the section where the physician was asked "7. Does this person require restraints (including bed rails)?". The physician put an X in front of "No". 5. In an interview, E1 stated that R3 had just moved into the facility four days ago and had not been in R3's room to see bed rails attached to R3's bed.

Based on documentation review, and interview, the manager failed to ensure a 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: A.A.C. R9-10-818.A.3. states, "A manager shall ensure that documentation of the disaster plan review required in subsection (A)(2) includes: a. The date and time of the disaster plan review; b. The name of each employee or volunteer participating in the disaster plan review; c. A critique of the disaster plan review; and d. If applicable, recommendations for improvement" 1. A review of documentation revealed the following "Evacuation/Disaster Plan Evaluation Form Yearly Review" approved by: [E1] dated April 2, 2021." No other documentation was available for review during this survey. 2. In an interview, E1 acknowledged the disaster plan had not been reviewed at least once every 12 months.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and were inaccessible to residents. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. During a tour of the facility the Compliance Officer opened the doors under the kitchen sink. The Compliance Officer observed the doors did not have a lock on them. Inside the unlocked cabinet contained the following toxic materials or poisonous materials: - "Great Value" Oven Cleaner, 16 oz spray can; - "Corrosive" UN1791, Hypochlorite Solution; - "Auto-Chlor Mach Turbo" Mechanical Warewashing Detergent 3.78L (1 US Gal); - "Auto-Chlor HI Solids Rinse Aid Mechanical Warewashing Rinse Aid; 3.78L (1US Gal); - "Auto-Chlor Pot & Pan Supreme" Dish Liquid, 1 Gal; - "Great Value" Lemon Scent Multi-Purpose Cleaner, 1 QT; and - "Monogram" Disinfectant Bleach, 1 Gal. 2. In an interview, E1 acknowledged poisonous and toxic materials stored by the assisted living facility were not in a locked area and inaccessible to residents. This is a repeat citation from the compliance survey conducted on January 31, 2023.