Best Assisted Living of Surprise

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance for one of three sampled personnel regarding a valid fingerprint clearance card. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. 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 review of E1's personnel record revealed a fingerprint clearance card with an expiration date of January 14, 2025. A further review of E1's personnel record revealed a valid fingerprint clearance card issued on January 22, 2025. However, E1did not have a valid fingerprint clearance card for eight days. 3. A review of the Arizona Department of Public Safety's website revealed E1's fingerprint clearance card "expired" on January 14, 2025, and E1's fingerprint clearance card was "renewed" and "valid" dated January 22, 2025. 4. In an interview, E2 acknowledged E1 did not have a valid fingerprint clearance card from January 14-21, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures (P&P) were implemented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident. Findings include: 1. A review of R1's medical record revealed a service plan for directed level of care. 2. A review of R1's medical record revealed a document titled "Incident Report Form" dated January 9, 2025. The document stated, "Patient had been observed since this morning visiting other resident's rooms which was not a normal action for [R1] to do. Caregivers kept on redirecting [R1] to stay on one spot but [R1] would do it again after 20-30 minutes. Caregivers notified the admin and made sure [R1] took [R1's] scheduled morning meds. In addition, [R1] was given PRN medication (Hydroxyzine 12.5mg) for anxiety. At 3:00PM, the caregiver shaved [R1's] head. After this, [R1] was last seen at 3:15PM at the facility's hallway walking back and forth. Caregiver's reported [R1] missing to the facility admin at 3:30PM. [R1] was found on the other street (W Watson Lane) laying on the ground. Paramedics were called, and [R1] was alert in answering questions. [R1] mentioned the pain in [R1's] mouth due to the fall. [R1] was sent to Banner Del Webb for further assessment. Describe actions taken by employees, support staff, or volunteers: AFTER FINDING OUT THAT THE RESIDENT WAS MISSING, THE CAREGIVERS IMMEDIATELY NOTIFIED THE MANAGERS/OWNERS OF THE HOME, WHILE CONTINUOUSLY SEARCHING FOR THE MISSING RESIDENT." 3. A review of R1's medical record revealed a document titled "Banner Del Webb Medical Center Encounter Summary" dated January 9, 2025. The document stated, "[R1] Facial trauma Fracture of incisor teeth Ground-level fall." 4. A review of facility documentation revealed a P&P titled "Whereabouts of a Resident." The P&P stated, "Directed level of care residents are only allowed to leave the facility accompanied by a responsible family member or friend or if available by a caregiver." 5. In an interview, E2 and E3 reported R1's behavior was unusual on January 9, 2025. E2 reported there were attempts to contact R1's representative by phone without success. E2 reported R1's representative was sent an email on January 9, 2025, at 6:30 PM. The Compliance Officer asked E2 and E3 about R1 and exiting the facility. E2 and E3 reported the facility doors were locked and alerts on the doors were working and knowledge of how R1 exited the facility is undetermined. E2 and E3 reported not being sure how R1 exited the facility. E2 and E3 reported R1 may have exited the facility when one of the RN nurses left the facility. E2 and E3 acknowledged the facility was unaware of the general or specific whereabouts of R1 on January 9, 2025, at 3:15 PM.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three sampled personnel. The deficient practice posed a potential 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E4's personnel record revealed E4 was hired as a caregiver. The review revealed one negative TB skin test before E4's hire date. However, a second TB test and TB screening was not available for review during the inspection. 4. In an interview, E3 acknowledged a second TB test and TB screening for E4 was not available for review during the inspection. Technical assistance was provided during the compliance and complaint inspection on June 7, 2023.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of three sampled personnel. The deficient practice posed a risk if E4 was unable to meet a resident's needs during an accident, emergency, or injury. Findings include: 1. A review of E4's personnel record revealed CPR and first aid training from "NSC LEARNING FA CPR AED", completed on December 12, 2022 and expired on December 11, 2024. A further review of E4's personnel record revealed a completed CPR and first aid training on January 13, 2025, with an expiration date of January 2027. 2. A documentation review of the facility's staff work schedule revealed E4 worked on December 12-13, 16-20, 30-31, 2024, and January 1-3, and 6-10, 2025. 3. In a interview, E3 acknowledged E4 worked and provided services to residents during the aforementioned dates. E2 confirmed E4's personnel record had no record of valid CPR or first aid training from December 12, 2024 - January 12, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures (P&P) were established, documented, and implemented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident. Findings include: 1. A review of R1's medical record revealed a service plan for directed level of care. 2. A review of facility P&P revealed a P&P titled "Whereabouts of a Resident" the P&P stated, "Directed level of care residents are only allowed to leave the facility accompanied by a responsible family member or friend or if available by a caregiver." 3. In an interview, E2 and E3 reported R1's behavior was unusual on January 9, 2025. E2 reported there was attempts to contact R1's representative by phone without success. E2 reported R1's representative was sent an email on January 9, 2025 at 6:30PM. The Compliance Officer asked E2 and E3 about R1 and exiting the facility. E2 and E3 stated, " the facility doors were locked and alerts on the doors were working and knowledge of how R1 exited the facility is undetermined." E2 and E3 reported they are not sure how R1 exited the facility. E2 and E3 reported R1 may have exited the facility when one of the RN nurses left the facility. E2 and E3 acknowledged the facility was unaware of the general or specific whereabouts of R1 on January 9, 2025 at 3:15PM.

Based on observation, documentation 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. During the environmental tour the Compliance Officers observed two storage bins in the garage containing a variety of expired bubble packs containing medication. 2. A documentation review of the facility's policies and procedures revealed a policy titled " Part VII-Disposal (discarding) of Medications Including Opioids and Narcotics." The policy stated "...1. On a monthly basis the facility manager or manager designee will check all medication in the facility to identify and locate any discontinued medications (by physician's or medical practitioner's order), expired medications, including medication of deceased residents'. 2. Such medications will be disposed of by the facility manager or manager designee on the last day of the month. 3. The medication disposal will be recorded in the Medication Disposal Form." 3. A documentation review of the facility's "Medication Disposal Form", revealed a blank form. 4. During an interview, E3 reported the medication was stored in the garage to await return to the pharmacy. E3 reported the"Medication Disposal Form" was not filled out. The medication was not disposed of per the facility's policy. This is a repeat citation from the compliance and complaint inspection on June 7, 2023.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(111) states "[i]mmediate" means "without delay." 2. A review of facility documentation revealed an incident report which indicated R1 had an accident, emergency, or injury at 3:15 PM on January 9, 2025, that resulted in R1 needing medical services. However, the incident report revealed facility personnel did not notify R1's representative until 6:30 PM via email, on January 9, 2025, and R1's primary care provider until January 10, 2025. 3. In an interview, E2 and E3 acknowledged R1's representative and primary care provider were not notified immediately.

Based on documentation review, record review, and interview, the manager failed to ensure the assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. The deficient practice posed a risk as E2 and E5 was unable to meet R3's needs. Findings include: 1. A review of R3's medical record, contained an incident report dated February 14 2023. The document stated, "Resident unlocked wheelchair and leaned over to the right before the caregiver could get to resident, resident fell out of the wheelchair on the floor and landed on right side...bumped the right side of forehead and back of head on the recliner...sustained brushing to right leg laceration forehead...POA transported resident to ER". R3's file contained emergency room discharge paperwork dated February 14, 2023 that identified a foot sprain. E1 reported the sprain was to the ankle area. E1 reported two caregivers were to assist with toileting needs for safety. An incident report dated February 20, 2023 stated "caregiver was standing behind resident providing incontinence care while resident was holding onto arms of the wheelchair...with gait belt secured to the resident. Caregiver who was also present in the room to assist with the completion of the transfer as needed. Resident's knee gave way and came into contact with the wheelchair. Resident was lowered to the floor to minimize injury...then transferred into recliner ...sustained quarter size bruise below left knee...". 2 .In an interview, E2 was asked about the aforementioned incidents. E2 reported that R3 became a two-person assist. E2 stated for the incident that occurred on February 20, 2023, there were two staff assisting with incontinence care. However, a call pendant sounded in another room and E5 left the room to see what a resident needed. E2 reported R3 was asked to stand while the adult brief was changed and peri-care was performed and R3 fell to the floor. 3. A review of personnel files documented knowlege and skills through a checklist form and contained documentation of caregiver requirements 4. In an interview, E1 reported R3 did not returned to the facility after the February 20, 2023 incident per R3's representative. E1 reported being unaware that E5 left the room while attending to R3's needs and that R3 was a two person assist.

Based on record review and interview, the manager failed to ensure a residency agreement included whether the manager or a caregiver was awake during nighttime hours, for one of three residents reviewed accepted by the assisted living home on or after July 1, 2014. The deficient practice posed a health and safety risk if a resident was unable to awaken the caregivers during nighttime hours. Findings include: 1. Review of R1's medical record revealed a residency agreement. However, this residency agreement did not include documentation of whether the manager or a caregiver was awake during nighttime hours. Based on R1's acceptance date, this documentation was required. 2. During an interview, E1 reported caregivers sleep at night but wake up for nighttime checks. E1 acknowledged R1's residency agreement did not include that information.

Based on interview and record review, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of three residents reviewed. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed. Findings include: 1. During an interview, E1 reported R3 experienced a change of condition approximately towards the end of January 2023 and required more care with toileting and was non ambulatory but weight bearing. E1 reported it was harder to turn E3 in bed to change adult briefs so caregivers would have E3 stand for a brief time to change the brief and provide peri-care. 2. Review of R3's medical record revealed a current written service plan dated December 9, 2022. This service plan indicated R3 required assistance with transferring, dressing, toileting, and bathing. The section titles "uses adaptive devices" documented "uses wheelchair. resident has walker but uses very infrequently". The service plan had a handwritten note in this section of the service plan that stated "Resident is unable and in danger of using walker". The service plan was not updated to reflect the change in condition. 3. During an interview, E1 acknowledged R3's service plan was not updated no later than 14 days after a significant change of condition.

Based on observation, documentation 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. During the facility tour, the surveyor observed a Ziploc bag full of medication bottles with R3's name on the prescription label. 2. During an interview, E1 reported R3 left the facility in February 2023. 3. Review of the facility's policies and procedures revealed a policy titled "Disposal of Medications Including Opioids and Narcotics" reviewed and signed by E1 February 1, 2023. This policy stated "...1. On a monthly basis the facility manager or manager designee will check all medication in the facility to identify and locate any discontinued medications (by physician's or medical practitioner's order), expired medications, including medication of deceased residents'. 2. Such medications will be disposed of by the facility manager or manager designee on the last day of the month..." 4. During an interview, E1 acknowledged R3 was no longer at the facility and the medication was not discarded per the policy and procedure.

Based on record review, documentation review, and interview, the manager failed to ensure a current therapeutic diet manual was available for use by employees. Findings include: 1. A review of R1's medical record revealed a physician order form signed and dated by a medical practitioner on April 1, 2023. The form stated, "Mechanical soft diet...". 2. The Compliance Officer requested the facility's therapeutic diet manual. However, a therapeutic diet manual was not provided for review. 3. In an interview, E1 acknowledged there was no therapeutic diet manual available for review.