Best Home Care of Surprise LLC

Based on observation and interview, the manager failed to ensure the premises were cleaned. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During the environmental inspection, the Compliance Officer observed the following: In R2's bathroom, the toilet seat had a buildup of dried feces around the edges. In R2's bathroom, there was a pungent odor of urine. 2. In an exit interview, the findings were reviewed with E2; no other information was provided.

Based on documentation review, observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. A.R.S. \'a7 36-425(I) states "A health care institution shall immediately notify the department in writing when there is a change of the chief administrative officer..." 2. The Compliance Officers observed a manager's certificate near the front door indicating E1 as the manager. 3. A review of E1's personnel record showed E1 was hired March 16, 2024. 4. A review of documents revealed an email that was sent to the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers about the change in manager. However, documentation was not available showing notification to the Department. 5. In an interview, E3 reported that E1 was not aware about notifying the Department about the change in manager.

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 one of two residents reviewed. 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 R1 had a TB skin test. However, there was not a tuberculosis screening test in R1's medical record. 3. A review of the facility's policy and procedures revealed a policy titled, "Tuberculosis (TB) Control- Tuberculosis Screening", which stated, "TB screening is a process that includes an individual risk assessment, a symptom evaluation, a TB test (e.g. a TB blood test or a TB skin test), and additional evaluation for TB disease as needed," 4. In an interview, E3 acknowledged R1 did not provide documentation of freedom from infectious TB as specified in R9-10-113. 5. Technical assistance was provided on this Rule during the compliance inspection conducted April 4, 2023.