Best of Heart LLC

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to residents with access to the poisonous or toxic materials. Findings include: 1. At approximately 12:40 PM, the Compliance Officer observed a cabinet under the sink in the kitchen with a lock hanging from one of the handles. However, the Compliance Officer observed the cabinet was not locked. Inside the cabinet, the Compliance Officer observed a variety of poisonous or toxic materials, including antibacterial cleaner, disinfecting multi-surface cleaner, dishwasher tablets, Fabuloso, multi-surface cleaner with bleach, odor-eliminator, oven and grill cleaner, and stovetop cleaner. 2. In an interview, E1 reported the cabinet was unlocked because the caregivers had been cleaning. When the Compliance Officer informed E1 the caregivers had been out of sight of the cabinet several times while it was unlocked, E1 acknowledged the caregivers should have locked the cabinet. E1 asked E2 and E3 to lock the cabinet. 3. The Compliance Officer observed a counter in the office area near the kitchen. On the counter, the Compliance Officer observed a bottle of disinfecting wipes. In the unlocked cabinet under the counter, the Compliance Officer observed a second bottle of disinfecting wipes. The Compliance Officer observed a bottle of air freshener and a bottle of skunk odor eliminator on the counter in an unlocked bathroom. At approximately 1:10 PM, the Compliance Officer observed an unlocked door leading to the garage with the key hanging in the chain lock at eye level. Inside the garage, the Compliance Officer observed several cans of paint and primer. 4. In an interview, E1 asked E2 to lock the garage door. 5. At approximately 1:15 PM, the Compliance Officer observed the garage door still unlocked with the key still in the chain lock. 6. In an interview, E1 reported E2 had locked the garage door. The Compliance Officer pointed out the key still hanging from the chain lock and the door still not locked, other than the deadbolt which could be unlocked from inside the house. E1 motioned to the deadbolt, turned the deadbolt to the open position, opened the door, closed the door, turned the deadbolt to the closed position, and reported the door was locked. The Compliance Officer turned the deadbolt, opened the door, and again pointed out the door was not locked. E1 then acknowledged the door was not locked and reported facility personnel needed to use the chain lock. 7. At approximately 3:15 PM, the Compliance Officer observed the cabinet under the sink in the kitchen was unlocked. On several occasions, the Compliance Officer observed no personnel within sight of the unlocked cabinet. 8. In an interview, the Compliance Officer again informed E1 the cabinet under the sink in the kitchen was unlocked. E1 again asked E2 and E3 to lock the ca

Based on documentation review, 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 facility documentation revealed a policy and procedure (P&P) titled “ARS 36-40.01: HEALTH CARE INSTITUTIONS; FALL PREVENTION AND FALL RECOVERY; TRAINING PROGRAMS (Ref: SB1373).” The P&P stated: “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 E1 was hired as the manager. The review revealed E1 received training regarding fall prevention and fall recovery on March 4, 2024. However, the review revealed no documentation of continued competency training in fall prevention and fall recovery within 12 months after March 4, 2024, as required per P&P. 3. A review of E2’s personnel record revealed E2 was hired as a caregiver. The review revealed E2 received training regarding fall prevention and fall recovery on March 4, 2024. However, the review revealed no documentation of continued competency training in fall prevention and fall recovery within 12 months after March 4, 2024, as required per P&P. 4. In an interview, E1 reported believing E1 and E2 had taken the training after March 4, 2024. However, E1 reported not knowing where the certificates were. By the end of the inspection, E1 had not provided the certificates for continuing competency training.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included terms of occupancy, including the date of occupancy or expected date of occupancy, for two of two sampled residents. Findings include: 1. A review of R1's and R2’s medical records revealed residency agreements. However, the residency agreements did not include R1's and R2’s dates of occupancy or expected dates of occupancy. 2. In an interview, E1 acknowledged R1’s and R2’s residency agreements did not include this information.

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established and documented that included the amount, type, and frequency of assisted living services and ancillary services being provided to the resident, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a current service plan. The service plan indicated R1 was to receive assistance with baths (complete and partial), combing hair, dressing, laundry, room maintenance, toileting, transferring, and shaving. However, the service plan did not include the frequencies of these services. 2. In an interview, E1 reported the service plan was incorrect and R1 did not require assistance from facility personnel with bathing, combing hair, or transferring. E1 acknowledged the service plan was missing the frequency for the other aforementioned services. E1 further reported the service plan was missing changing R1’s briefs, including the frequency of the changes. 3. A review of R2's medical record revealed a service plan. The service plan indicated R2 was to receive assistance with bed partial, dressing, laundry, room maintenance, toileting, and transferring. However, the service plan did not include the frequencies of these services. The service plan further revealed R2 was to receive assistance with combing hair daily. 4. In an interview, E1 reported the service plan was incorrect and R2 did not require assistance from facility personnel combing hair. E1 acknowledged the service plan was missing the frequency for the other aforementioned services. E1 further reported the service plan was missing changing R2’s briefs, including the frequency of the changes.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for two of two sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. A review of R1’s medical record revealed a current service plan which indicated R1 required assistance with complete baths and combing hair and was dependent on facility personnel for transfers. The review revealed documentation of assisted living services provided to R1 (ADLs) dated June 2025 through July 2025. However, the ADLs revealed no documentation demonstrating facility personnel provided R1 complete baths, combed R1’s hair, or transferred R1. 2. In an interview, E1 reported facility personnel did not provide R1 complete baths, comb R1’s hair, or transfer R1. 3. A review of R2’s medical record revealed a service plan which stated facility personnel would comb R2’s hair daily and “Empty [R2’s catheter] drainage bag every 8 hour[s].” The review revealed ADLs dated June 2025 through July 2025. However, the ADLs revealed no documentation demonstrating facility personnel combed R2’s hair or drained R2’s catheter bag every eight hours. 4. In an interview, E1 reported facility personnel had not combed R2’s hair because R2 had not had enough to comb. When the Compliance Officer asked about R2’s catheter drainage bag, E1 reported facility personnel drained it at least two times a day.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan and the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a current service plan which stated R1 would be “Turn[ed] every 3 hours in bed” and “Reposition[ed] every 3 hours” as well. The review revealed documentation of assisted living services provided to R1 (ADLs) dated June 2025 through July 2025. However, the ADLs revealed no documentation demonstrating whether R1 was turned and repositioned. The ADLs further revealed R1 was bathed on a daily basis. 2. In an interview, E1 confirmed the ADLs were missing R1’s turning and repositioning and caregivers had not documented those services. E1 reported facility personnel did not bathe R1. 3. A review of R2's medical record revealed a service plan which stated R2 would be “Turn[ed] every 2 hours in bed” and “Reposition[ed] every 2 hours” as well. The service plan further indicated facility personnel would shower R2 two times per week, wash R2’s laundry, and empty R2’s catheter drainage bag every 8 hours. The review revealed ADLs for R2 dated June 2025 and July 2025. However, the ADLs revealed no documentation demonstrating whether R2 was turned and repositioned or whether R2’s catheter bag was drained. 4. In an interview, the Compliance Officer requested documentation of R2’s showers and laundry service in June 2025. E2 reported E2 would find the documentation. 5. A review of the documentation provided by E2 several minutes after the aforementioned request revealed a document titled “Bath and Laundry Schedules” dated June 2025. The document revealed documentation demonstrating R2 was showered on June 24, 2025, and R2’s laundry was done on June 26, 2025. However, the ink appeared fresh and the Compliance Officer was able to smear the ink in several places. 6. In an interview, when the Compliance Officer asked if E2 had created the document after the Compliance Officer’s request, E2 stated, “No.” The Compliance Officer then smeared the ink in front of E2. E2 then stated: “Yeah, I just wrote it. I look for the paper. I didn’t see it.” 7. In a separate interview, E1 reported E2 should not have created the document. When the Compliance Officer asked if caregivers documented R2’s turning, repositioning, and catheter drainage, E1 stated, “No” and “We don’t have it.”

Based on record review and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible, for two of two sampled residents. Findings include: 1. A review of R1’s medical record revealed a document titled “ADMISSION ORDERS.” However, the document contained white corrective fluid over the “Resident’s Name” at the bottom of the second page, making the initial entry illegible. 2. A review of R2’s medical record revealed a document titled “DETERMINATION FOR ADMISSION” signed by a “Physician, NP, PA, or Registered Nurse.” However, the document contained white corrective fluid over the option to mark “Personal Care Services,” making the initial entry illegible. The review further revealed a service plan. However, the service plan contained white corrective fluid over the “CODE STATUS,” making the initial entry illegible. 3. In an interview, when the Compliance Officer asked who made the initial entry illegible, E1 hesitated and stated, “I did that.” E1 reported the doctor had chosen the incorrect level of care for the R2.

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk as protected and sensitive resident health information was lost. Findings include: 1. The Compliance Officers observed a medication bag on a kitchen counter containing R2’s personally identifiable information (PII) (i.e. information also contained within R2’s medical record). The Compliance Officer observed an unlocked cabinet in the office area near the kitchen with resident medical records inside. On the counter below the cabinet, the Compliance Officer observed resident medical records as well as a medication box containing R3’s PII. Below the counter, the Compliance Officer observed an unlocked drawer inside with a prescription medication bottle with R3’s PII. 2. In an interview, E1 reported the medical records in the cabinet belonged to current and previous residents. E1 reported the medical records on the counter below the cabinet belonged to current residents. E1 acknowledged E1 did not protect the residents’ medical records from loss, damage, or unauthorized use.

Based on record review and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for two of two sampled residents. Findings include: 1. A review of R1’s medical record revealed a series of medication administration records (MAR) dated June 2025 through July 2025. The MARs indicated R1 received lisinopril and trazodone on a daily basis. However, the review revealed no authenticated medication orders for lisinopril and trazodone. 2. A review of R2’s medical record revealed a MAR dated July 2025. The MAR indicated R2 received cefdinir on July 13-15, 2025. However, the review revealed no authenticated medication order for cefdinir. 3. In an interview, E1 reported E1 did not have authenticated medication orders for the aforementioned medications.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed a sliding glass door in the dining room leading to the back yard. The Compliance Officer observed the facility did not have a monitoring system in place but the door did have an alert installed. However, the alert did not sound when the Compliance Officer opened the door and walked outside. 3. In an interview, E1 reported the alert had worked in the past, stating, “Why is that not turned on?” The Compliance Officer informed E1 the alert was on but was likely too far from the accompanying magnet to function properly. When the Compliance Officer asked if the alert or magnet had been recently moved or changed, E1 reported the affirmative.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a service plan which indicated R1 received medication administration. The review revealed a series of medication administration records (MARs) dated June 2025 through July 2025. The MARs revealed R1 received lisinopril and trazodone on a daily basis. However, the review revealed no authenticated medication orders for lisinopril and trazodone. 2. In an interview, E1 reported E1 did not have authenticated medication orders for R1’s lisinopril and trazodone. 3. A review of R2’s medical record revealed a service plan which indicated R2 received medication administration. The review revealed a series of medication orders dated June 18, 2025, for the following medications: - “HumaLOG Solution [insulin] 100 UNIT/ML…Inject as per sliding scale…subcutaneously before meals;” - “Polyethylene Glycol 3350 Powder…Give 17 gram[s] by mouth one time a day;” and - “Senna S Oral Tablet 8.6-50 MG…Give 2 tablet[s] by mouth at bedtime.” The review revealed a series of MARs dated June 2025 through July 2025. The MARs revealed the following: - Facility personnel administered cefdinir on July 13-15, 2025; - Facility personnel did not administer R2’s insulin; - Facility personnel did not administer R2’s polyethylene glycol; and - Facility personnel did not administer R2’s senna on June 27, 2025, or July 12, 2025. 4. In an interview, E1 reported E1 did not have an authenticated medication order for the cefdinir. E1 reported facility personnel had not administered R2’s insulin, stating, “We’ve never received [R2’s] insulin from [R2’s family member].” E1 reported the facility did not have R2’s polyethylene glycol. E1 reported facility personnel did not administer R2’s senna on the aforementioned dates due to loose stools. However, E1 acknowledged the medication order did not include orders to hold the senna for any reason and E1 confirmed E1 had not received an order to hold the senna.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. The Compliance Officer observed an unlocked refrigerator in the kitchen. In the door of the refrigerator, the Compliance Officer observed a bag containing two bottles of insulin and an insulin pen. On a shelf in the refrigerator, the Compliance Officer observed a lockbox with a lock hanging from it. However, the Compliance Officer observed the box was not locked. Inside the box, the Compliance Officer observed one bottle of “Tuberculin, Purified Protein Derivative,” one bottle of insulin, and five insulin pens. 2. In an interview, E1 reported the bagged medication in the door belonged to E2 and should not have been in the refrigerator. Regarding the lockbox, E1 reported the facility did not have any residents with controlled medication at the moment so the lockbox did not stay locked. E1 reported facility personnel lock the box when it contains controlled medication but do not lock it when it does not, stating, “It stays unlocked.” 3. The Compliance Officer observed an unlocked drawer in an office area near the refrigerator. Inside the drawer, the Compliance Officer observed a bottle of latanoprost ophthalmic eye drops. 4. In an interview, E1 reported not knowing who the eye drops belonged to.