Arizona Desert Falls

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for one of five residents sampled. The deficient practice posed a risk as there was no service plan to direct the services to be provided to a resident. Findings include: 1. A review of R3's medical record revealed the initial service plan dated April 17, 2025 was not signed by a nurse or medical practitioner as of May 5, 2025. The service plan indicated that R3's medications were provided by the facility staff. 2. In an interview, E1 revealed that R3 was not approved for insurance and did not have a medical practitioner assigned to the resident. E1 acknowledged that R3 did not have a signed service plan as required.

Based on record review and interview, the manager failed to ensure that the emergency responder was provided written documentation upon arrival as required under Arizona Revised Statute (A.R.S.) 36-420.04. Findings include: 1. A record review of form used by the facility revealed that R1, R2, R3, R4, nor R5 had prefilled Emergency Medical Services (EMS) Face Sheet readily available. 2. In an interview, E1 revealed that the employees filled out the EMS sheet while on the phone with 911. E1 completed the EMS Transfer Checklist for all residents during the inspection process. E1 acknowledged that there was no prefilled EMS Face Sheet/Assist Transfer Checklist available for any of the residents.

Based on record review, documentation review, and interview, the manager failed to ensure that an employee and/or resident provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for four sampled residents and two of five sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A record review of R1, R2, R3, and R4's medical records revealed that there was no TB screening assessment for any of the sampled residents. 2. A record review of R4 and R5's personnel record revealed that neither completed a TB screening assessment. 3. A documentation review of the facility's Policies and Procedure titled, "Tuberculosis (TB) Control" describes " Tuberculosis Baseline Screening" requirements for all new hires and residents. The policy required new hires to complete the form at the time of hire and residents to complete at the time of admission. 4. In an interview, E1 acknowledged that three residents and two employees did not meet the TB screening and assessment requirements, nor the two-step TB requirements for employees.