Desert Breeze Alh LLC

Based on record review and interview, the manager failed to ensure an individual employed by the facility completed a screening that consisted of assessing risks of prior exposure to infectious tuberculosis and determining if the individual had signs or symptoms of tuberculosis for one of four employees sampled. Findings include: 1. In a review of E4’s personnel record revealed there was no documentation of a screening assessing the employees’ risks of prior exposure to infectious tuberculosis and determining if the individual has signs or symptoms of tuberculosis. 2. In an interview, E1 reviewed E4’s personnel records. E1 acknowledged the above required documentation was not available for review at the time of the survey.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver provided valid documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three caregivers sampled. The deficient practice posed a risk if the individuals were not qualified to provide the required services and provided false and misleading documentation. Findings include: 1. Upon arrival at the facility, the surveyor observed E1, E2, and E3 present inside the facility. 2. A review of E3's personnel record revealed E3 had been employed with the facility since November 2024. E3's record contained a caregiver certificate issued April 11, 2025, with a validation code of “AZCG21785”. However, a check of the tmuniverse website revealed that AZCG21785 was assigned to a different person. 3. In an interview, E1 and E3 reported being unaware of any discrepancies regarding E3's caregiver certification.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with assistance with activities of daily living according to the resident's service plan, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan dated September 19, 2025, which reflected that R2 required moderate assistance with oral care, maximum assistance with nail care, hair care, and washing R2's face. 2. A review of R2's medical record revealed a document titled "Activities of Daily Living" dated October 2025, which states “self” on nail care, hair care, and face wash, despite R2’s service plan reflecting that R2 required the above services. 3. In an interview, E1 acknowledged R2’s service plan and documentation of assistance provided were inconsistent.

Based on record review and interview, the manager failed to ensure a verbal order for a resident’s medication received from a medical practitioner by the assisted living facility, a written order verifying the verbal order was obtained from the medical practitioner within 14 calendar days after receiving the verbal order, for one of two sampled residents. Findings include: 1. A review of R1’s medical record contained a verbal order dated September 18, 2025, which stated “Lantus Solostar U-100 Insulin 100 unit/MI (3MI) Subcutaneous Pen administer 8 unit one time daily." 2. A review of R1’s October 2025 medication administration record (MAR) reflected that R1 was administered Lantus 8 units from October 1, 2025, through October 23, 2025. 3. In an interview, E1 acknowledged that a written order verifying R1’s verbal order was not obtained from R1’s medical practitioner within 14 calendar days after receiving R1’s verbal order.

Based on a record review and interview, the manager failed to ensure that medications administered to a resident were in compliance with a medication order for two of the two sampled residents. Findings include: 1. A review of R1’s medical record contained a medication order dated May 30, 2025, for Famotidine 40mg two times a day. R1’s October 2025 medication R1’s administration record (MAR) reflected that R1 was administered Famotidine at 7:30 am from October 1, 2025, through October 23, 2025. R1’s October 2025 MAR reflected that R1 received one dosage of Famotidine 40mg. 2. A review of R1’s October 2025 MAR reflected that R1 was administered a Nifedipine ER 30mg tablet at 7 am from October 1, 2025, through October 23, 2025. However, R1’s medical record did not contain a medication order for Nifedipine ER 30mg tablet one time daily. 3. A review of R2’s medical record contained a medication order dated September 8, 2025, for Alprazolam 0.5mg every four hours. R2’s October 2025 medication administration record (MAR) reflected that R2 was administered Alprazolam 0.5mg once at 8 pm from October 1, 2025, through October 23, 2025. R2’s October 2025 MAR reflected that R2 received one dosage of Alprazolam 0.5mg. 4. In an interview, E1 acknowledged that medication administered to a resident was not administered in compliance with a medication order.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance the individual submitted documentation, dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; signed and dated by a physician, registered nurse practioner, registered nurse, or physician assistant, for two of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's (admitted July 2023) medical record revealed documentation, dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; signed and dated by a physician, registered nurse practioner, registered nurse, or physician assistant was not available for review. 2. A review of R2's (admitted July 2023) medical record revealed documentation, dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; signed and dated by a physician, registered nurse practioner, registered nurse, or physician assistant was not available for review. 3. In an interview, E1 acknowledged E1 failed to ensure before or at the time of acceptance the individuals submitted documentation, dated within 90 calendar days before they were accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; signed and dated by a physician, registered nurse practioner, registered nurse, or physician assistant

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R1's medical record revealed a medication list signed by a medical practitioner (dated August 26, 2023) . The list included "Trazadone 100 MG routine tablet oral... Take 1.5 tablet at bedtime." However, a review of R1's medication administration record listed "Trazadone 150 MG 1 Tab PO QHS" had been administered to R1. 2. A review of R2's medical record revealed a "medication profile" signed by a medical practitioner (dated August 3, 2023) . The list included "Senna plus 8.6mg-50mg tablet... 1 Tab by mouth 2 times a day for constipation." However, a review of R2's medication administration record listed "Senna plus 8-6mg 1 Tab PO QD" had been administered to R2. 3. In an interview, E1 acknowledged E1 failed to ensure a medication administered to a resident was administered in compliance with a medication order.