Desert Dreams Adult Care Home, LLC

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a current service plan describing the services provided by the facility staff. The plan included a section titled “Turning” which indicated R2 needed “hands on assist.” The service plan also included a section titled “Basic Skin Care,” which indicated R2 suffered from “Stage 1 breakdown on buttocks,” and would benefit from “changing positions every 2-3 hours.” 2. A review of R2’s medical record revealed a document used for tracking the services provided to R2. The document included a section for documenting basic skin care; however, evidence of documentation to indicate the service “turning” was unavailable for review. Evidence of documentation R2 was repositioned as indicated in R2’s service plan was unavailable for review. 3. In an interview, E1 advised caregivers repositioned R2 approximately every two hours. E1 agreed the caregivers were not documenting the positioning service provided per R2’s service plan.

Based on documentation review, record review, and interview, the assisted living home failed to provide the required documentation to an emergency responder, for two of two residents sampled for whom an emergency responder had been contacted. The deficient practice posed a risk as the Department was provided false and misleading information. Findings include: 1. A review of facility documentation revealed an incident report dated March 31, 2024. The incident report indicated R3 had been transported to the hospital after expressing groin pain and an inability to urinate. The incident report contained six sections which identified a specific date of March 31, 2024. However, a line was drawn through five of the six noted dates and a new date of April 20, 2024 was written in. The original date entries were not made illegible. 2. A review of R3's medical record revealed a document titled, "TMC Healthcare After Visit Summary," dated March 31, 2024. The document indicated R3 was seen in the Tucson Medical Center emergency department on the same date for a "Urinary track infection..." and "Foley catheter problem, initial encounter." Evidence of any other record to indicate R3 was transferred to a medical facility or received emergency medical services on April 20, 2024 was unavailable for review. Further review of R3's medical record revealed a standardized form titled, "Assisted Living Resident Transfer Checklist," which was dated April 20, 2024. The form was also signed by E4 and E5 with the date "4-20-24" noted next to each signature. However, the form did not include the following required information: - a list of all the resident's medications, their dosages, and how frequently they were administered; - The address and telephone number of the resident's current pharmacy; - Basic information about the resident's physical and mental conditions and basic medical history; - A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge; and - A copy of the resident's advance directives, if any. 3. A review of facility documentation revealed an incident report dated June 11, 2024. The incident report indicated R4 was experiencing stomach pain and was vomiting. The report also indicated 911 was called and the resident was transported to a hospital. Further review of R4's medical record revealed a standardized form compliant with A.R.S. 36-420.04 was unavailable for review. 4. In an interview, E6 recalled R3 was taken to the emergency department only one time. E6 advised R3 was not transported to the emergency department in late April 2024. E6 reported not knowing why there were two different dates on the March 31, 2024 incident report regarding R3. 5. In an interview, E1 reported emergency medical services were called only one time for R3. E1 advised they did not know why R3's Resident Transfer

Based on observation, documentation review, record review and interview the manager failed to ensure a caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults, prior to providing assisted living services to a resident for one of ten personnel members sampled. Findings include: 1. During a tour of the facility the Compliance Officer observed E3 providing assisted living services to various residents. 2. A review of facility policy and procedures, last reviewed March 29, 2024, revealed a policy titled, "Administering CPR, First Aid and Fall Recovery to Residents." The policy read, in part, "...all caregivers will be required to provide current training in CPR and First Aid before providing services to the residents. Caregiver's will be required to submit new training documentation on month prior to the expiration date." 3. A review of E3's personnel record revealed E3 was hired as a caregiver on July 29, 2016. Further review, revealed documentation indicating E3 completed cardiopulmonary resuscitation (CPR) and first aid training on June 13, 2022. The documentation included an "Expiration Date" for the training of June 13, 2024. However, evidence of documentation of E3's current CPR and first aid training was not available for review. 4. In an interview, E3 acknowledged providing assisted living services to residents during the month of June and in July 2024. E3 confirmed their CPR and first aid certification had not been renewed prior to providing assisted living services. 4. In an interview, E1 acknowledged E3's personnel record did not include current documentation of CPR and first aid training.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical record revealed current service plans for directed care services. Both service plans included the service, "Dressing," and each indicated R1 and R2 required "Complete" assistance dressing "morning & bedtime." 2. A review of R1's and R2's medical record revealed a tracking sheet dated June, 2024, used for tracking activities of daily living (ADLs) and services provided. The tracking sheet did not contain a section for documenting the service "Dressing." Evidence of documentation the service was provided to either R1 or R2 was unavailable for review. 3. In an interview, E1 acknowledged the caregivers were not correctly documenting all services provided for R1 and R2 in their medical records.

Based on document review, observation and interview, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees to the egress of a residents from the facility. The deficient practice posed a potential elopement risk to residents. Findings include: 1. A review of facility documentation revealed the facility was licensed at Directed Care level. 2. A review of R1's medical record revealed a service plan dated May 8, 2024, which indicated R1 received directed care services and was ambulatory. 3. During a tour of the facility, the Compliance Officer observed no less than three ambulatory residents. The Compliance Officer also observed R1's bedroom which had a door leading to the main driveway outside the facility. Mounted to the wall above the door was an "EXIT" sign. Also mounted to the door was a door chime designed to alert employees when the door was opened. The door had a deadbolt locking mechanism with a thumb turn and a handle which could be locked with a key. However, the door handle was not locked, and the Compliance Officer was able to turn the thumb tun deadbolt with little effort and open the door. When the Compliance Officer opened the door, the chime did not sound. 3. In an interview E1 acknowledged that the bedroom door providing egress from the facility did not have a functioning chime to alert employees of an egress of a resident. This is a repeat citation from a compliance inspection conducted on April 28, 2023.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an emergency and needed medical services, as required per R9-10-818.D.2. Findings include: 1. A review of facility documentation from April 2024 through June 2024 revealed one incident report involving R3 which documented and emergency where 911 was contacted. A review of the incident report dated June 11, 2024 revealed the report contained most documentation required per R9-10-818.D.2. The report included a section for documenting actions taken to prevent the incident from occurring in the future, however the section was not completed. 2. In an interview, E1 agreed the incident report did not contain all documented required per R9-10-818.D.2.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed a metal mounting bracket, attached to the wall inside a common bathroom used by guests and residents. The bracket, which extended away from the wall and had a sharp edge, appeared to be for mounting a towel bar. 2. In an interview, E1 agreed the mounting bracket presented a condition that may cause a resident to suffer physical injury. E1 submitted a verbal work order to have maintenance remove the mounting bracket.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During a tour of the facility the Compliance Officer observed no fewer than three ambulatory residents. The Compliance Officer entered an office through a door which did not have a locking handle, and observed a bookshelf filled with wire baskets containing a wide variety of resident's medications including the following: -Trazodone 50MG tablets -Calcitriol 0.25 MCG Capsules -Donepezil 10MG Tablets -Hydrochlorothiazide 25MG Tablets -Levothyroxine 0.100MG Tablets -Sertraline 50MG Tablets 2. In an interview, E1 advised the facility had recently changed offices and moved the resident's overstock medications. E1 acknowledged the medications had not been stored in a separate locked room, and E1 was observed replacing the door handle with a locking handle.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility staffing schedules revealed the facility had two shifts, 7:00 a.m. - 7:00 p.m. and 7:00 p.m.-7:00 a.m. 2. A review of facility documentation revealed documentation of disaster drills for employees on both shifts conducted on January 1, 2021. However evidence of documentation of disaster drills for employees conducted on each shift at least once every three months since January 2021 was not available for review. 3. In an interview, E2 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented as required.

Based on documentation review and interview, the manager failed to ensure a evacuation drill for employees and residents was conducted at least once every six months and documented. Findings include: 1. A review of facility documentation revealed documentation of evacuation drills for employees and residents on October 1, 2020. However evidence of documentation of evacuation drills for employees and residents conducted at least once every six months since October 2020 was not available for review. 2. In an interview, E2 acknowledged an evacuation drill for employees and residents was not conducted on each shift at least once every six months and documented as required.

Based on observation, record review, and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom or residential unit being used by a resident receiving personal care services. Findings include: 1. During a tour of the facility, the Compliance Officer observed R2's bedroom did not have a bell, intercom, or other mechanical means to alert employee to a residents' needs or emergencies that was accessible. 2. A review of R2's medical record revealed a service plan (dated August 5, 2022) which indicated R2 required personal care services. 3. In an interview, E1 acknowledged no bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95 \'baF and 120 \'baF in areas of an assisted living facility used by residents. Findings include: 1. During a tour of the facility the Compliance Officer observed the water temperature, in one community bathroom used by residents on the south side of the facility, to be 141.5 \'baF. The Compliance Officer observed the water temperature in a community bathroom used by residents on the north side of the facility to be approximately 137.7 \'baF. 2. In an interview, E1 advised the facility utilizes three hot water heaters which supply hot water to the south, central, and north sides of the facility. E1 acknowledged the water supplied to the south and north sides of the facility was greater than 120 \'baF.

Based on documentation review, record review, and interview, the the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the health and safety of residents if employees were not able to assist a resident in the event of a fall. Findings include: 1. A review of facility documentation revealed evidence of a training program for fall prevention and fall recovery was not available for review. 2. A review of E3's and E4's personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged a training program for all staff regarding fall prevention and fall recovery had not been developed and administered.

Based on documentation review, record review, observation and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation required by policies and procedures, for one of three personnel sampled. The deficient practice posed a risk if the caregivers were unable to meet a resident's needs. Findings include: R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of facility policy and procedures (reviewed November 30, 2021) revealed a policy titled, "Caregiver Orientation and Continuing Education." The policy stated "At the time of hire of a new employee the Manager or Manager's Designee will ensure that the employee receives the appropriate training and orientation needed." The policy further stated a description of each new employee's "job duties" will be maintained in the employee's personnel record. Lastly, the policy stated, "All caregivers are required to complete at least six hours of continuing education...on an annual basis." 2. A review of E3's personnel record revealed E3 was hired as a caregiver in 2021. However, evidence of documentation of E3's completed continuing education was not available for review. 3. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in 2018. However, evidence of documentation of E4's orientation was unavailable for review. Further, evidence of documentation of E4's completed continuing education was not available for review. 4. During a tour of the facility, the Compliance Officer observed both E3 and E4 to be working and providing assisted living services to residents. 5. In an interview, E2 acknowledged E3 and E4 had not received continuing education as required by facility policy. E2 also acknowledged documentation E4 received orientation was not available for review.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative for one of two residents sampled. The deficient practice posed a risk as there was no evidence R2 or R2's representative was involved and agreed to the services to be provided to R2. Findings include: 1. A review of R2's medical record revealed R2 was admitted in 2022. Further review of R2's medical record revealed a service plan dated August 5, 2022. The service plan was signed by an RN and a manager's designee, however the service plan was not signed by R2 or R2's representative. 2. In an interview, E2 acknowledged that R2's service plan was not signed by R2 or R2's designee as required by the rule.

Based on observation, document review and interview, the manager failed to ensure a smoke detector installed in each bedroom, hallway that adjoins a bedroom, and room or hallway adjacent to the kitchen was tested at least once a month. Findings include: 1. During a tour of the facility the Compliance Officer observed smoke alarms placed on the ceiling of all bedrooms, adjoining hallways and rooms and adjoining hallways adjacent to the kitchen. 2. A review of facility documents revealed a "Smoke Detector Log," which stated, "All smoke detectors are tested at least once every month." The log documented smoke detector tests for the months of March and April 2022, however evidence of documentation the smoke detectors were tested after April 2022 was unavailable for review. 3. In an interview, E1 acknowledged they had not tested the smoke detectors monthly since April 2022.

Based upon document review and interview the manager failed to ensure a pest control program which complies with A.A.C R3-8-201.C.4 was implemented and documented. Findings include: 1. A review of facility documentation revealed a document titled "Pest Control Program Log." The log documented monthly pest control from August 1, 2021 through April 1, 2022. Evidence of documented monthly pest control after April 1, 2022, was not available for review. In addition, the log included columns reading "Pesticide Used" and "Treated Area/Comments/Concerns." The log indicated "Aptive Pest Control" provided pest management services on September 1, November 1, 2021 and on February 1 and March 1, 2022. The log also indicated "Ortho Home Defense" was applied in "living room, closets, offices, hallways, bedrooms, kit[chen]" on August 1, October 1, December 1, 2021, and on January 1 and April 1, 2022. 2. In an interview E1 advised Aptive Pest Control is a licensed applicator, however the facility does not have a contract with the pest control company. E1 acknowledged E1 had applied insecticide to the facility and E1 was not a licensed applicator.

Based on document review, observation and interview, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees to the egress of a residents from the facility. Findings include: 1. A review of facility documentation revealed the facility was licensed at Directed Care level. 2. During a tour of the facility, the Compliance Officer observed no less than three ambulatory residents. The Compliance Officer also observed an unoccupied bedroom which had a door leading to the main driveway outside the facility, and mounted to the wall above the door was an "EXIT" sign. Also mounted to the door was a door chime designed to alert employees when the door was opened. The door did have a handle which locked with a key, however the door was not locked. When the Compliance Officer opened the door, the chime did not sound. 3. E1 was observed opening the door chime battery compartment and the Compliance Officer observed the chime required four small batteries to operate, however the chime battery compartment only had three batteries. 4. In an interview E1 acknowledged that the bedroom door providing egress from the facility did not have a functioning alert.

Based on documentation review, observation, and interview, the licensee implemented a change without an approval or amended license issued by the Department. The deficient practice posed a risk as the Department was unable to assess and approve the addition of four bedrooms as the facility did not submit an updated floor plan, and documentation of compliance with local building and zoning codes. Findings include: 1. A review of Department documentation revealed a floor plan, for AL8418 which indicated the facility had five bedrooms, three bathrooms, a laundry room, a living room, a dining room, a kitchen, a storage room and four closets. 2. A review of Department documentation revealed AL8418 was approved for a ten-bed capacity in April 2011. 3. During an environmental tour the Compliance Officer observed a total of five additional bedrooms, with corresponding closets, and two additional bathrooms which were not identified on the original floor plan. However, the additional bedrooms, closets and bathrooms were identified on "Emergency Escape Route" floor plans, which were posted in the hallways of the facility. 4. In an interview, E1 reported the additions were completed "about ten years ago," and the additions were permitted through Pima County. E1 acknowledged the facility did not request a modification of the physical plant of AL8414. E1 added the facility census was eight, and each resident had their own bedroom. 5. A review of Department documentation revealed evidence to indicate the licensee requested a modification to the physical plant of AL8418 was not available for review. 6. Research conducted through Pima County, Public Works, Development Services, http://www.pima.gov/2587/Records-Search, revealed a building permit record, "P12CP06228," dated July 6, 2012, which documented "(2) bedroom wing additions...at existing assisted living residence..."