Desert Garden Assisted Living, INC

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed an unlocked dresser in the hallway. Upon opening one of the unlocked drawers, the Compliance Officer observed a bottle of "Robitussin" cough syrup and an inhaler with "Albuterol Sulfate" sitting in one of the drawers with clothing and other assorted items. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review, record review and interview, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances, for one of two residents sampled. Findings include: 1 . A review of facility documentation revealed a policy titled "Opioid Administration and Treatment." The policy stated, "Ensure that all opioids or controlled substances are inventoried daily..." 2 . A review of R2's medical record revealed a medication order for Morphine 20 MG/ML on November 19, 2025. Further review of R2's medical record revealed no documentation of a "Controlled Substance Assessment Form" for November 2025, and a blank "Controlled Substance Assessment Form" for the month of December 2025. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure the disaster plan review included the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. Findings include: 1. A review of facility documentation revealed a disaster plan review dated January 15, 2023; January 9, 2024; and January 5, 2025. However, the disaster plan reviews did not include documentation of the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a pair of accordion doors that led to a laundry room held together by a chain with a padlock. However, the compliance officer was able to open the accordion doors far enough to allow the Compliance Officer to reach in and pull out a bottle of "Oxi Clean" laundry detergent and a bottle of "Cloralen" bleach. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department of the Board of Examiners for the Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for one of the three caregivers sampled. The deficiency practice posed a risk if a caregiver was not qualified to provide the required services, and provided false and misleading information to the Department. Findings include: 1. In a record review, E2's personnel record revealed a hiring date as a caregiver on June 1, 2021. E2's personnel record included a copy of a caregiver certificate dated October 7, 1999, from the "Desert Rose Training and Consultation." 2. A review of the NCIA board website revealed the Desert Rose Training and Consultation ALTP #58 Training Program had a "Start Date October 28, 2002," and "Expiration Date June 12, 2006." 3. In a documentation review, the facility's policies and procedures per R9-10-806(A)(1)(b) stated, "A manager shall ensure that a Caregiver has documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for the Nursing Care Institution Administrators and Assisted Living Facility Managers." 4. In an interview, E1 reported E1 did not know that E2's Caregiver Certificate was not valid according to the NCIA. E1 reported being unaware the caregiver certificate was dated prior to the date the training program was started. E1 reported to use the NCIA website to verify Certificates issued after August 3, 2013. E1 acknowledged that E2's personnel record did not contain documentation of completion of a caregiver training program approved by the NCIA.

Based on observation and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled 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 general or specific whereabouts of a resident. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed the alert on the door was deactivated when entering the facility through the front door. The Compliance Officers observed caregivers activating alerts on all doors while on site. 2. In an interview, E1 reported the facility had an alarm system and reported that it was not activated today. E1 reported the facility did not have residents who may wander at the present time. E1 acknowledged the facility was licensed for directed care services and the facility did not have a means to control or alert employees to the egress of a resident from the facility.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for two of two caregivers sampled. The deficient practice posed a risk if E1 and E2 were unable to meet a resident's needs, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. The Compliance Officer observed E1 and E2 on the premises upon arrival at 1:20 PM. 2. A review of the facility's documentation, per R9-10-807.A.7, revealed E1 and E2 were scheduled to work every Monday through Friday with alternating weekends off. 3. A review of E1's (hired in 2021) personnel record revealed documentation of E1's verified skills and knowledge was not available for review. 4. A review of E2's (hired in 2021) personnel record revealed documentation of E2's verified skills and knowledge was not available for review. 5. In an interview, E1 acknowledged E1's and E2's skills and knowledge were not verified and documented before E1 and E2 provided physical health services.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least twelve months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk if there was no record to ensure shifts and tasks were covered, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. The Compliance Officer observed a "WORK SCHEDULE FOR THE MONTH" of "2023 JUNE" hanging on a wall of the facility. However, schedule did not display the hours worked by each caregiver each day. 2. In an interview, E1 acknowledged E1 failed to ensure hours worked by each caregiver was documented each day.