Desert Gem Assisted Living Facility

Based on observation and interview, the manager failed to ensure a life preserver or shepherd's crook was available and accessible in the swimming pool area.  Findings include: 1. The Compliance Officer observed a swimming pool located in the back yard of the facility. However, no life preserver or shepherd's crook was available or accessible. 2. In an interview, E2 acknowledged a life preserver or shepherd's crook was not available and accessible in the swimming pool area.

Based on observation, record review, and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to residents' needs or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies. Findings include: 1. During a facility tour, the Compliance Officers observed the bedroom of R1 and R3. However, neither resident had a bell or other mechanical means to alert the staff to their needs. 2. A review of R1's medical record contained a service plan dated July 5, 2025, which reflected R1 was receiving personal level care. 3. In an interview, E2 acknowledged R1 and R3 did not have call bells or other mechanical means to alert the staff of their needs at the time of the inspection.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the facility, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed no documentation to indicate R2 received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after R2's acceptance by the facility. Based on R2's date of admission, this documentation was required. 2. In an interview, E1 acknowledged R2's medical record did not contain documentation of orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after R2's acceptance by the facility.

Based on record review and interview, the manager failed to ensure individuals employed by the facility obtained one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that was recommended by the U.S. Centers for Disease Control and Prevention (CDC), was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution, and included the date and the type of tuberculosis screening test, and a screening that consisted of assessing risks of prior exposure to infectious tuberculosis and determining if the individual has signs or symptoms of tuberculosis for one of the four employees sampled. Findings include: 1. A review of E1’s personnel record revealed there was no documentation of a negative Mantoux skin test or other tuberculosis screening test that was recommended by the U.S. CDC, was administered within 12 months before the date E1 provided services at or on behalf of the health care institution and 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, E2 reviewed E1’s personnel record and acknowledged that the above employee record did not have the required documentation.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for one of four personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states: " C. Each residential care institution, nursing care institution, and home health agency shall make documented, good-faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution, or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency may not hire the potential employee." 2. The compliance officer observed E1 to be a caregiver on-site during the compliance survey. 3. A review of E1's personnel records revealed there was no documentation of verification that E1 was not on the adult protective services registry. 4. In an interview, E2 acknowledged there was no documentation of verification that E1 was not on the adult protective services registry.

Based on 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 one of four caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E1's personnel records revealed no documented verification of E1's skills and knowledge. 2. The compliance officer observed E1 to be a caregiver on-site during the compliance survey. 3. In an interview, E2 reviewed and acknowledged that E1's personnel file did not contain documented verification of E1's skills and knowledge.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed before providing assisted living services to a resident, for one of the four sampled caregivers. The deficient practice posed a health and safety risk to the residents if the caregiver was not informed of the duties that needed to be performed. Findings include: 1. The compliance officer observed E1 to be a caregiver on-site during the compliance survey. 2. A review of E1's personnel record revealed no documentation of E1's completion of orientation specific to the duties to be performed before providing assisted living services to a resident. 3. In an interview, E2 was provided the opportunity to review E1's personnel file and acknowledged that E1's personnel record did not contain documentation of completed orientation.

Based on observation, record review, and interview, the manager failed to ensure that, before providing personal care services or directed care services to a resident, a caregiver provided documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults, for two of two caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. At the time of the inspection, the Compliance Officer observed E1 to be working in the facility as a caregiver. 2. A review of E1's personnel records revealed no documentation of first aid and CPR training certifications. 3. In an interview, E2 acknowledged E1's personnel record had no documentation of first aid and CPR training certifications.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility, which included the requirements in R9-10-807(D)(1-10), for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed there was no documented residency agreement available for review at the time of the inspection. 2. During an interview, E2 was provided an opportunity to review the medical record for R2. E2 confirmed there was no residency agreement was available for review for R2.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for one of two sampled residents. The deficient practice posed a risk to the health and safety of the resident, as there was no service plan to direct services to be provided to the resident. Findings include: 1. A review of R2's medical record revealed it did not contain documentation of a service plan. Based on R2’s date of admission, a service plan was required. 2. In an interview, E2 acknowledged R2's record did not contain a service plan for review.