Desert Haven Adult Care Home LLC

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of three personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411 states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.”… “E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked.”… and “F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.” 2. A review of E4’s personnel record revealed no evidence of a fingerprint clearance card. The record included an application for a finger

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. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. During the environmental tour of the facility, the Compliance Officer inspected the kitchen refrigerator and found an unlocked drawer which contained the following medications: two boxes of five 3 mL prefilled pens of "Basaglar Kwik Pen (insulin glargine) injection"; two bottles of “Latanoprost Ophthalmic Solution”; a box with four single dose prefilled syringes of “Orencia (abatacept) injection 125mg/mL”; a box of 15mL of “Morphine Sulfate Oral Solution 100mg per 5mL”; and a 30mL box of “Lorazepam Oral Concentrate USP 2mg/mL”. 2. The Compliance Officer observed E1 remove the medications from the main refrigerator in the kitchen and secure them in a refrigerator in a locked room. 3. In an interview, E1 acknowledged the medication was stored in an unlocked refrigerator drawer and reported the medications were not usually stored in the main refrigerator. This is a repeat citation from the compliance inspection conducted on November 9, 2023.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training for applicable employees to include the method and content of CPR training, including a demonstration of the employee's ability to perform cardiopulmonary resuscitation, for one of two sampled caregivers. The deficient practice posed a risk to the health and safety of residents if employees were unable to perform life saving measures in the event of an emergency. Findings include: 1. A review of the facility's policies and procedures, reviewed February 1, 2019, revealed a policy covering CPR training which repeated the rule and did not elaborate on how the facility would implement the rule. The policy stated, "The manager shall ensure that the manager and each caregiver working in the facility has received CPR and First Aid from qualified instructors certified to provide CPR and First Aid training through a nationally accepted CPR and First Aid Program, and provides documentation including: 1) The method and content of CPR and First Aid training, which includes a demonstration of the caregiver's ability to perform CPR. 2) The qualifications for an individual to provide CPR and First Aid training, 3) The time-frame for renewal of CPR and First Aid Training, and 4) The documentation that verified that the caregiver has received CPR and First Aid training." 2. A review of E3's personnel file indicated E3 was hired as a caregiver in January of 2022. E3's personnel file included a CPR certification from "CPR Select," an online only provider which did not include a demonstration of E3's ability to perform CPR. 3. In an interview, E1 acknowledged the facility's policy and procedure covering CPR training repeated the rule and acknowledged E3's provided documentation of CPR training did not include a demonstration of E3's ability to perform CPR.

Based on observation, record review, 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 an environmental inspection of the facility, the Compliance Officer observed a cabinet in the kitchen which did not have a lock. Inside the cabinet, the Compliance Officer observed the following medications: - "Vicks Vaporub"; - "Equate 70% Isopropyl Alcohol"; - "Equate Hydrogen Peroxide Topical Solution": and - "Lactulose Solution USP 10g / 15ml." 2. During an environmental inspection of the facility, the Compliance Officer observed R1 had a container of, "Systane Lubricant Eye drops" unsecured in R1's room. 3. A review of R1's medical record revealed a service plan for personal care services which included medication administration. 4. In an interview, E1 acknowledged medications stored by the assisted living facility had not been stored in a locked area. This is a repeat deficiency from the on-site compliance inspection conducted on November 3, 2022.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a shelving in a hallway leading to the garage door was used for food storage and was accessible to residents. On the shelves, the Compliance Officer observed a spray can of, "Misty Oven and Grill Cleaner." 2. During an environmental inspection of the facility, the Compliance Officer observed a cabinet above the stove did not have a lock. Inside the cabinet, the Compliance Officer observed a container of "Gorilla Glue." 3. During an environmental inspection of the facility, the Compliance Officer observed a linen closet in a hallway adjacent to R1's room. The linen closet did not have a lock. Inside the closet, the Compliance Officer observed a container of nail care supplies which included two containers of Acetone nail polish remover. 4. During an environmental inspection of the facility, the Compliance Officer observed the laundry room was secured with a chain latch and did not have a lock. Inside the laundry room, the Compliance Officer observed various cleaning chemicals were being stored. 5. In an interview, E1 reported the chain latch had been recommended at a previous survey. E1 reported the Gorilla Glue was in a high cabinet the residents could not reach. E1 acknowledged the oven spray and nail polish remover were not stored a locked area separate from food preparation and storage areas and were not inaccessible to residents.