Desert Hills Assisted Living LLC

Based on observation and interview, the manager failed to ensure that residents' medical records were protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected, sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed residents' medications sitting out on an office desk, as well as resident documents that contained private health information. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was reviewed and updated at least once every six months for a resident receiving personal care services, for one of the three sampled residents. Findings include: 1. A review of R1's medical record revealed that R1 required personal care services. Further review revealed R1's service plan was last updated on May 26, 2025; no other service plan was available for review. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on the record review and interview, the manager failed to ensure that a caregiver documented the services provided in the residents' medical records for three of three sampled residents. Findings include: 1. A review of R1's, R2’s, and R3's medical records revealed activities of daily living documentation for February 2026. However, there was no documentation of services provided from February 1, 2026, to February 4, 2026. 2. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record for one of three residents sampled. Findings include: 1. A review of R2’s medical record revealed a medication order for: · Senna lax 8.6mg oral tablet/ 1 tablet/ orally/ daily. 2. A review of R2’s medical record revealed a January 2026 and February 2026 MAR. The MAR listed the following medications: · Senna lax 8.6mg oral tablet/ 1 tablet/ orally/ daily. The medication; however, was only given from January 1, 2026 to January 23, 2026. There was no documentation on the MAR to indicate whether it was given from January 24, 2026, to February 5, 2026, and no reason was indicated on the MAR for the medication not being administered. 3. In an interview, E1 reported that the medication was discontinued. When asked for documentation that showed the medication was discontinued, E1 was unable to provide the documentation. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance/complaint inspection conducted September 3, 2025.

Based on documentation review, interview, and observation, the licensee failed to ensure an application was submitted for a modification in a Department-provided format, which contained a narrative description of the changes being made to the physical plant. Findings include: 1. A review of documentation revealed a facility's layout, which reflected that from the facility's main entrance, there would be a living room and diagonally across a nook area. 2. In an interview, E1 reported that the nook area was measured and approved as a bedroom during the initial. 3. The compliance officer observed the facility's nook area to be occupied as a sixth bedroom with one resident. The nook contained two beds, a couch, and a television. 4. A review of Department documentation revealed the facility's floor plan. The floor plan did not include a sixth bedroom. A review of the document titled "Room Occupancy Verification Form" dated March 13, 2018, which included the measurements of five bedrooms. 5. In an interview, E1 acknowledged that the licensee failed to ensure an application was submitted for modification in a Department-provided format, which contained a narrative description of the changes being made to the physical plant. This was a repeat citation from the complaint investigation and compliance inspection conducted on September 6, 2024.

Based on record review and interview, the manager failed to ensure a notice of termination of residency included the date of notice, the reason for termination, the policy for refunding fees, charges, or deposits, the deposition of a resident’s fees, charges, and deposits, and contact information for the State Long-Term Care Ombudsman. Findings include: 1. In an interview, E1 reported R4 was not "fit for the home" and a verbal discharge was given to R4 and R4's representative. 2. A review of R4's medical record did not contain documentation of a termination of residency which included the date of notice, the reason for termination, the policy for refunding fees, charges, or deposits, the deposition of a resident’s fees, charges, and deposits, and contact information for the State Long-Term Care Ombudsman. 3. In an interview, E1 acknowledged R4 did not receive a written termination, which included the date of notice, the reason for termination, the policy for refunding fees, charges, or deposits, the deposition of a resident’s fees, charges, and deposits, and contact information for the State Long-Term Care Ombudsman.

Based on record review and interview, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided in a resident's medical record for one of the two sampled residents who were required to have a service plan. Findings include: 1. A review of R2's medical record contained a service plan dated July 3, 2025, which reported R2 required assistance with showers weekly, toileting twice daily, and oral care twice daily. The documentation of services provided for September 2025 and August 2025 was left blank. 2. In an interview, E1 acknowledged that there was no documentation of services provided to R2 available for review during the survey.

Based on observation, record review, and interview, the manager failed to ensure that a medical record was established and maintained for one of four sampled residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. During the facility tour with E1, R3 was observed sitting in R3's wheelchair. 2. Review of facility records revealed there was no medical record for R3. 3. During an interview, E1 acknowledged that a medical record had not been established for R3 yet.

Based on record review and interview, the manager failed to ensure that for two of two sampled resident, who was unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner examined the resident at the onset of the condition or within 30 days before acceptance and at least once every six months throughout the duration of the resident's condition, to determine if the resident's needs could be met based upon a current examination and the assisted living facility's scope of services Findings include: 1. In an interview, E1 reported R2 and R3 were confined to a bed or chair because of the inability to ambulate even with assistance. 2. A review of R2's medical record revealed a service plan dated July 3, 2025, for directed level of care. R2's service plan reflected that R2 was wheelchair bound . R2's record contained a document dated March 1, 2023 which determined R2's needs could be met based upon a current examination and the assisted living facility's scope of services. 3. A review of R3's medical record revealed there was no documented determination completed within 30 days before acceptance or at the onset of R3's condition, nor anytime since acceptance, by the resident's PCP or medical practitioner that reflected R3's condition was examined, and the facility's scope of services were reviewed to determine if R3's needs could be met. 4. In an interview, E1 acknowledged R2's and R3's primary care provider (PCP) or other medical practitioner did not examine R2 and R3 at the onset of the condition or within 30 days before acceptance, and at least once every six months throughout the duration of the residents' condition, and did not sign and date a determination that stated that the residents' needs could be met by the facility. This is a repeat citation from the complaint investigation and compliance inspection conducted on September 6, 2024.

Based on record review and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order for one of four sample residents who receive medication administration services. Findings include: 1. A review of R1's medical record contained a medication administration record (MAR) dated August 2025, which reflected that R1 was administered Metronidazole 500mg at 8 am, 12 pm, and 5 pm from August 14, 2025, through August 31, 2025. This was a total of 17 days. 2 . A review of R1’s medical record contained a document titled “List of New/Refill Orders” dated August 14, 2025 reported the following medication order: Metronidazole 500mg 1 tab three times a day for seven days.  3. The compliance officer observed a Metronidazole 500mg medication bottle inside R1's medication bin, which stated "One tablet by mouth for 7 days". 4. In an interview, E1 reported R1's medication was stored locked by the facility, and R1 received medication administration from the facility's caregivers. E1 acknowledged R1's medication was not administered to R1 in compliance with R1's medication order.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was documented in the resident’s medical record for two of four sampled residents. Findings include: 1. A review of R1’s medical record contained a document titled “List of New/Refill Orders” dated August 14, 2025 reported the following medication orders: Losartan Potassium 25 mg 1 tab Oral once daily; Nifedipine 60mg Extended-Release 60 mg 1 tab once daily; Carvedilol 12.5mg 1 tab twice daily; Trazadone 50mg 1 tab once daily; Pantoprazole 40mg 1tab once daily; Cefdinir 300mg 1 tab twice daily for seven days; Metronidazole 500mg 1 tab three times a day for seven days. R1's September 2025 Medication Administration Record (MAR) was blank and did not reflect that R1's medications were administered. 2. In an interview, E3 reported that R1 received R1's medications for September 2025; however, R1's MAR was not documented.

Based on record review and interview, the manager failed to ensure that when medication was stored by an assisted living facility, policies and procedures were implemented for discarding medication. Findings include: 1. A review of R1’s medical record contained a document titled “List of New/Refill Orders” dated August 14, 2025, which included the following medication order: Metronidazole 500mg 1 tab three times a day for seven days.  2. The compliance officer observed a Metronidazole 500mg medication bottle inside R1's medication bin, which stated "One tablet by mouth for 7 days". 3. In an interview, E1 reported that the facility still stored R1's Metronidazole.

Based on record review and interview, the manager accepted or retained an individual requiring continuous medical services, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: A.R.S. \'a7 36-401.13. "Continuous" means available at all times without cessation, break or interruption. 1. Review of Department documentation revealed the facility was not authorized to provide continuous medical services. 2. A review of the facility's scope of services revealed the scope of services did not include continuous medical services as an identified service to be provided to residents. 3. A review of R2's medical record revealed a determination letter dated July 12, 2023. The letter reflected R2 required continuous medical services. 4. In an interview, E1 acknowledged R2's determination letter reflected R2 required continuous medical services.

Based on record review and interview, the manager failed to ensure a resident requiring continuous nursing services was not accepted or retained, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: A.R.S. \'a7 36-401.13. "Continuous" means available at all times without cessation, break or interruption. 1. Review of Department documentation revealed the facility was not authorized to provide continuous nursing services. 2. A review of the facility's scope of services revealed the scope of services did not include continuous nursing services as an identified service to be provided to residents. 3. A review of R2's medical record revealed a determination letter dated July 12, 2023. The letter reflected R2 required continuous nursing services. 4. In an interview, E1 acknowledged R2's determination letter reflected R2 required continuous nursing services.

Based on documentation review, record review, and interview, the manager retained an individual who required continuous behavioral health services. The deficient practice posed a risk as the health care institution was not authorized to provide behavioral health services. Findings include: A.R.S. \'a7 36-401.11. "Behavioral health services" means services that pertain to mental health and substance use disorders and that are either: (a) Performed by or under the supervision of a professional who is licensed pursuant to title 32 and whose scope of practice allows for the provision of these services. (b) Performed on behalf of patients by behavioral health staff as prescribed by rule. A.R.S. \'a7 36-401.13. "Continuous" means available at all times without cessation, break or interruption. 1. Review of Department documentation revealed the facility was not authorized to provide behavioral health services. 2. A review of the facility's scope of services revealed the scope of services did not include behavioral health services as an identified service to be provided to residents. 3. A review of R2's medical record revealed a determination letter dated July 12, 2023. The letter reflected R2 required behavioral health services. 4. In an interview, E1 acknowledged R2's determination letter reflected R2 required behavioral health services.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount and frequency of assisted living services being provided to the resident, for two of three sampled residents. Findings include: 1. A review of R1's and R3's service plans reflected the R1 and R3 would require assistance with incontinence care. However, R1's and R3's service plan did not reflect the amount, type and frequency of incontinence care R1 and R3 would receive. 2. In an interview, E1 reviewed R1's and R3's service plan and acknowledged the service plans did not include the amount, type and frequency of incontinence care services.

Based on observation, record review, and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(199) states "restraint" means "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body." 2. During the environmental inspection of the facility, the Compliance Officer observed R1 in a geriatric chair with an attached table. R1 was in a geriatric chair and the table was in front of R1's lower torso. The table could not be removed by R1, without the assistance of staff. 3. In an interview, E1 reported R1's has the ability to ambulate, but requires staff supervision. E1 reported the table prevent R1 from wandering without staff supervision and the decision was agreed upon by R1's representative and R1's hospice.

Based on observation, interview, and record review, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner every six months stating the resident's needs were met by the facility and the resident's needs were within the facility's scope of services, for one of one directed care resident sampled. The deficient practice posed a risk if the facility was unable to meet the needs of the resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R3 in bed. 2. In an interview, E1 reported R3 was unable to ambulate even with assistance and R3 was bed bound. 3. A review of R3's medical record contained a document titled "Consent for Resident's Stay in Facility" dated December 6, 2023. The document reflected R3's needs could be met by the facility. 4. In an interview, E1 acknowledge there was no more recent documentation available to reflect R3's needs could be met at the facility while R3 was bed bound.

Based on documentation review, interview, and observation, the licensee failed to ensure an application submitted for modification in a Department-provided format, which contained a narrative description of the changes being made in the physical plant. Findings include: 1. A review of documentation revealed a facility's layout, which reflected from the facility's main entrance there would be living room and diagonally across a nook area. 2. In an interview, E1 reported the nook area was measured and approved as a bedroom during the initial. 3. The compliance officer observed the facility's nook area to be occupied as a sixth bedroom with two residents. The nook contained two beds, a couch, and a television. 4. A review of Department documentation revealed the facility's floor plan. The floor plan did not include a sixth bedroom. A review of the document titled "Room Occupancy Verification Form" dated March 13, 2018, which included the measurements of five bedrooms. 5. In an interview, E1 acknowledged the facility provided floor plan did not reflect the nook area was changed into a bedroom .

Based on observation, documentation review, and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. Findings include: 1. Upon arriving at the facility, the Compliance Officer observed E2 working at the facility with no other staff present. 2. A review of posted documentation revealed a document titled "Delegation of Manager's Authority" dated March 4, 2022. The form listed E3 as the manager's designee, however E2 was not listed. 3. In an interview, E2 reviewed and acknowledged the posted "Delegation of Manager's Authority" did not include E2 as a manager's designee. No other delegation documentation was provided for review.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented for obtaining resident preferences for food and the provision of assisted living services. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Scope of services provision of assisted living services" edited February 2, 2016. The policy stated: "A resident or the resident representative has the right to make choices and recieves services in a way that will promote the resident's dignity, autonomy, independance, and quality of life...1. Before or at the time of move into the facility the resident or the representative will complete a form "Preliminary admission information". The resident's preferences in these areas will be assessed, evaluated and documented including: a. Food allergies b. Food preferences, likes and dislikes c. Social and recreational preferences d. Hobbies and interest 2. The resident's preferences will also be communicated to the appropriate personnel. 3. The personnel will make every attempt to plan the resident's activities and food service in consideration of the preference identified." 2. A review of R1's and R2's medical records revealed no documentation of R1's and R2's food preferences, likes, and dislikes. 3. At approximately 12:45 PM, the Compliance Officer observed lunch being served to the residents. The Compliance Officer observed R4 was located in R4's bedroom laying in bed, and was not served a meal during this time. 4. At approximately 2:34 PM, the Compliance Officer observed R4 was still laying in bed. While sitting in the office area near R4's bedroom, R4 was heard shouting "I have not ate yesterday and today." 5. In an interview, E2 reported R4 sometimes refuses meals and doesn't always like what's cooked. 6. At approximately 2:48 PM, the Compliance Officer observed E2 wheeling R4 to the dining area in a "geri chair."

Based on record review and interview, the manager failed to ensure if a resident received services from a home health agency or hospice service agency, care instructions provided to the facility by the agency were documented in the resident's service plan, for one of three sampled residents who received services from hospice. Findings include: 1. A review of R1's medical record revealed a document from Bella Vista Health and Rehabilitation Center, titled "Discharge Summary and Post-Discharge Plan of Care" dated January 7, 2023. The discharge summary stated: "You will need ongoing treatment for: c1a. Site: Left Heel...c1b. Treatment ordered: Cleanse with wound cleanser, pat dry with gauze, apply alginate, cover with ABD pad, cover with Kerlix and secure with tape...c2c. Site #2: Sacralcoccygeal...c2d. Treatment ordered: Apply skin prep every shift, monitor skin integrity. c3e Site #3: Offloading foam boot LLE: c3f. Treatment ordered: check proper use and placement on left lower extremity and monitor skin integrity with use." 2. A review of R1's medical record revealed a service plan dated January 21, 2023. R1's service plan was not documented with hospice care instructions provided to the facility. 3. In an interview, E1 acknowledged R1's service plan was not documented to reflect hospice care instructions provided to the facility.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the name, address, and telephone number of the resident's primary care provider, for one of three residents sampled. Findings include: 1. A review of R2's medical record revealed no documentation of the address and telephone number of R2's primary care provider. The medical record contained forms to document the resident's contacts, including the primary care provider, however the sections were not completed. 2. In an interview, E2 reviewed R2's medical record and acknowledged there was no documentation of the address and telephone number of R2's primary care provider.

Based on record review and interview, the manager failed to ensure the requirements in R9-10-814(B)(2) were met for a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, for two of three sampled non-ambulatory residents. Findings include: 1. A review of R1's medical record revealed a service plan dated January 21, 2023, which stated "Walking/Mobility Requires total care daily as needed...Bed bound, wheelchair, hoyer lift, fall risk requires repositioning: Yes, 2 hour(s) Transfer assistance: Yes, 2 person(s)". R1's medical record also contained a document titled "Physician, behavioral health professional or medical practitioner authorization", however the document was not signed by a medical practitioner to indicate authorization for R1's continued residency. 2. A review of R2's medical record revealed a service plan dated October 21, 2022, which stated "Walking/Mobility Requires total care daily as needed...Bed bound, wheelchair, hoyer lift, fall risk requires repositioning: No, Transfer assistance: Yes, 2 person(s)". R2's medical record also contained a document titled "Determination and Authorization for Continued Residency" dated October 8, 2022, however the document was not signed by a medical practitioner to indicate authorization for R2's continued residency. 3. In an interview, E1 acknowledged R1's and R2's determination forms were not signed by a medical practitioner.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a bottle of "Lorazepam 2 mg" (milligrams) and "Lispro insulin" stored inside the facility's kitchen refrigerator. The refrigerator was not locked and was accessible to residents. 2. In an interview, E2 acknowledged the medications in the refrigerator were not stored in a locked area.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of facility documentation revealed no documentation to indicate an annual review of the facility's disaster plan was conducted. 2. In an interview, E1 reported being unable to find documentation indicating a disaster plan review was conducted at least once every 12 months. This is a repeat citation from the previous on-site compliance inspection conducted on May 2, 2022.

Based on record review and interview, the manager failed to ensure when a resident had an emergency resulting in the resident needing medical services, a caregiver documented the date and time of the incident, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future, for one of one resident sampled who had an incident resulting in the resident needing medical services. Findings include: 1. In an interview, E2 reported R1 was sent to an emergency room via paramedics due to a wound on R1's buttocks. E2 reported R1's wounds were unmanageable and R1's bone was showing, and due to the severity of R1's wound R1 was sent to the hospital. 2. A review of R1's medical record revealed no documentation regarding R1's emergency requiring medical services. 3. In an interview, E1 reported there was no documentation to reflect the required components.