Desert Hills Heart of Gold Assisted Living

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record for three of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed no documentation of the services provided for August 2025 and September 2025. 2. A review of R2's medical record revealed no documentation of the services provided for August 2025 and September 2025. 3. A review of R3's medical record revealed no documentation of the services provided for September 2025. 4. In an interview, E1 reported that R1, R2, and R3 received assisted living services from the caregivers. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 6. This is a repeat deficiency from the inspection conducted on August 3, 2023, and July 8, 2025.

Based on record review, documentation review, and interview, the health care institution failed to ensure a training program for all staff regarding fall prevention and fall recovery, which included initial training, was implemented for two of two personnel sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E1’s and E2’s personnel records revealed no documentation indicating E1 and E2 had received initial training in fall prevention and fall recovery. 2. A review of facility documentation revealed a fall prevention and fall recovery program, which included initial training and continued competency training for all employees of the facility. 3. In an interview, E1 acknowledged E1 and E2 had not completed initial fall prevention and fall recovery training as required, per A.R.S. § 36-420.01. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, interview, and documentation review, the manager failed to ensure a personnel record for each caregiver included documentation of cardiopulmonary resuscitation (CPR) training, which included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of two employees reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2's personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on February 7, 2025. There was no other current documentation of CPR training available for review that included a demonstration of E2's ability to perform CPR. 2. In an email exchange, a representative from NationalCPRFoundation stated, "Our courses are online only." 3. A documentation review revealed the employee's work schedule, dated June and July 2025, showed E2 had worked every day on the day shift. 4. In an interview, E1 reported that E1 was unaware that online classes were not acceptable. 5. 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 a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of four residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1 . A review of R1's and R2's medical records revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1’s and R2's acceptance dates, this documentation was required. 2 . In an interview, E1 reported that E1 did not realize that documentation was not completed or in the records. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 4. This is a repeat deficiency from the inspection conducted on August 3, 2023.

Based on the record review and interview, the manager failed to ensure that a resident had a service plan which included the level of service the resident was expected to receive, for one of four reviewed residents. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a current service plan dated June 17, 2025. However, the service plan did not include the level of service R2 was expected to receive. 2. In an interview, E1 acknowledged that the service plan did not include the level of service R2 was expected to receive. 3. 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 caregiver provided assistance with activities of daily living according to the resident's service plan for one of the four review residents. The deficient practice posed a risk as the service plan to direct services was not followed. Findings include: 1. A review of R2's medical record revealed a service plan dated June 17, 2025. R2's service plan indicated R2 required the following: -incontinence care every 2 hours or as needed -turning every 2 hours 2. A review of R2's medical record revealed an activities of daily living (ADL) document dated June and July 2025. The ADL document was blank. 3. In an interview, R2 reported that R2 did not get incontinence care every 2 hours or as needed. R2 stated, “E2 was upset with me because I had to call each time I felt I needed to be changed.” R2 also stated that E2 said to R2, “I don’t know why you keep calling me, I only have to change every 2 hours”. 4. In an interview, R2 also reported that the staff would not turn or move R2 up in bed when needed. R2 reported that there was paralysis on the right side of the body and R2 needed assistance. R2 reported that R2 had to call 911 because the staff would not help. 5. In an interview, E1 reported that R2 did call 911 to be adjusted in bed. 6. 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 the caregiver documented the services provided in the resident's medical record, for four of four residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed no documentation of the services provided for June 2025 and July 2025. 2. A review of R2's medical record revealed no documentation of the services provided for June 2025 and July 2025. 3. A review of R3's medical record revealed no documentation of the services provided for April 2025, May 2025, June 2025, and July 2025. 4. A review of R4's medical record revealed no documentation of the services provided for June 2025 and July 2025. 5. The Compliance Officer requested documentation of the services provided to R1, R2, R3, and R4. E1 gave the Compliance Officer blank activities of daily living (ADL) sheets for June 2025. The Compliance Officer asked if any other documentation was available. E1 stated, "I will go print them." The Compliance Officer observed E1 filling out the ADL sheets for the missed days. 6. In an interview, E1 reported that R1, R2, R3, and R4 required assisted living services. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 8. This is a repeat deficiency from the inspection conducted on August 3, 2023.

Based on 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, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of four residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. In an interview, E1, E2, and R2 reported R2 was non ambulatory even with assistance since R2's date of acceptance. 2. A review of R2's medical record revealed a document titled “Determination and Authorization For Continued Residency”. This document was not filled out, signed, or dated by a medical professional. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of four employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A... 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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work... C. Owners 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..." 2. In an interview, E2 reported E1 worked as a manager and had a hire date of April 2022. 3. Review of E1's personnel record revealed a fingerprint card issued on November 17, 2017. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E1's fitness to work in a residential care institution. In addition, E1's record did not contain documentation of good faith efforts to verify the current status of a E1's fingerprint clearance card. 4. Review of the Department of Public Safety (DPS) fingerprint clearance card database on August 3, 2023, revealed E1's fingerprint clearance card was valid. 5. In an interview, E2 reported E2 worked as a caregiver and had a hire date of April 2022. 3. Review of E2's personnel record revealed a fingerprint card issued on February 10, 2020. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution. In addition, E2's record did not contain documentation of good faith efforts to verify the current status of a E2's fingerprint clearance card. 4. Review of the Department of Public Safety (DPS) fingerprint clearance card database on August 3, 2023, revealed E2's fingerprint clearance card was valid. 5. In an intervie

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. However, the document was signed and dated by a physician after R2's acceptance. Based on R2's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged the documentation was not submitted before or at the time of R2's acceptance.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's record revealed a current written service plan for personal care services dated July 23, 2023. This service plan stated the following services were needed: "Catheter Care - wash skin around catheter with soap and water daily empty drainage bag every 4-8 hours". However, documentation was not available indicating this service was provided August 1 - present. 2. In an interview, E1 acknowledged R1's medical record did not include documentation of the above listed service and reported the service was provided as indicated in the service plan.