Desert Joy Assisted Living

Based on documentation review, record review, and interview, the manager failed to ensure that a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. § 36-411(C). The deficient practice posed a risk as the required information could not be verified for all employees. Findings include: 1. A.R.S. § 36-411.C states: "C. Owners shall make documented, good faith efforts to: ...4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A review of E1's and E4's personnel records revealed that an APS Central Registry check was not available for review. 3. In an interview, the findings were reviewed with E1, and no additional information was provided

Based on observation and interviews, A manager shall ensure that the premises at the assisted living facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents. Findings include: 1. During the environmental inspection of the outside of the facility, the Compliance Officers observed a fire pit with piled-up weeds and broken-down piles of wood, with an ax on the ledge of the fire pit. 2. During the environmental inspection of the outside of the facility, the Compliance Officers Observed a long the side gate on the left of the house, hazardous piles of wood with nails sticking out of the wood and splinters of wood. 3. In an exit interview, the findings were reviewed with E1, and no further information was provided.

Based on observation and interview, the manager failed to ensure the swimming pool on the premises of the assisted living facility was enclosed by a wall or fence. The deficient practice posed potential dangers to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a swimming pool that was not enclosed by a wall or fence. 2. In an exit interview, the findings were reviewed with E1, and no further information was provided.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance there was a documented residency agreement with the assisted living facility to include whether the manager or a caregiver will be awake during nighttime hours, for two of two residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's medical record revealed a residency agreement (updated January 2023). However, the residency agreement did not include whether the manager or a caregiver was awake during nighttime hours. 2. A review of R2's medical record revealed a residency agreement (dated January 2023). However, the residency agreement did not include whether the manager or a caregiver was awake during nighttime hours. 3. In an interview, E1 acknowledged the documented residency agreements for R1 and R2 did not include whether the manager or a caregiver was awake during nighttime hours.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom or residential unit being used by a resident receiving personal care services. The deficient practice posed a risk to the physical health and safety of a resident if the resident was unable to summon assistance. Findings include: 1. During a tour of the facility, the Compliance Officer observed R4 lying in the bed. The Compliance Officer observed no bell, intercom, or other mechanical means to alert caregivers was available within reach of R4 or within R4's bedroom. 2. In an interview, when the Compliance Officer asked if R4 had a call button, E1 stated, "Yes." However, R4 did not know where it was. 3. The Compliance Officer observed E1 was unable to locate R1's call button. 3. A review of R1's medical record revealed a service plan. The service plan revealed R1 was at the personal level of care. 4.. In an interview, E2 acknowledged the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. A.R.S. 36-401(A)(39) defines personal care services qs"assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law.

Based on observation and interview, the manager failed to ensure that at least one bathroom was accessible from a common area that contained paper towels in a dispenser or a mechanical air hand dryer. Findings included: 1. During a tour of the facility, the Compliance Officer observed a hand towel hanging from a ring towel rack in the common bathroom. However, no paper towels in a dispenser or mechanical air hand dryer were observed. 2. In an interview, E1 acknowledged the bathroom was the common bathroom used by visitors and had no paper towels in a dispenser or a mechanical air hand dryer.