Desert Oasis Healthy Living LLC

Based on record review and interview, for one of two residents sampled, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident’s date of occupancy. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(A)(2)(a)(i-ii) states: “a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious [TB], ii. Determining if the individual has signs or symptoms of [TB].” 2. A review of R1’s medical records revealed evidence of documentation of a negative skin test for TB conducted before or within seven days of R1’s acceptance. However, evidence of baseline screening for signs and symptoms of, and risk assessment for exposure to TB, was unavailable for review. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. Technical assistance was provided to E1 during a compliance inspection conducted on January 16, 2023.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a current service plan for Personal care services, which included numerous assisted living services to be provided by the facility staff. 2. A review of R1’s medical record revealed a document used for tracking and documenting activities of daily living for R1 during January 2026. The document included a section titled “Service Plan Followed:” used for documenting services provided as outlined in the service plan, on “Moring,” “Afternoon,” and “Evening” shifts. However, the section contained gaps in documentation for all shifts on January 4, 13, 14, 15, 18, 20, 21, 22, and 25, 2026. 3. In an interview, E1 indicated R1 did receive assisted living services as outlined in R1’s service plan for January 2026. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager accepted and retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2). The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R2’s medical record revealed a service plan, which indicated R2 was non-ambulatory. Further review of R2’s medical record revealed evidence of documentation indicating R2 was examined by a medical provider per R9-10-814(B)(2) in December 2024, and again in June 2025. However, evidence of documentation demonstrating R2 was examined by a medical provider after June 2025, was unavailable for review. 3. In an interview, E1 acknowledged R2 was not examined by a medical provider every six months as required per R9-10-814(B)(2). 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. A review of the facility’s policies and procedures revealed a medication policy, which included medication administration. However, there was no documentation of review and no signature from a medical practitioner, registered nurse, or pharmacist. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than two ambulatory residents, and the Compliance Officer observed the kitchen area to be unoccupied by any staff or resident. The Compliance Officer observed a double-door cabinet under the kitchen sink. While the left-side door was secure, the Compliance Officer was able to open the right-side door with little effort. The door was affixed with a locking mechanism that required a magnet to operate. However, the locking mechanism was not operating as designed. Inside the cabinet was a bottle of “Formula 409 Multi-Surface Cleaner,” with a label reading “KEEP OUT OF REACH OF CHILDREN.” Also inside was a one-gallon plastic container of “Windex Glass Cleaner,” as well as two 32-ounce plastic spray bottles of Windex. The containers also had labels reading “KEEP OUT OF REACH OF CHILDREN.” In addition, numerous loose pods of dishwasher detergent were observed inside the cabinet. 2. In an interview, E2 advised the cabinet’s locking mechanism had been working when E2 last worked, on January 23, 2026. E2 was not able to provide any further information as to when the sink cabinet locking mechanism had broken, or if anyone had notified the manager or attempted to fix it. 3. In an interview, E1 advised that a maintenance worker had replaced the locking mechanism on the kitchen sink, and the door had been secured. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included the individual's name, date of birth, and contact telephone number, the individual's starting date of employment or volunteer service, documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, the individual's education and experience applicable to the individual's job duties, the individual's completed orientation and in-service education required by policies and procedures, the individual is a behavioral health technician, clinical oversight required in R9-10-115, cardiopulmonary resuscitation training, First aid training, and documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C) for one of three personnel members sampled. The deficient practice posed a risk if the employee was unable to meet a resident's needs. A.A.C. R9-10-101(165) states a "Personnel member" means, "except as defined in specific Articles of this Chapter and excluding medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services." Findings include: 1. The Compliance Officer observed E3 in the facility when the Compliance Officer arrived. When introduced E3 reported to be the new house manager/caregiver. 2. The Compliance officer requested the personnel record for E3. E2 reported not having a record at this location. The Compliance Officer asked E2 if E2 could get the record. E2 reported not in the two hours requested by the Compliance Officer. The following documentation was unavailable for review: - The individual's name, date of birth, and contact telephone number; - The individual's starting date of employment or volunteer service and, if applicable, the ending date; - The individual's qualifications, including skills and knowledge applicable to the individual's job duties; - The individual's education and experience applicable to the individual's job duties; - The individual's completed orientation and in-service education required by policies and procedures; - The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; - Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); - Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; - First aid training, if required for the individual in this Article or policies and procedures; and - Documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C). 3. The Compliance Officer requested the facility's policy and procedure manual. E2 reported not having a copy at this location. The manual was at another of E2's facility's. The policy and procedure manual was unavailable for review. 4. The Com

Based on record review and interview, the manager failed to ensure an individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, and if an individual was requesting or was expected to receive supervisory care services, personal care services, or directed care services, 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 two of three residents sampled. This deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1, and R2's medical records revealed no documentation dated within 90 calendar days before R1 was accepted by the facility, and if an individual was requesting or was expected to receive supervisory care services, personal care services, or directed care services, 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. 2. In an interview, E1 acknowledged documentation dated within 90 calendar days before the individual was accepted by the facility for R1, and R2 was unavailable for review.