Desert Ridge Manor Tbi & Behavioral Care LLC

Based on documentation review and interview, the manager failed to ensure the facility's policies and procedures for the quality management (QM) program was documented to include all of the required components, and was implemented. The deficient practice posed a risk as a quality management program documents and tracks the necessary information required to effectively evaluate and manage services provided. Findings include: 1. In documentation review, a facility policy titled, "Quality Management," (QM) documented, "This facility shall document any and all incidents... The manager... shall evaluate each incident... shall evaluate all incident reports each month to identify any concerns about the delivery of services, upon discovery of a concern the manager shall take action to correct issue... The manager shall document the concern and the action taken.. A copy of the incident report, supporting documentation related to the concern and the written summary sent to DHS shall be maintained for 12 months after the date the report is submitted to the governing authority..." 2. In documentation review, the facility did not have documentation showing the quality management program was implemented, data was collected, or reports were documented. 3. During an interview, the findings were reviewed with E1, who reported incident reports were completed when required; however, acknowledged the documented QM program documentation did not include all of the required methods, data had not been collected and evaluated, and reports had not been submitted.

Based on observation, documentation review, record review, and interview, for three of four caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services. The deficient practice posed a health and safety risk to residents, if a caregiver did not have the documented skills and knowledge to provide care and services for a resident. Findings include: 1. In observation, R1 was observed to have a feeding tube. 2. In record review, R1's medical record (received directed care and G tube feeding and care services) included documentation G tube feeding and care services were provided daily for R1 by E1, E2, and E4. 3. In record review, the personnel records for E1 (hired May 8, 2006, as a manager), E2 (hired May 8, 2006 as a caregiver), and E4 (hired January 1, 2015, as a caregiver), did not include documentation the caregivers' skills and knowledge to provide G tube feeding and care services, were verified and documented. 4. During an interview, E1 reported a home health agency trained the caregivers on G tube feeding ervices and care services ; however, E1 acknowledged the training and verification of skills and knowledge was not documented, as required.

Based on observation, record review, documentation review and interview, for one of four caregivers reviewed, the manager failed to ensure that before providing assisted living services, a caregiver or assistant caregiver received orientation specific to the duties to be performed by the caregiver. The deficient practice posed a health and safety risk to residents if a caregiver did not receive the required orientation. Findings include: 1. In observation, E5 was observed at the facility during the inspection. E5 was observed interacting with residents, pushing residents in wheelchairs, and cooking. 2. During an interview, E5 reported [E5] had worked at the facility for a week, and helped take care of residents, i.e., "grooming, hygiene, going to the toilet..." 3. In record review, E5's personnel record did not include a date of hire, and did not include documentation of orientation. 4. In documentation review, a facility policy, titled "Employee Orientation...," page 136, documented, "... The manager/owner of the facility shall ensure that a new employee completes orientation before the starting date of employment that includes: characteristics, health and safety needs of the ... facility's residents... facility's philosophy and goals; ... resident dignity, independence... rights... service plan... Confidentiality... Infection control... Food preparation... [etc.]. 5. During an interview, E1 reported E5 started employment the day of the inspection, and had worked at the facility many years ago. E1 acknowledged having no documentation of E5's orientation.

Based on record review and interview, for two of two residents reviewed, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation which included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, which was signed by a Physician, Registered Nurse practitioner, Registered nurse, or Physician assistant. Findings include: 1. In record review, the medical records for R1 (received directed care services), and R2 (received directed care services), did not include documentation, signed by a Physician, Registered Nurse practitioner, Registered nurse, or Physician assistant, which included whether these residents required continuous medical services, intermittent nursing services, or restraints. Based on each resident's date of acceptance, this documentation was required. 2. During an interview, E1 acknowledged the required documentation was not in the residents' medical records, and was not available for review.

Based on record review, observation, documentation review, record review, and interview, for one of two residents reviewed and receiving controlled substances, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. Findings include: 1. In observation, R1 had Clonazepam (Klonopin) medication (a schedule IV controlled substance), on site, and stored by the facility. The compliance officer observed several packages of the medication totaling 163 pills. 2. In record review, R1's medical record included a medication order for Klonopin 0.5 ML every eight hours for anxiety. R1's medication administration record (MAR) for August, 2023, included documentation R1 received the medication, during August 1, through August 2023, 2023. A separate narcotic inventory record included an inventory of the medication and documented 152 pills remaining. 3. In documentation review, a facility policy titled, "Controlled Medications," documented, "... All controlled medication should be counted at the end of every shift to ensure that it is all there and no errors have occurred...." 4. During an interview, E1 reviewed the inventory for R1's controlled medication, and acknowledged an inventory had not been accurately maintained for the controlled substance. E1 reported the inventory was documented at each administration of the controlled substance.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a health and safety risk to residents and employees, if the employees were unable to implement the disaster plan. Findings include: 1. During an interview, E1 reported E1 and E2 were at the facility during all shifts, and implemented and documented disaster drills once every three months. 2. In documentation review, the facility did not have documentation a disaster drill had been conducted since April 4, 2023. 3. During an interview, E1 reported the facility was late in completing a current disaster drill, and acknowledged a disaster drill had not been conducted since April 4, 2023.

Based on observation, and interview, for two bedrooms observed, the manager failed to ensure a resident's sleeping area had a window or door that could be used for direct egress to outside the building. The deficient practice posed a safety risk to a resident who would not be able to exit to the outside of the building in the event of an emergency, and an inability to exit the window. Findings include: 1. During an environmental inspection with E1, the compliance officer observed the bedrooms for R2 and R3, had a window with furniture blocking direct egress from the window. R2's bedroom was occupied by two residents and had a bed in front of the window exit. R3's bedroom was occupied by two residents and had a bed and a storage cabinet in front of the window exit. 2. During an interview, E1 acknowledged the bedrooms had furniture blocking direct egress to the outside, and acknowledged a resident sleeping area is required to have a window or door that can be used for direct egress to outside the building.