Desert Springs Assisted Living, LLC

Based on documentation review and interview, the assisted living home that contacted an emergency responder on behalf of a resident failed to provide to the emergency responder a written document that includes all of the information required in A.R.S. § 36-420.04.A.1-9, for one of one applicable residents reviewed. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1 . A review of facility documents revealed a Face Sheet form used for Emergency Medical Services (EMS), however the form was missing the Pharmacy and reason for calling EMS. 2 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. The facility was licensed at the directed care level. 2. A.R.S. § 36-401.A.42. defines "Supervision" means directly overseeing and inspecting the act of accomplishing a function or activity. 3. A review of E3’s personnel record revealed that E3 was an assistant caregiver. 4 . During the Compliance inspection the Compliance Officer observed the Assistant Caregiver unsupervised with residents, in the kitchen area and resident rooms. 4 . During an interview, E2 reported that E3 was an assistant caregiver. E2 was the certified caregiver. 5 . In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on record review and interview the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility to include if the resident required continuous medical services, continuous or intermittent nursing services or restraints and was dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant. Findings include: 1 . A review of E2's records revealed a document for continued residency, however the Compliance Officer did not find a 90 day determination form, from when E2 was accepted to the assisted living facility. 2 . In an exit interview the findings were shared with E2 and there was no further information.

Based on observation and interview, the manager failed to ensure that a resident's medical record was protected from loss, damage, or unauthorized use. Findings include: 1 . When arriving at the facility and setting up for the inspection, the Compliance Officer observed a medication order for R3, on the table, that was not protected from loss, damage, or unauthorized use. 2 . In an exit interview, E2 acknowledged that there was a medical record that was unprotected from loss, damage, or unauthorized use.

Based on observation and interview, the manager failed to ensure that there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitors or alerts employees of the egress of a resident from the facility. Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During a tour of the facility, the Compliance Officer observed a door in the garage, that led to the backyard, that was not monitored or alarmed to notify employees of the egress of a resident from the facility. 3 . In an interview, E2 acknowledged that the door in the garage, that led to the outdoors, was not monitored or alarmed to notify employees of the egress of a resident from the facility.

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the interventions used for behavior management. Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover interventions used for behavior management. 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the systems to accommodate visitors, staff, and residents who do not need controlled egress Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover systems to accommodate visitors, staff, and residents who do not need controlled egress. 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the requirements in R9-10-815(C)(8) regarding the prevention of unsafe wandering or exit seeking, which may include the use of tracking systems Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover the requirements in R9-10-815(C)(8) regarding the prevention of unsafe wandering or exit seeking, which may include the use of tracking systems 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the promotion of nutrition and hydration care Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover Promotion of nutrition and hydration care. 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the evacuation and emergency procedures specific to residents receiving memory care services, that include the requirements in R9-10-819(A)(5). Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover evacuation and emergency procedures specific to residents receiving memory care services, that include the requirements in R9-10-819(A)(5). 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the prevention techniques of elopement and responding to elopement incidents promptly and effectively. Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover prevention techniques of elopement and responding to elopement incidents promptly and effectively.. 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the monitoring residents receiving memory care services in outdoor areas on the premises. Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover the monitoring residents receiving memory care services in outdoor areas on the premises.  3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the specialized environmental features to support memory care that include secure areas to prevent wandering and spaces designed for cognitive stimulation and engagement. Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover the specialized environmental features to support memory care that include secure areas to prevent wandering and spaces designed for cognitive stimulation and engagement. 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover the specialized environmental features to support memory care that include strategies for providing person-centered care that aligns with the principles of dementia-friendly environments, including familiar surroundings, optimized sensory stimulation, and meaningful activities. Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services. 2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover the specialized environmental features to support memory care that include strategies for providing person-centered care that aligns with the principles of dementia-friendly environments, including familiar surroundings, optimized sensory stimulation, and meaningful activities. 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on document review and interview, the manager failed to ensure that policies and procedures for memory care services were established, documented, and implemented to cover specialized accommodations and progressive support for activities of daily living tailored to persons living with dementia following evidence-based best practices. Findings include: 1 . Review of Department documentation revealed the facility was authorized to provide directed care services.  2 . A review of facility documents revealed no policy and procedure for memory care services that was established, documented and implemented to cover specialized accommodations and progressive support for activities of daily living tailored to persons living with dementia following evidence-based best practices. 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that medication was administered in compliance with a medication order. The deficient practice posed a risk if an individual was unable to meet a resident's needs. Findings include: 1 . A review of R1’s medical record revealed a service plan which reported R1 received medication administration. 1. Review of R1's medical record revealed no documentation of signed written or verbal medication orders for the following medications: Acetaminophen 325 mg oral tablet; Aspirin 81 mg oral tablet; Gabapentin 100 mg oral capsule; Lasix 20 mg oral tablet; Pantopraole 40 mg oral tablet; Quetiapine 25 mg oral tablet; Trazadone 100 mg oral tablet; 2. Review of the signed physician orders and medication administration record for R1 revealed the following medications were ordered and administered to R1 on the following dates and times: Acetaminophen 325 mg oral tablet - October 1-15, 2025 Aspirin 81 mg oral tablet - October 1 -16, 2025 at 8 am Gabapentin 100 mg oral capsule - October 1 -16, 2025 at 8am and October 1-15, 2025 at 8 pm Lasix 20 mg oral tablet - October 1 -16, 2025 at 8 am Pantopraole 40 mg oral tablet - October 1 -16, 2025 at 8 am Quetiapine 25 mg oral tablet - October 1 -16, 2025 at 8 am Trazadone 100 mg oral tablet. - October 1 -16, 2025 at 8 am 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided. This is a repeat deficiency from the inspection 0093982 conducted on 7/20/2022

Based on observation and interview, the manager failed to ensure that food was stored to ensure food was free from spoilage, filth, or other contamination and was safe for human consumption. Findings include: 1 . During a tour of the facility, the Compliance Officer observed a bowl on the counter that contained raw chicken. E2 reported that E2 set it out to thaw. 2 . In an interview, E2 acknowledged that there was food was not stored to prevent spoilage, filth or contamination.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were in a locked area and inaccessible to residents. Findings include: 1 . While conducting the inspection, the Compliance Officer observed office supplies, (white out and gorilla glue) left out and accessible to residents, which are poisonous or toxic. 2 . In an interview, E2 acknowledged that there were poisonous or toxic chemicals unlocked and accessible to residents.

Based on observation and interview the manager failed to ensure that there were nonporous surfaces for shower enclosures and slip resistant surfaces in tubs and showers. Findings include: 1 . On a tour of the facility, the Compliance Officer observed a shower in one of the bathrooms that did not have a nonporous surface or slip resistant surface. E2 reported that there is a mat for the shower but it was in another bathroom. 2 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. \'a7 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. During the environmental tour, the Compliance Officer observed resident medical records were openly visible, sitting on a cabinet located on the left-hand side near the entrance of the facility. 3. In an interview, E2 was questioned why the medical records were not protected from unauthorized use. E2 reported not knowing the medical records needed to be stored securely. 4. In an interview, E2 acknowledged that resident's medical records were not protected from loss, damage, or unauthorized use.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a service plan (dated April 2024) for directed care services that included medication administration. 2. A review of R1's medical record included the following medication order dated April 26, 2024: - "Atorvastatin 80 mg tablet Take 1 tablet(s) Oral every night at bedtime." 3. A review of R1's medical record revealed a May 2024 medication administration record (MAR). This MAR stated the following: - "Atorvastatin 80 MG Tab PO QHS FOR HLD" 4. A review of R1's pill container revealed the medication was refilled March 04, 2024. However, the dosage read as "Atorvastatin 40 mg tablet Take 1 tablet by mouth every night at bedtime." 5. In interview, E2 reported only 1 tablet of Atorvastatin 40 mg was administered to R1 at bedtime and acknowledged R1's medication was not administered in compliance with the available medication order.

Based on observation and interview, the manager failed to ensure there was a current toxicology reference guide was available for use by personnel members. Findings include: 1. During the environmental tour, the Compliance Officer requested the current toxicology reference guide. However, the toxicology reference guide was "Casarett & Doull's Toxicology 8th Edition," published in June 2013. 2. An internet search revealed the current version of this toxicology reference guide was "Casarett & Doull's Toxicology 9th Edition," published November 2018. 3. In an interview, E2 acknowledged a current toxicology reference guide was not available for use by personnel members.