Desert Springs Communities

Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse, neglect, or exploitation according to A.R.S. \'a7 46-454. The deficient practice posed a risk of a potential resident rights violation if the resident was subjected to abuse. Findings include: 1. A.R.S. \'a7 46-454(A) stated "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.111 stated "Immediate" means without delay. 3. Review of Department documentation revealed incident reports dated January 8, 2024 (resident to resident physical fight to include injuries) and September 18, 2023 (resident unauthorized access to medications) to include suspected abuse and neglect. 4. In an interview, E1 reported that suspected abuse and/or neglect was not reported to Adult Protective Services as required; however, internal incident reports were codnucted. 5. In an interview, E1 acknowledged the suspected abuse, neglect, or exploitation was not reported according to A.R.S. \'a7 46-454.

Based on documentation review, record review, and interview, the manager failed to ensure that a manager or caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, 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 tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E2's personnel record revealed a negative one step TB skin test administered before E1's date of hire; however, a two step TB skin test was not contained in E1's record. 4. A review of E2's personnel record revealed it did not contain documentation of TB screening. 5. In an interview, E1 acknowledged documentation of evidence of freedom from infectious TB by way of two step TB skin tests or a TB blood test as well as TB screening were not available for review within 12 months before the date E2 began providing services at or on behalf of the health care institution as specified in R9-10-113.

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 for one of two sampled residents. 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 medical record revealed documentation indicating whether residents 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; however, the document was dated after R1's date of acceptance. 2. A review of R2's medical record revealed documentation indicating whether residents 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; however, the document was dated after R2's date of acceptance. 2. In an interview, E1 acknowledged R1's and R2's documentation was not dated within 90 calendar days before R1 and R2 were accepted by the assisted living facility.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of three residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated in August 2024. R1's previous service plan was updated in March 2024. No service plans for R1 between March 2024 and August 2024 or after August 2024 were provided for review. 2. In an interview, E1 acknowledged R1 received directed care services and R1's service plan was not updated at least once every three months.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for one of three residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. Review of R2's medical record revealed the most recent written service plan for directed care services dated August 1, 2024; however, this service plan did not include a signature and date from the resident or representative. 2. In an interview, E1 acknowledged R2's written service plan did not include the signature and date from the resident or representative.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of three residents sampled. 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 a current service plan dated in August, 2024. The service plan stated the following services were required: -"Complete Bath: bed bath, 2x/week, resident is dependent"; -"Partial Bath: on days when complete bath is not given, at bedside, resident is dependent"; -"Oral Care: 2x/day, brush natural teeth, resident is dependent". Documentation was not available indicating these services were provided in December 2024. 2. In an interview, E1 reported that a resident medical record usually contains an "Activities of Daily Living" sheet that is faxed to the caregiver each month to place in the resident's medical record; however, it was not faxed for R1 this month. E2 reported that the services were provided as indicated in the service plan. 3. In an interview, E1 acknowledged R1's medical record did not include documentation of the services provided for December of 2024.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of three residents requested. The deficient practice posed a risk as required information could not be verified and the Department was unable to determine substantial compliance during the inspection. Findings include: A.R.S. \'a7 12-2297(A)(1) Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider. 1. The Compliance Officer observed R3 to be an occupant in the assisted living facility. 2. The Compliance Officer requested to review R3's medical record; however, no medical record was available for review. 3. In an interview, E1 reported that R3 was previously admitted to the facility and discharged; however, R3 returned approximately a week prior to the inspection and R3 did not have a medical record. 4. In an interview, E1 acknowledged that a medical record for R3 was not maintained for at least six years after the last date of services from the facility.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated for a resident receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of R1's medical record revealed a service plan dated August, 2024 for directed care services. The service plan contained no documentation of R1's weight. In addition, R1's medical record did not contain documentation of R1's weight after November of 2023 or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. A review of R2's medical record revealed a service plan dated August, 2024 for directed care services. The service plan contained no documentation of R2's weight. In addition, R2's medical record did not contain documentation of R2's weight or documentation rom a medical practitioner stating weighing R2 was contraindicated. 3. During an interview, E1 reported that the facility does not have a machine to weigh residents who are immobile. 4. During an interview, E1 acknowledged R1's and R2's service plans did not include documentation of R1's and R2's weight and documentation was not available in R1's or R2's record from a medical practitioner stating weighing R1 and R2 was contraindicated.

Based on documentation review, observation, and interview for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the license issued by the Department revealed the facility was licensed at the directed care level. 2. During an environmental inspection of the facility, the Compliance Officer observed the front door to have a door alarm; however, it was turned off and did not alert employees of the egress of a resident from the facility. 3. During an environmental inspection of the facility, the Compliance Officer observed the back door leading to the backyard of the facility to have a door alarm; however, it was turned off and did not alert employees of the egress of a resident from the facility. 4. During an interview, E1 reported that the door alarms were possibly turned off by a resident. 5. During an interview, E1 acknowledged the front and back doors of the facility provided access to the outside and did not control or alert employees of the egress of a resident from the facility.

Based on document review, record review and interview, the manager failed to ensure the premises and equipment were sufficient to accommodate an individual accepted as a resident at the facility. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R1's medical record revealed a service plan dated August, 2024 for directed care services. The service plan contained no documentation of R1's weight. In addition, R1's medical record did not contain documentation of R1's weight after November of 2023 or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. A review of R2's medical record revealed a service plan dated August, 2024 for directed care services. The service plan contained no documentation of R2's weight. In addition, R2's medical record did not contain documentation of R2's weight or documentation rom a medical practitioner stating weighing R2 was contraindicated. 3. During an interview, E1 reported that the facility does not have a machine to weigh residents who are immobile. E1 acknowledged the facility did not have the equipment necessary to accommodate all residents at the facility.

Based on document review, observation, record review and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), which required immediate notification to the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager. Findings include: 1. Review of Department records revealed E4 listed as the manager. 2. During an environmental inspection of the facility, the Compliance Officer observed E3's manager's certificate posted in the facility. 3. Review of E3's personnel record revealed a hire date of April 20, 2023. 4. In an interview, E1 reported E3 was the current manager and acknowledged the Department was not notified in writing of the change in manager.

Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for two of two caregivers sampled. The deficient practice posed a risk if the caregivers were unable to meet a resident's needs. Findings include: 1. Review of E1's and E2's personnel records revealed both were hired as caregivers. 2. Review of E1's and E2's personnel records revealed no documentation that E1's and E2's skills and knowledge were verified. 3. In an interview, E1 and E2 acknowledged that the manager failed to ensure that caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services.

Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During the facility tour, the Compliance Officer observed a plastic tray in the refrigerator containing Lantus insulin and Semglee insulin syringes. The refrigerator was not locked. 2. A review of facility policy and procedure documentation revealed a policy titled "Policy and Procedure for Safe Storage of Medications" which stated "Insulin and other medications that require refrigeration should be stored in the refrigerator in a lockable zippered bag with the resident's name, and the date the medication was opened." 3. In an interview, E1 and E2 acknowledged medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. During a tour of the facility, the Compliance Officer observed a food menu dated May 5, 2024- May 11, 2024. 2. In an interview, E1 reported that the manager had not been at the facility to post the new menu. E1 acknowledged the food menu was not conspicuously posted at least one calendar day before the first meal on the food menu was served.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for two of two caregivers sampled. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. Review of E1's personnel record revealed E1 worked as a caregiver. The personnel record revealed a first aid and CPR card with an expiration date of April 2, 2024. There was no other current documentation of first aid and CPR training in E1's record. 2. Review of E2's personnel record revealed E2 worked as a caregiver. The personnel record revealed a first aid and CPR card with an expiration date of April 2, 2024. There was no other current documentation of first aid and CPR training in E2's record. 3. Review of the facility's policy and procedure revealed a policy titled "Policy and Procedure for CPR and First Aid Training" which stated "The Licensee at Desert Springs Assisted Living Facility will ensure that each manager and caregiver: . . . 2. Maintains current training in first aid and CPR." 4. In an interview, E1 and E2 acknowledged E1's and E2's first aid and CPR training had expired.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance for one of two residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident within the required timeframe. Findings include: 1. Review of R1's medical record revealed a written service plan; however, based on R1's acceptance date, this service plan was completed more than 14 calendar days after R1 was accepted. 2. During an interview, E1 and E2 acknowledged R1's service plan was not completed within 14 calendar days of acceptance.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for one of two residents sampled. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. Review of R2's medical record revealed the most recent written service plan for personal care services dated February 2, 2024. However, this service plan did not include a signature and date from the resident or representative. 2. In an interview, E1 and E2 acknowledged R2's service plan did not include a signature and date from the resident or representative.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of one residents receiving medication administration sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated March 11, 2024. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed no documentation of signed written or verbal medication orders. 3. Review of R1's May 2024 medication administration record (MAR) indicated the following: -Metoprolol Succinate 25mg was administered once a day May 1st-31st; -Pregabalin 50mg was administered twice a day May 1st-31st; -Rosuvastatin 10mg was administered once a day May 1st-31st; -Levothyroxine 25mg was administered once a day May 1st-31st; -Trazadone 50mg was administered once a day May 1st-31st. 4. In an interview, E1 reported the medications were administered per the MAR and acknowledged the medications were not administered in compliance with an available medication order.

Based on record review and interview, the manager failed to ensure the assistance in self-administration of medication provided to a resident was provided in compliance with an order, for one of one resident sampled receiving assistance in self-administration of medication reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated February 2, 2024. This service plan indicated R2 received assistance in self-administration of medication. 2. Review of R2's medical record revealed no documentation of signed written or verbal medication orders. 3. Review of R2's May 2024 medication administration record (MAR) indicated the following: -Donepezil 5mg was administered once a day May 1st-31st; -Metoprolol 25mg was administered once a day May 1st-31st; -Escitalopram 20mg was administered once a day May 1st-31st; -Aspirin 81mg was administered once a day May 1st-31st; -Levothyroxine 1 tab was administered once a day May 1st-31st; -Amlodipine 2.5mg was administered once a day May 1st-31st; -Omeprazole 40mg was administered once a day May 1st-31st. 4. During an interview, E1 reported the medications were administered per the MAR and acknowledged the medications the facility provided assistance in the self-administration of were not administered in compliance with an available medication order.

Based on observation and interview, the manager failed to ensure a current drug reference guide was available for use by personnel members. Findings include: 1. The facility was unable to provide a current drug reference guide for review when requested. 2. In an interview, E1 reported that the facility used to have a drug reference guide, but that the old owners had taken it. E1 acknowledged a current drug reference guide was not available for use by personnel members.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The facility was unable to provide a current toxicology reference guide for review when requested. 2. In an interview, E1 reported that the facility used to have a toxicology reference guide, but that the old owners had taken it. E1 acknowledged a current toxicology reference guide was not available for use by personnel members.