Desert View Assisted Living

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for three of six personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states: " C. Each residential care institution, nursing care institution and home health agency shall make documented, good-faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services (APS) registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 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 E2’s, E5’s, and E6’s personnel records revealed there was no documentation to reflect verification that E2, E5, and E6 were not on the APS registry, available for review at the time of the survey. Based on E2’s, E5’s, and E6’s date of hire verification, each employee was required to be verified on or before March 1, 2025. 3. In an interview, E1 acknowledged there was other documentation available for review at the time of the survey to verify E2, E5, and E6 were not on the APS registry as required by statute.

Based record review and interview, the manager failed to ensure residency agreements included terms of occupancy including resident responsibilities, for two of three sampled residents. Findings include: 1. A review of R1's and R2's medical records revealed that R1 and R2's residency agreements were left blank on the residents' responsibility for the basic monthly fee. 2 In an interview, E4 reviewed the residency agreements with the compliance officer and acknowledged that the residency agreements reflecting R1’s and R2’s financial responsibility were left blank.

Based on record review and interview, the manager failed to ensure that a caregiver documented the assisted living services provided to a resident for three of three residents sampled. Findings Include: 1. A review of R1’s medical record revealed a service plan dated May 5, 2025, which reflected R1 required assistance with oral care twice daily, nail care daily, hair care daily, dressing twice daily, bathing twice weekly, toileting daily, and transferring daily. R1’s record did not include documentation that the above services were provided to R1 for May 2025. 2. A review of R2’s medical record revealed a service plan dated March 10, 2025 reflected R2 required assistance with bathing twice weekly and nail care daily. R2’s documentation of services provided dated May 2025 reflected that R2 was provided one bath between May 4, 2025, to May 10, 2025, and there was no documentation of nail care services provided to R2. 3. A review of R3’s medical record revealed a service plan dated February 15, 2025 reflected R3 required assistance with feeding via G-tube. R3’s documentation of services provided dated May 2025 reflected that R3 had not been provided assistance with feeding, and there was no documentation of feeding assistance provided to R3. 3. In an interview, E4 acknowledged there was no other documentation available for review at the time of the survey to reflect that R1, R2, and R3 provided services in R1’s, R2’s, and R3’s service plans. This is a repeat deficiency from the complaint investigation conducted on December 13, 2024.

Based on record review and interview, the manager failed to ensure a resident representative was designated for a resident who was unable to direct self-care, for one of two residents sampled who was at the directed level of care. Findings include: 1. A review of R2’s medical record revealed a service plan dated March 10, 2024, which reflected that R2 was at the directed level of care. 2. A Review of R2’s medical record revealed a residency agreement dated September 10, 2024, which reflected that R2 was R2’s own representative. 3. A review of R2’s medical record revealed there was no documentation available for review to reflect that a representative was designated for R2, who was unable to direct self-care. 4. In an interview, E4 was unable to provide documentation of a designated representative for R2 available for review during the survey.

Based on record review and interview, the manager failed to ensure when a resident had an emergency resulting in the resident needing medical services, a caregiver documented the time of the incident, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future, for one of one sampled resident who had an incident resulting in the resident needing medical services. The deficient practice posed a risk of potential re-injury if the resident did not receive adequate follow-up care. Findings include: 1. A review of R1’s medical record revealed a document titled “Narrative Notes” dated May 17, 2025, which reflected “[R1] was taken to the hospital because [R1’s] hip was pulled out from falls”. The above document did not include the time of the accident, emergency, or injury, the names of the individuals who observed the accident, emergency, or injury, individuals notified by the caregiver or assistant caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future. 2. In an interview, E1 and E4 reported that there was no documentation to reflect the required components available for review at the time of the survey. E1 reported that the above information was on E1’s laptop, and E1 was away from E1’s laptop and could not send the information to the compliance officer at the time of the survey.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered by an individual under the direction of a medical practitioner, for one of three sampled residents. The deficient practice posed a risk if services were provided by an unqualified individual. Findings include: 1. A review of R2's medical record revealed a medication administration record (MAR) dated December 2024. The MAR reflected R2 was administered medication by various persons. However, there was no documentation from a medical practitioner indicating who was authorized to administer medications to R2. 2. In an interview, E1 acknowledged medication was administered to R2 prior to receiving documentation stating who was authorized to administer medication.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for two of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan dated December 2, 2024. R2's service plan reflected R2 required assistance with nail care checks daily and trim as needed, and bathing assistance twice weekly. A review of R2's "Activities of Daily Living Sheet (ADL)" dated December 2024 reflected R2 was not provided assistance with nail care daily, and was given a bath once per week. 2. In an interview, E1 acknowledged R2's December 2024 ADL sheet reflected R2 was not provided the aforementioned services according to R2's service plan.

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 facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of three sampled residents. The deficient practice posed a risk if the facility was unable to meet the needs of the resident. Findings include: 1. A review of R2's medical record revealed a determination letter. However, the determination was blank and did not indicate whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E1 acknowledged there was no completed documentation in R2's medical record to indicate if R2 required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services provided to the resident, for one of three sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated September 26, 2024. The service plan reflected R1 required assistance with the following services: "Bathing and grooming". However, the amount of services were not included. 2. In an interview, E1 reviewed R1's service plan and acknowledged the service plan did not include the amount of the aforementioned services.