Desert Willow Assisted Living LLC

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated January 10, 2023 for personal care services. The service plan stated the following services were to be provided for R1: "Nail Care, CG assist...Cleans nails prn, Clip Nails." 2. Further review R1's medical record revealed an activities of daily living (ADL) log for May 2023. R1's May 2023 ADL log included a line titled, "Grooming, Nail Care." However, the ADL log revealed no documentation indicating the aforementioned services were provided to R1 in May 2023. 3. In an interview, E1 reported R1's nails were cleaned every day in May 2023. E1 also reported facility staff clips R1's nails every two weeks, and clipped R1's nails twice in May 2023. E1 acknowledged the services provided to R1 were not documented in R1's medical record. 4. A review of R2's medical record revealed a service plan dated March 3, 2023 for personal care services. The service plan stated the following services were to be provided for R2: "Nail Care, Max CG assist...Cleans nails prn, Clip Nails." 5. Further review R2's medical record revealed an ADL log for May 2023. R1's May 2023 ADL log included a line titled, "Grooming, Nail Care." However, the ADL log revealed no documentation indicating the aforementioned services were provided to R2 in May 2023. 6. In an interview, E1 reported R2's nails were cleaned every day in May 2023. E1 also reported facility staff clips R2's nails every two weeks, and clipped R2's nails twice in May 2023. E1 acknowledged the services provided to R2 were not documented in R2's medical record.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements in R9-10-814.B.2. at least once every six months throughout the duration of the resident's condition, for one of one residents sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. Findings include: 1. A review of R2's medical record revealed a service plan for personal care services. The service plan was created on March 28, 2022 and updated on September 13, 2022 and March 3, 2023. R2's service plan included a section titled "Mobility" which stated, "Transfer assistance, bed-bound." R2's service plan also included a section titled "Activity" which stated "Type: Bedbound." 2. Further review of R2's medical record revealed a document titled "Authorization for Continued Residency," which stated, "The resident is confined to a wheelchair/bed, appears to be well cared for, and his/her needs met." The document was signed and dated by R2's physician on March 22, 2022 and February 3, 2023. However, additional documentation to indicate the manager met the requirements in R9-10-814.B.2. at least once every six months throughout the duration of R2's condition was unavailable for review. 3. In an interview, E1 reported R2 was non-ambulatory upon admission to the facility. E1 reviewed R2's medical record and acknowledged no examination signed and dated by R2's primary care provider at least once every six months throughout the duration of R2's condition was available for review.