Fairwinds - Desert Point

Based on observation, documentation review, and interview, the Governing Authority failed to designate, in writing, a manager compliant with R9-10-803.A.3.b. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. During a tour of the facility, the Compliance Officer observed that a manager’s license was not prominently displayed. 2. A review of Department documentation revealed O1 notified the Department of O1's termination of employment as the licensed manager of the facility on April 28, 2025. 3. A review of facility documentation revealed O2 managed the facility from June 2, 2025, to August 4, 2025. 4. In an interview, E1 produced an email dated September 10, 2025, appointing E1 as the facility’s licensed manager, effective September 10, 2025. 5. Online research conducted through the Arizona Nursing Care Institution Administrators and Assisted Living Facility Managers, https://aznciab.portalus.thentiacloud.net/webs/portal/register/#/, revealed E1 was a licensed assisted living manager. 6. In an interview, E1 acknowledged the facility did not have an appointed manager from April 28, 2025, to June 2, 2025, and from August 4, 2025, to September 10, 2025. 7. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the Governing Authority failed to ensure compliance with A.R.S. § 36-411 by failing to make documented good faith efforts to contact previous employers to obtain information or recommendations which may be relevant to a person's fitness to work in a residential care institution. The deficient practice posed a risk if E3, E6, and E7 were a danger to a vulnerable population. Findings include: 1. A review of E3’s, E6’s, and E7’s personnel records revealed each employee had a valid fingerprint clearance card on each employee's respective date of hire. Further review revealed applications for employment for E3 and E6, which included previous employment and dates of employment. However, evidence of documentation E7’s application for employment, or any documentation of prior work history, was unavailable for review. Furthermore, evidence of documentation of good faith efforts to contact previous employers of E3, E6, or E7 was unavailable for review. 2. In an interview, E1 agreed E3’s, E6’s, and E7’s employment records did not include documented good faith efforts to contact previous employers as required in A.R.S. § 36-411. 3. This is a repeat citation from the compliance/complaint inspection conducted May 14, 2024.

Based on record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services for three of five certified caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of facility staff schedules revealed E3, E5, and E6 worked numerous shifts each in September 2025. 2. A review of E3's, E5’s, and E6’s personnel records revealed evidence of documentation of verification of skills and knowledge was unavailable for review. 3. In an interview, E1 agreed documentation of verification of E3's, E5’s, and E6’s skills and knowledge was unavailable for review.

Based on record review and interview the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at the assisted living facility, for three of seven employees sampled who were expected to have more than eight hours per week of direct interaction with residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E3’s and E6’s personnel records revealed evidence of documentation of one negative skin test for infectious tuberculosis (TB) within twelve months of E3’s and E6’s respective dates of hire. However, evidence of documentation of a second negative skin test for infectious TB, administered not less than seven days after the initial test and within twelve months of E3’s or E6’s respective date of hire, was unavailable for review. In addition, evidence of E3’s or E6’s baseline assessment for signs and symptoms of, and risk of exposure to TB, as required in R9-10-113(B)(1), was not available for review. 2. A review of E5’s personnel record revealed evidence of documentation of two negative skin tests for infectious TB within twelve months of E5’s date of employment. However, evidence of documentation of E5’s baseline assessment for signs and symptoms of, and risk of exposure to TB, was unavailable for review. 3. In an interview, E1 agreed E3’s, E5’s, and E6’s personnel records did not include documentation of freedom from infectious TB as required. E1 acknowledged that they failed to ensure a caregiver, who was expected to have more than eight hours of direct interaction with residents per week, provided evidence of freedom from infectious TB as required.

Based on document review, record review, and interview, for one of two residents sampled, the manager failed to obtain a documented residency agreement, which included the manager's signature. Findings include: 1. A review of R6’s medical record revealed a residency agreement, signed by R6’s representative prior to R6’s acceptance at the facility. The residency agreement included a signature line for the facility’s “General Manager.” However, the manager’s signature line was blank. 2. In an interview, E1 advised the facility did not have a licensed manager at the time of R6’s acceptance. E1 acknowledged R6’s residency agreement had not been signed by the facility’s manager as required.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift, at least once every three months, and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility staffing schedules revealed the facility operated three shifts: days, 6:00 a.m. – 2:30 p.m., swing shift, 2:00 p.m. – 10:30 p.m., and nights, 10:00 p.m. – 6:30 a.m. 2. A review of facility documentation revealed evidence of documentation of disaster drills conducted as follows: Days: March 19, 2025, June 18, 2025; and Swing shift: February 12, 2025, July 31, 2025. Evidence of documentation of any additional disaster drills conducted was unavailable for review. 3. In an interview, E1 agreed disaster drills were not being conducted on each shift, at least once every three months, and documented. 4. This is a repeat citation from the compliance/complaint inspection conducted May 14, 2024.

Based on document review and interview, the manager failed to ensure an evacuation drill was conducted at least every six months. Findings include: 1. A review of facility documentation revealed evidence of documentation of an evacuation drill conducted in the 12 months following July 16, 2024, was unavailable for review. 2. In an interview, E1 advised they were unable to locate documentation of any evacuation drill conducted after July 2024. E1 acknowledged the facility had not conducted an evacuation drill every six months as required.

Based on documentation review, record review, and interview, the assisted living facility failed to provide the required documentation to an emergency responder, for one of one sampled residents for whom an emergency responder had been contacted. Findings include: 1. A review of facility documentation revealed an incident report dated November 12, 2024. The incident report indicated R1 had been transported to the hospital after R1 had been found on the floor of their bedroom with a head injury. 2. A review of R1's medical record revealed a copy of any documentation given to the emergency responder was not available for review. 3. In an interview, E1 reported being aware of the implementation of A.R.S. 36-420.04. E1 advised all documentation required per the statute had been provided to the emergency services responder. However, E1 acknowledged a copy of the documentation given to the emergency responder regarding R1 was not made, and therefore was not available for review.

Based on document review, record review and interview, the manager failed to ensure the facility caregivers had the qualifications, experience, skills, and knowledge necessary to provide the assisted living services, meet the needs of a residents and ensure the health and safety of a resident, for one of two caregivers sampled. The deficient practice posed a health and safety risk if employees were unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a service plan dated October 11, 2024 for personal care services. The service plan indicated R1 was to receive the service, ".TED Hose Assist...[R1\ has compression garments that need to stay one (sic) for one hour. Please assist [R1] with putting on garment while [R1] is laying down and removing the garments after one hour." In addition the service plan included the service, "Hearing Aid: Physical Assist 1...Assist [R1] with placing hearing aids." Further review of R1's medical record revealed a document titled, "Service Checkoff List, (checklist)" used for documenting activities of daily living and services provided. The checklist indicated E4 provided the services, ".TED Hose Assist," and "Hearing Aid: Physical Assist 1," on November 5, 6 and 7, 2024. 2. A review of E4's personnel record revealed E4 was hired as a caregiver on February 26, 2024. Evidence of documentation of verification of E4's skills and knowledge prior to providing physical health services was available for review. However, evidence of documentation of E4's skills and knowledge pertaining to compression garments or TED hose, or pertaining to hearing aid placement assistance was unavailable for review. 3. In an interview, acknowledged E4 did not have the verified and documented skills and knowledge necessary to meet the needs of the resident.

Based on record review and interview, the manager failed to ensure a caregiver was only assigned to provide the assisted livng services the caregiver has the documented akills and knowledge to perform. Findings include: 1. A review of R1's medical record revealed a service plan dated October 11, 2024 for personal care services. The service plan indicated R1 was to receive the service, ".TED Hose Assist...[R1\ has compression garments that need to stay one (sic) for one hour. Please assist [R1] with putting on garment while [R1] is laying down and removing the garments after one hour." In addition the service plan included the service, "Hearing Aid: Physical Assist 1...Assist [R1] with placing hearing aids." Further review of R1's medical record revealed a document titled, "Service Checkoff List, (checklist)" used for documenting activities of daily living and services provided. The checklist indicated E4 provided the services, ".TED Hose Assist," and "Hearing Aid: Physical Assist 1," on November 5, 6 and 7, 2024. 2. A review of E4's personnel record revealed E4 was hired as a caregiver on February 26, 2024. Evidence of documentation of verification of E4's skills and knowledge prior to providing physical health services was available for review. However, evidence of documentation of E4's skills and knowledge pertaining to compression garments or TED hose, or pertaining to hearing aid placement assistance was unavailable for review. 3. In an interview, acknowledged E4 did not have the verified and documented skills and knowledge necessary to meet the needs of the resident.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, injury or emergency and needed medical services, as required per R9-10-818.D.2. Findings include: 1. A review of facility documentation revealed an incident report dated November 12, 2024, documenting an unwitnessed fall in which R1 was injured and required medical services. The report indicated R1 was "found on [R1's] floor in [R1's] bedroom, and indicated [R1] "Hit Head," but did not include a description of the injury. Further, the report included actions taken by the caregiver, and included documentation of individuals notified. However, the report did not include any actions taken to prevent the incident from occurring in the future. 2. In an interview, E1 agreed the incident report did not contain all documented required per R9-10-818.D.2.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance for one of ten resident records reviewed. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R5's medical record revealed an initial service plan for personal care level services with medication administration, signed and dated June 1, 2024. Based on R5's date of acceptance, the service plan was not completed within 14 calendar days of R5's date of acceptance. 2. In an interview, E1 acknowledged the service plan was not completed within 14 calendar days of the residents' date of acceptance.

Based on record review, and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for two of ten resident records reviewed. Findings include: 1. A review of R2's medical record revealed a service plan update, signed and dated December 20, 2023, for personal care services. However, the next service plan update, dated August 23, 2024 was not signed and was more than six months later. 2. A review of R7's medical record revealed a service plan update, for personal care services, was due on or before June 5, 2024. The service plan update, dated August 23, 2024 was unsigned and more than six months later. 3. In an interview, E1 acknowledged R2's and R7's service plans were not reviewed and updated at least once every six months.

Based on record review, document review, and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for seven of ten resident records reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2's medical record revealed R2 received personal care level services. 2. Further review of R2's medical record revealed a document titled, "Service Checkoff List", for July 2024. The document recorded the service received, the time scheduled, and initials of the person who provided the service. Further review revealed a document titled, "Service Checkoff List Notes" for July 2024, which detailed "Canceled Services". 3. A review of R2's Service Checkoff List Notes form, revealed the following canceled services: - On July 5, 2024, ".Oxygen Assistance, Completed by another"; - On July 5, 2024, "Bed making, Completed by another"; - On July 5, 2024, "Dressing: Set-Up, Completed by another"; - On July 25, 2024, ".Oxygen Assistance, Completed by another"; - On July 25, 2024, "Bed making, Completed by another"; - On July 25, 2024, "Dressing: Set-Up, Completed by another"; and - On July 25, 2024, "Trash Removal, Completed by another". 4. In an interview E1 reported the services were canceled because they would be provided by another caregiver or had already been provided by another caregiver, though was unable to state who provided the service or provide documentation that the service had been provided. E1 reported only one caregiver at a time could be logged in to document when services are provided. 5. A review of R3's medical record revealed R3 received personal care level services. A review of R3's "Service Checkoff List Notes" form, revealed the following canceled services: - On July 13, 2024, "Weight Monitor, Completed by another", though no weight was recorded for this date; and - On July 13, 2024, "Toileting: Physical Assist 1, Completed by another". 6. A review of R6's medical record revealed R6 received personal care level services. A review of R6's "Service Checkoff List Notes" form, revealed the following canceled services: - On July 1, 2024, "TED Hose: Physical Assist 1, Completed by another"; - On July 8, 2024, "TED Hose: Physical Assist 1, Completed by another"; - On July 15, 2024, "TED Hose: Physical Assist 1, Completed by another"; - On July 29, 2024, "TED Hose: Physical Assist 1, Completed by another"; - On July 29, 2024, "Trash Removal, Completed by another"; - On July 30, 2024, "TED Hose: Physical Assist 1, Completed by another"; and - On July 31, 2024, "TED Hose: Physical Assist 1, Completed by another". 7. A review of R7's medical record revealed R7 received personal care level services. A review of R7's "Service Checkoff List Notes" form, revealed the following canceled services: - On July 8, 2024, "Bed Making, Completed by another"; - On July 8, 2024, "Housekeeping: Additional

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for four of ten resident records reviewed. Findings include: 1. A review of R3's medical record revealed a signed medication orders dated February 1, 2024, which included: - "Lisinopril 20 mg Tab", "1 tab po daily hold for SBP less than 100"; - "Furosemide 20 mg Tab", "1 tab po daily "; and - "Potassium Cl ER 20 MEQ Tab", "1 tablet orally daily". 2. A review of R3's medical record revealed a Medication Administration Record (MAR) dated July and August 2024. The MAR indicated R3 received administration of the following medications: - Lisinopril 20 mg Tab, was documented as, "Held D/T Parameters", on July 2, 2024, July 14, 2024, August 13, 2024, and August 17, 2024. However on July 2, 2024 no blood pressure was measured to determine if outside parameters, and on July 14, 2024, R3's systolic blood pressure was recorded as, 104. On August 13, 2024 no blood pressure was measured to determine if outside parameters, and on August 17, 2024, R3's systolic blood pressure was recorded as, 100; - Furosemide 20 mg was not administered on August 10, 2024; and - Potassium Cl ER 20 was not administered on August 10, 2024. 3. A review of R5's medical record revealed a signed list of medications dated May 13, 2024. The medication list included: - "ELIQUIS 5MG TABLET, TAKE 1 TABLET BY MOUTH TWICE A DAY"; - "Potassium Chloride Crys ER 20 MEQ, Take 2 tablets (40mEq) by mouth in the morning"; - "Aspirin Buf 81MG, Take 81 MG by mouth in the morning"; - "Ipratropium Bromide 0.06%, ADMINISTER 1 SPRAY INTO EACH NOSTRILIN THE MORNING AND 1 SPRAY AT NOON AND 1 SPRAY IN THE EVENING AND 1 SPRAY BEFORE BEDTIME"; and - "Rosuvastatin Calcium 20 MG, Take 1 tablet (20 mg) by mouth daily". 4. A review of R5's medical record revealed a MAR dated July 2024. The MAR indicated R5 received administration of the following medications: - Eliquis 5 MG was administered twice on July 25, 2024 at 7 p.m.; - Potassium Chloride CL ER 20 MEQ was administered once per day from July 1, 2024 to July 25, 2024.; - Aspirin 81 MG was not administered in July 2024. The medication notes stated the medication was not given at the request of R5's representative and the doctor had been notified on May 29 and 31, 2024. No discontinue order was provided.; and - Ipratropium Bromide 0.06% was not administered in July 2024. The medication notes stated the medication was not given at the request of R5's representative and the doctor had been notified on May 29 and 31, 2024. No discontinue order was provided. 5. A review of R6's medical record revealed a signed list of medications dated June 20, 2024. The medication list included: - "DOCUSATE SOD 100MG SOFTGEL, TAKE 1 CAPSULE BY MOUTHAT BEDTIME ..."; - "FUROSEMIDE 20 MG TAB, TAKE I TABLET BY MOUTH EVERY MORNING ... "; - "MUPIROCIN 2% CREAM, APPLY TOPICALLY TO LIPS TWICE DAILY ..."; - "POLYETHYLENE GLY-3350P

Based on documentation review, record review, and interview, the health care institution failed to administer a training program regarding fall prevention and fall recovery, which included initial training and continued competency training in fall prevention and fall recovery, for two of six personnel records reviewed. Findings include: 1. A review of the facilities policy and procedure manual revealed no policies or procedures covering Fall Prevention and Fall Recovery Training. 2. A review of facility documentation revealed a binder, which included documents from a Fall Prevention Training provided by a nursing agency. A review of the binder revealed training for Fall Prevention from October 2022 for E2, E3, E5. and E7. 3. Further review revealed training's, for E2 and E3 from January 2023 for a device called a "Raizer", which assists the caregiver in getting a resident up after a fall. Also provided was a training titled, "Response to Falling or Fainting", for E1. 4. In an interview, E1 was unable to locate a policy regarding Fall Prevention and Fall Recovery which would include the training and continued competency expectations. 5. In an interview, E1 acknowledged documented training in fall prevention and fall recovery, which included initial training and continued competency training in fall prevention and fall recovery, was not available for review. E1 acknowledged initial competency for E4 and E6 was not available for review.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for three of six resident records reviewed. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed the following signed medication orders: - "AMLODIPINE BESYLATE 5MG TAB - TAKE 1 TABLET BY MOUTH DAILY ..."; - "ASPIRIN EC 81MG TABLET - TAKE 1 TABLET BY MOUTH DAILY ..."; - "ATORVASTATIN 80MG TABLET - TAKE 1 TABLET BY MOUTH DAILY ..."; - "DONEPEZIL HCL 10MG TABLET - TAKE 1 TABLET BY MOUTH AT BEDTIME ..."; - "DULOXETINE HCL DR 60MG CAP - TAKE 1 CAPSULE BY MOUTH DAILY ..."; - "FAMOTIDINE 20MG TABLET - TAKE 1 TABLET BY MOUTH DAILY ..."; - "LEVOTHYROXINE 100MCG TABLET - TAKE 1 TABLET BY MOUTH DAILY ..."; - "LIDOCAINE PAIN RELIEF 4% PATCH (Lidocaine) - APPLY 1 PATCH TOPIACLLY DAILY TO AFFECTED SITE(S) FOR 12 HOURS, THEN REMOVE FOR 12 HOURS 8AM, 8PM"; and - "LOSARTAN POTASSIUM 50MG TAB (Cozar) - TAKE 1 TABLET BY MOUTH DAILY ...". 3. A review of R1's medication administration record (MAR) dated June 2024, revealed blank spots, which were not marked in any way to indicate if R1 was administered the mediation or not, for the following medications and dates: - Amlodipine Besylate 5MG on June 3, 2024 at 8:30am; - Aspirin EC 81MG on June 3, 2024 at 8:30am; - Aspirin EC 81MG on June 24, 2024 at 8am; - Atorvastatin 80MG on June 2 and 18, 2024 at 7pm; - Donepezil HCL 10MG on June 2 and 18, 2024 at 7pm; - Duloxetine HCL DR 60MG on June 3, 2024 at 8:30am; - Duloxetine HCL DR 60MG on June 24, 2024 at 8am; - Famotidine 20MG on June 3, 2024 at 8:30am; - Famotidine 20MG on June 2 and 18, 2024 at 7pm; - Levothyroxine 100MCG - Lidocaine Pain Relief 4% Patch (Taken off) on June 18, 2024 at 8pm; - Losartan Potassium 50MG on June 3, 2024 at 8:30am; and - Losartan Potassium 50MG on June 24, 2024 at 8am. 4. A review of R4's medical record revealed R4 received medication administration. 5. A review of R4's medical record revealed the following signed medication orders: - "METFORMIN HCL ER 500MG TABLET - TAKE 2 TABLETS (1000MG) BY MOUTH EVERY EVENING ..."; - "SIMVASTATIN 20MG TABLET (Zocor) - TAKE 1 TABLET BY MOUTH AT BEDTIME ..."; and - "SYSTANE ULTRA 0.4-0.3% SOLN - Instill one drop into each eye two times per day ..."; 6. A review of R4's MAR dated June 2024, revealed blank spots, which were not marked in any way to indicate if R4 was administered the mediation or not, for the following medications and dates: - Metformin HCL ER 500MG on June 9, 2024 at 6pm; - Simvastatin 20MG on June 9, 2024 at 6pm; and - Systane Ultra 0.4-0.3% on June 9, 2024 at 6pm. 7. A review of R7's medical record revealed R7 received medication administration. 8. A review of R7's medical record revealed the following signed medication orders: - "FUROSEMIDE 20MG TABLET - TAKE 1 TABLET BY MOUTH EVERY MORNING ..."; - "MUPIROCIN 2% CREAM - A

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of facility incident reports revealed an incident report for R1, dated, June 4, 2024 at 7pm. The incident report stated, "Resident stated her kitty ran out and she ran after her into the parking lot, scrapping her R arm." ..."Found resident in the parking lot looking for her kitty with blood dripping from her arm." ..."Were there apparent injuries? Yes: Skin Tear: skin tears on RFA" ..."Assisted Resident back into apartment , cleaned up arm and bandaged it. When asked, resident stated she did not fall or hit anything, and that there was no pain anywhere. Resident stated she scraped her arm with the fence." The form also indicated the E2 completed the form and contacted the resident's "family" on June 4, 2024 at 8pm and left a message. 2. In an interview, E1 acknowledged E1 completed an investigation, in response to a complaint, and it was determined E2 did not contact R1's family as stated on the form. E1 stated a review of E2's cell phone revealed no evidence of the call being made and E2 was disciplined. 3. In an interview, E1 acknowledged the incident report for R1 did not include documentation of the immediate notification of R1's emergency contact.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(C), for four of five sampled employees. A.R.S. \'a7 36-411(C) states: C. Owners 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." Findings include: 1. A review of E2's personnel record revealed a form titled "Reference Check and Employment Verification". The document revealed two reference checks which stated "Friend" on who provided the information. 2. A review of E2's application revealed E2 had three previous employers, however, no references from any of them or any documentation of a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution. 3. A review of E3's personnel record revealed a form titled "Reference Check and Employment Verification". The document revealed two reference checks which stated "Friend" on who provided the information. Another document stated "Friend", however, no answer was written at the top of the page. 4. A review of E3's application revealed E3 had two previous employers, however, no references from any of them or any documentation of a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution. 5. A review of E4's personnel record revealed an application with three previous employers listed, however no documentation was provided to show a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to E4's fitness to work in a residential care institution. 6. A review of E5's personnel record revealed a form titled "Reference Check and Employment Verification". The document revealed three reference checks which stated "Friend" on who provided the information. 7. A review of E5's application revealed E5 had three previous employers, however, no references from any of them or any documentation of a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to E5's fitness to work in a residential care institution. 8. In an interview, E1 reported being unaware the reference checks were not being documented to meet Arizona Revised Statutes (A.R.S.) \'a7 36-411(C).

Based on record review, documentation review, and interview, the manager failed to ensure a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; offering sufficient fluids to maintain hydration; and incontinence care that ensures that a resident maintained the highest practicable level of independence when toileting, for two of seven residents sampled receiving personal care services. Findings include: 1. A review of R2's medical record revealed documentation of their current written service plan dated December 29, 2023, for personal care services did not contain the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Offering sufficient fluids to maintain hydration; and - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting. 2. A review of R6's medical record revealed documentation of their current written service plan dated March 12, 2024, for personal care services did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting. 3. In an interview, E1 acknowledged R2 and R6's service plans did not include documentation of skin maintenance to prevent and treat bruises, injuries, pressure sores infections, offering sufficient fluids to maintain hydration and incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's staffing schedule revealed three shifts: - 6:00 am - 2:00 pm (first shift), - 2:00 pm to 10:00 pm (second shift), and - 10:00 pm - 6:00 am (third shift). 2. A review of documentation titled, "Disaster Drill" revealed the following information: - April 4, 2023, AM ? (no time or shift documented) - July 17, 2023, 11 PM (third shift), - July 17, 2023, PM ?, (no time or shift documented) - August 23, 2023, ?, (no time or shift documented) - October 10, 2023, AM ?, (no time or shift documented) - October 14, 2023, AM ?, (no time or shift documented) - January 3, 2024, (shift 2)?, (no time documented) - January 4, 2024, 3:00PM (shift 1), - January 10, 2024, 5 AM (shift 1), - April 1, 2024, (shift 3), ? (no time documented) 3. In an interview, E1 acknowledged the disaster drill documentation for employees was not conducted on each shift at least once every three months. Technical assistance was provided during the on-site compliance inspection conducted on May 15, 2023.

Based on record review, observation, and interview, the manager failed to ensure a resident had a written service plan when initially developed and when updated was signed and dated by the resident's representative, the manager and if a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan for one of six residents sampled. Findings include: 1. A review of R2's medical record revealed R2 was receiving medication administration. 2. A review of R2's medical record revealed a service plan dated January 13, 2023, which indicated R2 was receiving personnel care services and medication administration. The service plan revealed the following: - No date when R2 signed the document; - No date when the manager signed the document; and - No date when the nurse signed the document. 3. In an interview, E1 and E2 acknowledged the service plan for R2 did not include the dates when the document was signed.

Based on record review, documentation review, and interview, the manager failed to ensure assistance in the self-administration of medication provided to a resident was documented in the resident's medical record for one of two resident records sampled. The deficient practice posed a risk as assistance with the self-administration of medication could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed documentation titled "Health Care Practioner's Statement" dated December 5, 2022. In this document under Medications was the following statement "Medication's: May patient self-administer their prescription medicines?". There were two boxes to choose, one Yes and one No box, the box with No had an X through it. On the third page of this document was the following: "Dear Doctor. In order to assist us in proving care for your patient: [R1] who requires medication assistance, you will need to agree to allow our STATE CERTIFIED CAREGIVERS at Fairwinds Desert Point to assist with the administration of medications by the following routes: oral, rectal, topical, vaginal, nasal, optic". This document was signed and dated by R1's physician on December 5, 2022. On page four of this document was a list of the medications R1 was to have administered by the facility. No documentation was available to review showing R1 was able to self-administer medication. 2. A review of R1's medical record revealed a document titled "FW Desert Point Negotiated Service Agreement". No documentation indicating R1 was able to self-administer medication. 3. A review of R1's medical record revealed no medication administration record (MAR) for R1 was available for review. No documentation was found in R1's medical record to indicate R1 was able to self-administer medications. 4. A review of policies and procedures titled "Medication" revealed "Staff Assistance with and Administration of Medication. Only staff properly credentialed and trained in accordance with state law will be permitted to provide medication services. ...When staff are providing medication services, the following practices shall be observed: ... The electronic Medication Administration Record (EMar) must be present and read prior to assisting with medications. ... Each resident must be observed taking the medication. Medication will not be left unattended by an employee unless the order prescribes the medication be left for the resident". 5. In an interview, with R1, the Compliance Officer asked R1 who assists R1 with R1's medications? R1 stated my son comes every weekend to fill up my containers. The Compliance Officer asked R1 if the facility's nurse or anyone else from the facility comes to check on the medications? R1 stated "no". 6. In an interview, E1, and E2 reported R1 can self-administer R1's own medications. However, acknowledged R1 did not have documentation from a physician indicating R1 was able to self-administer medication.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During the facility tour the Compliance Officer observed when entering R1's room the door was unlocked. In R1's bathroom, the following unlocked medications were sitting on the counter: - (2) medi sets with medications in the Monday and Tuesday compartments. 2. The Compliance Officer observed in a vanity drawer in the bathroom the following unlocked medications: - (2) Gabapentin 400 MG capsule; - (1) Omeprazole DR 20 MG capsules; - (1) Carvedilol 3.125 MG tablet; - (2) Losartan Potassium 50 MG tablets, USP; - (1) Levothyroxine 88 MG tablet; - (1) Tylenol 500 MG; - (1) Clopidogrel 75 MG tablet, USP; and - (1) Atorvastatin 10 MG tablet. 3. In an interview with R1 the Compliance Officer asked R1 who assists R1 with R1's medications? R1 stated my son comes every weekend to fill up my containers. The Compliance Officer asked R1 if the facility's nurse or anyone else from the facility comes to check on the medications. R1 stated "No". 4. When the Compliance Officer was exiting R1's room the Compliance Officer observed a handwritten sign on the back of the door "Do Not lock this door". 5. In an interview, E1 and E2 acknowledged medications were stored unlocked in R1's bathroom.