Pleasant Stay Care Home

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available. 2. In an interview, E4 and E5 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not available for review during the inspection.

Based on documentation review and interview, the manager failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of facility documentation revealed a quality management program reviewed in 2023. However, there was no documentation that the quality management program was reviewed and evaluated at least once every 12 months. 2. In an interview, E4 and E5 acknowledged that the facility did not have documentation of a review or evaluation of the effectiveness of the quality management program at least once every 12 months.

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. § 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 that as soon as you enter the house, there was an unlocked office area with medical records for R1, R2, R3, and other residents stored on top of a bookshelf. Multiple ambulatory residents and visitors were observed walking through the area, posing a risk to the confidentiality of resident information. 3. In an interview, E4 and E5 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.

Based on documentation review and interview, the manager failed to ensure that an employee disaster drill 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 the disaster plan. Findings include: 1. A review of the April 2025 personnel schedule revealed two shifts: 7 AM - 7 PM and 7 PM - 7 AM. 2. A review of the facility's personnel disaster drills revealed the following drills; - March 18, 2025, 2nd shift - February 24, 2025, 2nd shift - August 05, 2024, both shifts 3. In an interview, E4 and E5 acknowledged that the employee disaster drills were not conducted on each shift at least once every three months.

Based on documentation review, observation, and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed one ambulatory resident. 3. During the environmental tour with E3, the Compliance Officer observed multiple safety hazards in the backyard, including: - Large piles of wood and metal debris were stacked loosely against a wall - Two unsecured window screens were leaning on the pile - Scattered construction debris, such as rocks, garden tools, and an overturned planter - Multiple mobility devices and medical equipment, including wheelchairs and walkers, were stored on the patio and around walkways - A garden hose stretched across the walking path 4. In an interview, E3, E4, and E5 acknowledged that the items in the backyard presented conditions that could cause a resident or other individual to suffer physical injury. This is a repeat deficiency from the on-site compliance inspection conducted on April 4, 2023.

Based on observation and interview, the manager failed to ensure an oxygen container was secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During the environmental tour, the Compliance Officer observed one large oxygen container in a resident's closet. The oxygen container was upright but not secured. 2. In an interview, E4 and E5 acknowledged that the oxygen container was not secured in an upright position.