Southwest Healing Gardens

Based on observation and interview, the manager failed ensure a personnel record for each employee or volunteer included the requirements in R9-10-806(C)(1) for one of five personnel sampled. The deficient practice posed a risk as required information could not be verified for E4. Findings include: 1. Upon arrival to the facility, the compliance officer observed E1 and E4 on-site. 2. A review of facility documentation revealed a job description for volunteers and support staff titled, "4. Facility Job Descriptions, Duties, and Qualifications." Under the title, "Procedures" the document stated, "...4. To work as a Volunteer and Support Staff you must have a file that contains: a. The individual's name, home address, and telephone number 5. All of the above staff must have: a. A file that is maintained on the premises for each employee or volunteer containing the following: 1) The employee's name, date of birth, home address, and telephone number; 2) Documentation of...6) An employee's starting date of employment and ending date, if applicable 7. At least one personal references 8. At least one professional or work-related references." 3. The compliance officer requested all personnel records. However, E4's personnel record was not made available for review. 4. In an interview, E1 reported E4 was a "cleaner" and assisted E1 when needed. 5. In an interview, E1 acknowledged E4 did not have a personnel record available for review.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for two of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated April 5, 2023. However, the service plan did not include a description of R1's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. A review of R2's medical record revealed a service plan for personal care services dated April 14, 2023. However, the service plan did not include a description of R2's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 3. In an interview, E1 acknowledged R1's and R2's service plans did not include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments.