Twilight Haven - Mesa

Based on interview and record review, when a resident had an emergency resulting in the resident needing medical services, the assisted living home failed to maintain a copy of the document provided to the emergency responder, for one of one resident sampled who had an incident that resulted in the resident needing medical services. Findings include: 1. In an interview, E1 reported that R1 was transported to the hospital by Emergency Medical Services (EMS) on March 20, 2026. E1 reported that EMS took the EMS paperwork and there was no copy kept on file in R1's medical record. 2. Record review revealed R1's medical record did not contain a copy of the document provided to EMS on March 20, 2026. 3. In an interview, the findings were reviewed with E1 and no additional information was provided.

Based on interview, and record review, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one resident sampled who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. In an interview, E1 reported that R1 was transported to the hospital by Emergency Medical Services (EMS) on March 20, 2026. 2. Record review revealed R1's medical record did not include the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. 3. In an interview, findings were reviewed with E1 and no additional information was provided.

Based on observation, interview, and documentation, the manager failed to ensure the premises and equipment used 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 a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection, the Compliance Officers (COs) observed bedrails on R4's bed. 2. During the environmental inspection, the COs observed R4 asleep in bed with a food tray table across R4's abdomen and bedrails in the raised position. The CO asked the purpose/use of the bedrails. E3 reported for assistance with mobility and turning. The COs asked if R4 could raise and lower the bedrails alone without assistance, and E3 reported that R4 could not raise or lower the bedrails alone without assistance. 3. During the environmental inspection, the Compliance Officers observed that R4's call bell was located on the nightstand and out of reach. R4 would be unable to alert facility staff in the event of if emergency assistance was required. 4. In an exit interview, findings were discussed with E1 and E2, and no additional information was provided. 5. Technical assistance was provided on this rule during the inspection conducted on July 8, 2024.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked, self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the environmental inspection, the Compliance Officers observed medication stored in a unlocked cabinet in the kitchen. Medications included ClearLax and Polyethylene Glycol 3350. 2. During the environmental inspection, the Compliance Officers observed medication stored in an unlocked cabinet in the bathroom. Medication included: Calmoseptine ointment 3. In an exit interview, findings were reviewed with E2 and no additional information was provided.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area from which a resident may exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed two ambulatory residents. 3. During the environmental tour, the Compliance Officer observed the back yard did not allow residents to be at least 30 feet away from the facility. The door was not secured and was not equipped with a device that alerted caregivers of the egress of a resident. 4. During the environmental tour, the Compliance Officer observed a gate in the back yard leading to the front yard. The gate was unlocked and was not equipped with a device that alerted caregivers of the egress of a resident. 5. In an interview, E1 acknowledged the facility did not have a means of exiting to an outside area that allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees to the egress of a resident from the facility.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed two ambulatory residents. 3. During the environmental tour, the Compliance Officer observed a door in the hallway that led to the garage. The garage door was open, providing an access to the front yard. The outside area, in the front yard, allowed residents to be at least 30 feet away from the facility. The door was not secured and was not equipped with a device that alerted caregivers of the egress of a resident. 4. In an interview, E1 and E2 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.