White Dove at Silver Crest

Based on record review and interview, the manager failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. § 36-420.04.A. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A record review of form used by the facility revealed that R1 and R2 had prefilled Emergency Medical Services (EMS) Face Sheet that only had the residents names listed. 2. In an interview, E1 revealed that the employees filled out the EMS sheet while on the phone with 911. E1 acknowledged that the facility failed to maintain a standardized form for each resident that includes the information prescribed.

Based on records review and interview, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive, for one of two sampled residents. 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 "Pre-Admission Determination" dated and signed by a medical practitioner July 9, 2024 revealed that R2 was a Directed Care resident. 2. A review of R2's service plans dated July 22, 2024 and January 8, 2025 revealed a service plans for Personal Care services. 3. In an interview, E1 acknowledged the level of service for R2 was not listed correctly.

Based on observations, documentation review, and interview, the manager failed to ensure the 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, 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 documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection, the Compliance Officer observed that when the front door in the living room was opened, no alarm sounded to alert employees that a person was entering or exiting the facility. 3. A documentation review of the facility's Policies and Procedures titled, "General Whereabouts of Residents: Responsible Persons" stated, " All entrances and exits outside such as as but limited to front and back doors will be locked at all times." 4. In an interview, E1 acknowledged that that were no controls or alerts to notify employees of the egress of a resident from the facility who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility.

Based on observation, documentation review, and interview, the manager failed to ensure the premises 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 health and safety of the residents. Findings include: 1. The Compliance Officer observed ambulatory residents in the facility. 2. The Compliance Officer observed a swimming pool on the premises. However, the gate was unlocked and the Compliance Officer observed there was no water in the pool. 3. A review of the facility's policy and procedures revealed a policy titled, "Resident Safety with Swimming Pools," in subsection 3. a revealed, "The gate will remain locked at all times." 4. In an interview, E1 reported maintenance was done on the pool the day before and the gate was not locked since then. E1 acknowledged the situation may cause the residents to suffer physical injury.