Arizona's Golden Heart I.

“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 documentation review of the facility’s "Employee Disaster Drill Sheet” revealed that the last disaster drill was completed on December 10, 2024 for both shifts.   2. A review of the personnel schedule documented two shifts: 6:00 AM - 6:00 PM and 6:00 PM - 6:00 AM.   3. In an interview, E1 acknowledged the manager did not ensure a disaster drill for employees was conducted on each shift at least once every three months and documented.”

“Based on record review and interview, the manager failed to ensure that for one of two sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. This determination was to be completed at the time of acceptance or onset and at least once every six months throughout the duration of the residents' condition to determine if the resident's needs could be met based upon a current resident examination and the assisted living facility's scope of services, which posed a health and safety risk. The facility is licensed to provided directed care services. Findings include: 1. Review of R2's medical record revealed a documented determination dated January 30, 2024. Based on the date of acceptance there was no documentation to demonstrate the paperwork was updated at least every six months throughout the duration of the resident's condition. The determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R2 required directed care services. 2. In an interview, E1 acknowledged there was no other documentation of the required determinations available for review.”