Desert Haven.

“Based on documentation review, record review, and interview, the manager failed to develop and administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training, for three of the three personnel sampled.  The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently.     Findings include:     1.    A review of facility policy and procedures revealed a policy titled “Fall prevention and recovery training. Policy stated, “The facility has established a comprehensive training program for all caregiving staff focused on fall prevention and fall recovery. This program includes initial training upon hiring and annual competency review to maintain proficiency in these critical areas”.   2.    A review of E1 personnel records revealed documentation of fall prevention and fall recovery training on October 1, 2021. However, documentation of fall-prevention and fall-recovery training conducted after October 2021 was not available for review at the time of inspection.   3.    A review of E2 personnel records revealed documentation of fall prevention and fall recovery training on July 23, 2023. However, documentation of fall-prevention and fall-recovery training conducted after July 2023 was not available for review at the time of inspection.   4.    A review of E3 personnel records revealed documentation of fall prevention and fall recovery training on October 1, 2021. However, documentation of fall-prevention and fall-recovery training conducted after October 2021 was not available for review at the time of inspection.   5.    In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on documentation review, record review, interview, and observation, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) states: "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution…and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 2. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC).” 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel. 4.  A review of E2’s personnel record revealed E2 was hired as a caregiver in 2023. The review revealed a negative TST dated as read on November 10, 2023. However, a second TST was not available for review. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on the record review and interview, the manager failed to ensure that a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services for one of the three caregivers reviewed. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency.   Findings include:    1.     A review of E2's personnel record revealed that E2 worked as a caregiver. The personnel record revealed a first aid and CPR card with an expiration date of August 4, 2025. There was no other current documentation of first aid and CPR training in E2's record.   2.     In an interview, E1 acknowledged that E2's first aid and CPR training had expired.”

“Based on record review and interview, the manager failed to ensure that a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints for one of the two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.     Findings include:     1. A review of R2’s (admitted in 2025) medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2’s acceptance date. This documentation was needed.   2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the facility tour with E1, the Compliance Officer observed R4's bedroom did not have a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies accessible to a resident. 2. Review of R4's medical record revealed R4 received personal care services. 3. During an interview with R4, R4 stated R4's roommate lost a bell so R4 gave R4's bell to R4's roommate. R4 also stated R4 will either yell to get attention of the caregivers or go out and find a caregiver for assistance. 4. In an interview, E1 acknowledged that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was not available and accessible in a bedroom being used by a resident receiving personal care services.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic material was stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a facility tour, the Compliance Officer observed a bottle of Lysol spray disinfectant inside the common bathroom used by residents. 2. In an interview, E1 and E2 acknowledged poisonous or toxic material was not stored in a locked area and inaccessible to residents. This is a repeat deficiency from the compliance inspection conducted May 8, 2023.”