Desert Hills Heart of Gold Assisted Living.

“Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that included the frequency of assisted living services being provided to the resident, for two of two residents sampled. The deficient practice posed a risk if the resident’s needs were not being met. Findings include: 1. A review of R1’s medical record revealed a current service plan dated October 10, 2025. This service plan indicated R1 received the following services: dressing, maintenance of room, and laundry. These services were marked as dependent, and no frequency was described. 2. A review of R2’s medical record revealed a current service plan dated May 3, 2026. This service plan indicated R1 received the following services: dressing, maintenance of room, and laundry. These services were marked as dependent, and no frequency was described. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure there was a means of exiting a facility for a resident that provided access to a secure, outside area that allowed residents to be at least 30 feet (ft) away, and monitored or alerted employees to 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. During the environmental inspection of the facility, the Compliance Officers observed an unlocked sliding door that led to the backyard. The alert of the door did not sound when the door was opened.  2. During the compliance inspection, the Compliance Officers observed an ambulatory, wandering resident open the sliding door and walk outside unaccompanied and unbeknownst to the caregivers of the facility. The Compliance Officers notified the caregivers of the resident, and the resident was promptly brought inside. 3. A review of the department documentation of the facility revealed that the facility was licensed to provide directed care services. 4. In an interview, E1 reported that the alert was not working because the batteries of the alert were dead.  5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. The deficient practice posed a risk if the medical policies and procedures were not approved before administering medication.  Findings include: 1. Upon review of the facility’s medical policies and procedures, evidence of review and approval by a medical practitioner, registered nurse, or pharmacist through signature was missing. 2. In a documentation review of the facility’s policies and procedures, titled “Medication Services”, the policy read “This policy and procedure is reviewed and approved by a medical practitioner, registered nurse or pharmacist.” 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.   Findings include: 1. A review of R2’s medical record revealed a current service plan dated May 3, 2026. This service plan revealed R2 received medication administration.  2. A review of R2’s medical record revealed a medication administration record (MAR) for May 2026. This MAR revealed Tramadol 50 mg was administered on May 4, 2026, and May 6, 2026.  3. A review of R2’s medical record revealed no medication order for Tramadol 50 mg.  4. The Compliance Officers observed the pill bottle for Tramadol 50 mg prescribed for R2.  5. In an interview with E1 and E2, it was reported that when there is an initial on the MAR that means that medication was administered for that day and time.  6. In an interview, O1 reported they wanted the facility to administer Tramadol 50 mg to R2. O1 reported O1 does not have the medication order.  7. In an interview, E1 reported the facility does not have the medication order for tramadol 50 mg. E1 also reported O1 was persistent that the facility administered Tramadol 50 mg to R2.  8. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications.  Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed the following medications in resident rooms: Calmoseptine ointment; and Diclofenac Sodium Topical Gel 1%. 2. Upon further environmental inspection, the Compliance Officers observed an unlocked kitchen cabinet containing a small tote box of vitamins and medications. The tote box contained the following medications: Senna; and Fluticasone Propionate Nasal Spray USP 50 mcg. 3. In a documentation review of the facility’s policies and procedures, titled “Medication Services”, the policy read “All resident medications must be secured in a locked storage area.” 4. In an interview, E2 reported that the tote box of medications belonged to E2 and only E2 used the medications and vitamins inside.  5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility’s documentation revealed that there was no disaster plan review completed. 2. In an interview, E1 reported that the facility did not have a disaster plan review for 2026 or 2025. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a risk to the physical health and safety of a resident.  Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed that the hot water temperature reached 138º F in the kitchen sink. 2. Upon a documentation review of the facility’s policies and procedures, titled “Emergency, Safety, and Environmental Standards,” the policy read “Hot water temperature will be maintained between 95º F and 120º F at all times.” 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials were maintained 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 the environmental inspection of the facility, the Compliance Officers observed that the garage was unlocked. Upon further inspection, the Compliance Officers observed the following toxic materials inside: Lysol bleach cleaner; and Klean Strip Paint Thinner. 2. During the environmental inspection of the facility, the Compliance Officers observed a bottle of Oxi Clean detergent in the facility’s backyard. Upon further observation, the Compliance Officers noticed the liquid in the container was purple and smelled of detergent.  3. In a documentation review of the facility’s policies and procedures, titled “Emergency, Safety, and Environmental Standards,” the policy read “Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas.” 4. In an interview, E2 reported that the container was filled with water and was used by the other caregiver to water the plants, which is why it was left outside. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record for three of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan.   Findings include: 1. A review of R1's medical record revealed no documentation of the services provided for August 2025 and September 2025.   2. A review of R2's medical record revealed no documentation of the services provided for August 2025 and September 2025. 3. A review of R3's medical record revealed no documentation of the services provided for September 2025.   4. In an interview, E1 reported that R1, R2, and R3 received assisted living services from the caregivers.    5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.    6. This is a repeat deficiency from the inspection conducted on August 3, 2023, and July 8, 2025.”

“Based on record review, documentation review, and interview, the health care institution failed to ensure a training program for all staff regarding fall prevention and fall recovery, which included initial training, was implemented for two of two personnel sampled. The deficient practice posed a risk to the physical health and safety of a resident.     Findings include:    1. A review of E1’s and E2’s personnel records revealed no documentation indicating E1 and E2 had received initial training in fall prevention and fall recovery.   2. A review of facility documentation revealed a fall prevention and fall recovery program, which included initial training and continued competency training for all employees of the facility.   3. In an interview, E1 acknowledged E1 and E2 had not completed initial fall prevention and fall recovery training as required, per A.R.S. § 36-420.01. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review, interview, and documentation review, the manager failed to ensure a personnel record for each caregiver included documentation of cardiopulmonary resuscitation (CPR) training, which included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of two employees reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.   Findings include: 1. A review of E2's personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on February 7, 2025. There was no other current documentation of CPR training available for review that included a demonstration of E2's ability to perform CPR. 2. In an email exchange, a representative from NationalCPRFoundation stated, "Our courses are online only."   3. A documentation review revealed the employee's work schedule, dated June and July 2025, showed E2 had worked every day on the day shift. 4. In an interview, E1 reported that E1 was unaware that online classes were not acceptable. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure 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 two of four residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1 . A review of R1's and R2's medical records revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1’s and R2's acceptance dates, this documentation was required.    2 . In an interview, E1 reported that E1 did not realize that documentation was not completed or in the records. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 4. This is a repeat deficiency from the inspection conducted on August 3, 2023.”

“Based on the record review and interview, the manager failed to ensure that a resident had a service plan which included the level of service the resident was expected to receive, for one of four reviewed 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 R2's medical record revealed a current service plan dated June 17, 2025. However, the service plan did not include the level of service R2 was expected to receive. 2. In an interview, E1 acknowledged that the service plan did not include the level of service R2 was expected to receive. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a caregiver provided assistance with activities of daily living according to the resident's service plan for one of the four review residents. The deficient practice posed a risk as the service plan to direct services was not followed.     Findings include:     1. A review of R2's medical record revealed a service plan dated June 17, 2025. R2's service plan indicated R2 required the following: -incontinence care every 2 hours or as needed  -turning every 2 hours   2. A review of R2's medical record revealed an activities of daily living (ADL) document dated June and July 2025. The ADL document was blank.   3. In an interview, R2 reported that R2 did not get incontinence care every 2 hours or as needed. R2 stated, “E2 was upset with me because I had to call each time I felt I needed to be changed.” R2 also stated that E2 said to R2, “I don’t know why you keep calling me, I only have to change every 2 hours”.   4. In an interview, R2 also reported that the staff would not turn or move R2 up in bed when needed. R2 reported that there was paralysis on the right side of the body and R2 needed assistance. R2 reported that R2 had to call 911 because the staff would not help. 5. In an interview, E1 reported that R2 did call 911 to be adjusted in bed.    6. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for four of four residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed no documentation of the services provided for June 2025 and July 2025. 2. A review of R2's medical record revealed no documentation of the services provided for June 2025 and July 2025. 3. A review of R3's medical record revealed no documentation of the services provided for April 2025, May 2025, June 2025, and July 2025. 4. A review of R4's medical record revealed no documentation of the services provided for June 2025 and July 2025. 5. The Compliance Officer requested documentation of the services provided to R1, R2, R3, and R4. E1 gave the Compliance Officer blank activities of daily living (ADL) sheets for June 2025. The Compliance Officer asked if any other documentation was available. E1 stated, "I will go print them." The Compliance Officer observed E1 filling out the ADL sheets for the missed days. 6. In an interview, E1 reported that R1, R2, R3, and R4 required assisted living services. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 8. This is a repeat deficiency from the inspection conducted on August 3, 2023.”

“Based on interview and record review, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of four residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs.   Findings include: 1. In an interview, E1, E2, and R2 reported R2 was non ambulatory even with assistance since R2's date of acceptance. 2. A review of R2's medical record revealed a document titled “Determination and Authorization For Continued Residency”. This document was not filled out, signed, or dated by a medical professional.   3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”