Desert Dreams Adult Care Home, LLC.

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record for one of two residents sampled.      Findings include:     1. A review of R2's medical record revealed a current service plan describing the services provided by the facility staff. The plan included a section titled “Turning” which indicated R2 needed “hands on assist.” The service plan also included a section titled “Basic Skin Care,” which indicated R2 suffered from “Stage 1 breakdown on buttocks,” and would benefit from “changing positions every 2-3 hours.”     2. A review of R2’s medical record revealed a document used for tracking the services provided to R2. The document included a section for documenting basic skin care; however, evidence of documentation to indicate the service “turning” was unavailable for review. Evidence of documentation R2 was repositioned as indicated in R2’s service plan was unavailable for review.     3. In an interview, E1 advised caregivers repositioned R2 approximately every two hours. E1 agreed the caregivers were not documenting the positioning service provided per R2’s service plan.”

“Based on documentation review, record review, and interview, the assisted living home failed to provide the required documentation to an emergency responder, for two of two residents sampled for whom an emergency responder had been contacted. The deficient practice posed a risk as the Department was provided false and misleading information. Findings include: 1. A review of facility documentation revealed an incident report dated March 31, 2024. The incident report indicated R3 had been transported to the hospital after expressing groin pain and an inability to urinate. The incident report contained six sections which identified a specific date of March 31, 2024. However, a line was drawn through five of the six noted dates and a new date of April 20, 2024 was written in. The original date entries were not made illegible. 2. A review of R3's medical record revealed a document titled, "TMC Healthcare After Visit Summary," dated March 31, 2024. The document indicated R3 was seen in the Tucson Medical Center emergency department on the same date for a "Urinary track infection..." and "Foley catheter problem, initial encounter." Evidence of any other record to indicate R3 was transferred to a medical facility or received emergency medical services on April 20, 2024 was unavailable for review. Further review of R3's medical record revealed a standardized form titled, "Assisted Living Resident Transfer Checklist," which was dated April 20, 2024. The form was also signed by E4 and E5 with the date "4-20-24" noted next to each signature. However, the form did not include the following required information: - a list of all the resident's medications, their dosages, and how frequently they were administered; - The address and telephone number of the resident's current pharmacy; - Basic information about the resident's physical and mental conditions and basic medical history; - A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge; and - A copy of the resident's advance directives, if any. 3. A review of facility documentation revealed an incident report dated June 11, 2024. The incident report indicated R4 was experiencing stomach pain and was vomiting. The report also indicated 911 was called and the resident was transported to a hospital. Further review of R4's medical record revealed a standardized form compliant with A.R.S. 36-420.04 was unavailable for review. 4. In an interview, E6 recalled R3 was taken to the emergency department only one time. E6 advised R3 was not transported to the emergency department in late April 2024. E6 reported not knowing why there were two different dates on the March 31, 2024 incident report regarding R3. 5. In an interview, E1 reported emergency medical services were called only one time for R3. E1 advised they did not know why R3's Resident Transfer Checklist was dated April 20, 2024, and E1 had no knowledge as to why five of the six March 31, 2024 dates on the incident report had been struck through and replaced with April 20, 2024. E1 acknowledged the provided documentation of what was given to the emergency responder for R3 and R4 did not include all of the required information.”

“Based on observation, documentation review, record review and interview the manager failed to ensure a caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults, prior to providing assisted living services to a resident for one of ten personnel members sampled. Findings include: 1. During a tour of the facility the Compliance Officer observed E3 providing assisted living services to various residents. 2. A review of facility policy and procedures, last reviewed March 29, 2024, revealed a policy titled, "Administering CPR, First Aid and Fall Recovery to Residents." The policy read, in part, "...all caregivers will be required to provide current training in CPR and First Aid before providing services to the residents. Caregiver's will be required to submit new training documentation on month prior to the expiration date." 3. A review of E3's personnel record revealed E3 was hired as a caregiver on July 29, 2016. Further review, revealed documentation indicating E3 completed cardiopulmonary resuscitation (CPR) and first aid training on June 13, 2022. The documentation included an "Expiration Date" for the training of June 13, 2024. However, evidence of documentation of E3's current CPR and first aid training was not available for review. 4. In an interview, E3 acknowledged providing assisted living services to residents during the month of June and in July 2024. E3 confirmed their CPR and first aid certification had not been renewed prior to providing assisted living services. 4. In an interview, E1 acknowledged E3's personnel record did not include current documentation of CPR and first aid training.”

“Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical record revealed current service plans for directed care services. Both service plans included the service, "Dressing," and each indicated R1 and R2 required "Complete" assistance dressing "morning & bedtime." 2. A review of R1's and R2's medical record revealed a tracking sheet dated June, 2024, used for tracking activities of daily living (ADLs) and services provided. The tracking sheet did not contain a section for documenting the service "Dressing." Evidence of documentation the service was provided to either R1 or R2 was unavailable for review. 3. In an interview, E1 acknowledged the caregivers were not correctly documenting all services provided for R1 and R2 in their medical records.”

“Based on document review, observation and interview, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees to the egress of a residents from the facility. The deficient practice posed a potential elopement risk to residents. Findings include: 1. A review of facility documentation revealed the facility was licensed at Directed Care level. 2. A review of R1's medical record revealed a service plan dated May 8, 2024, which indicated R1 received directed care services and was ambulatory. 3. During a tour of the facility, the Compliance Officer observed no less than three ambulatory residents. The Compliance Officer also observed R1's bedroom which had a door leading to the main driveway outside the facility. Mounted to the wall above the door was an "EXIT" sign. Also mounted to the door was a door chime designed to alert employees when the door was opened. The door had a deadbolt locking mechanism with a thumb turn and a handle which could be locked with a key. However, the door handle was not locked, and the Compliance Officer was able to turn the thumb tun deadbolt with little effort and open the door. When the Compliance Officer opened the door, the chime did not sound. 3. In an interview E1 acknowledged that the bedroom door providing egress from the facility did not have a functioning chime to alert employees of an egress of a resident. This is a repeat citation from a compliance inspection conducted on April 28, 2023.”

“Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an emergency and needed medical services, as required per R9-10-818.D.2. Findings include: 1. A review of facility documentation from April 2024 through June 2024 revealed one incident report involving R3 which documented and emergency where 911 was contacted. A review of the incident report dated June 11, 2024 revealed the report contained most documentation required per R9-10-818.D.2. The report included a section for documenting actions taken to prevent the incident from occurring in the future, however the section was not completed. 2. In an interview, E1 agreed the incident report did not contain all documented required per R9-10-818.D.2.”

“Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was 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 residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed a metal mounting bracket, attached to the wall inside a common bathroom used by guests and residents. The bracket, which extended away from the wall and had a sharp edge, appeared to be for mounting a towel bar. 2. In an interview, E1 agreed the mounting bracket presented a condition that may cause a resident to suffer physical injury. E1 submitted a verbal work order to have maintenance remove the mounting bracket.”