DESERT HAVEN HOME CARE

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.

Based on documentation review and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident to cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.

Findings include:

1. A review of the facility's policies and procedures revealed policies and procedures to cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for an assistant caregiver was not available for review.

2. In an interview, E1 reported E3 was an assistant caregiver. E1 acknowledged policies and procedures to cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for an assistant caregiver was not available for review.

Based on documentation review and interview, the manager failed to ensure policies and procedures were implemented to cover orientation for employees.

Findings include:

1. A review of the facility's policies and procedures revealed policies and procedures to cover orientation and in-service education for an assistant caregiver was not available for review.

2. In an interview, E1 reported E3 was an assistant caregiver. E1 acknowledged policies and procedures to cover orientation and in-service education for an assistant caregiver was not available for review.

Based on documentation review and interview, the manager failed to ensure as part of the policies and procedures required in R9-10-803(C)(1)(h), a plan was established and documented to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "STAFFING POLICY". The policy stated: "Attendance and Punctuality Employees are expected to report to work on time and as scheduled. If, for any reason, you are unable to report for work at your scheduled time, you are expected to notify your manager as far in advance as possible so that arrangements can be made to cover your responsibilities..." However, the policy did not include a plan to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services.

2. In an interview, E1 reported E1 would be available to work as back-up to provided assisted living services. E1 acknowledged this plan was not documented as part of the aforementioned policy.

Based on record review and interview, the manager failed to ensure a personnel record for each employee or volunteer included all requirements in subsection (C)(1), for one of three employees sampled.

Findings include:

1. A review of E3's personnel record revealed an application for a fingerprint clearance card per A.R.S. \'a7 36-411(A). However, documentation of the requirements in subsection (C)(1)(a), (b), and (c)(i)-(viii) was not available for review.

2. In an interview, E1 acknowledged E3's personnel record did not include the requirements per subsection (C)(1)(a), (b), and (c)(i)-(viii).

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as services provided were unable to be verified and the required documentation was not provided during the inspection.

Findings include:

1. A review of R1's medical record revealed a current written service plan dated July 17, 2023 for directed care services. The service plan stated "Elopement Risk...5. Moderate assistance with elopement Elopement Risk Daily @ Morning, Afternoon, Evening, Night, As Needed 1 person(s) required for this task. Provide supervision and redirection to avoid and prevent elopement. Provide checks throughout day/night and document whereabouts..."

2. A review of R1's medical record revealed an activities of daily living (ADL) document for July 2023. The ADL document stated "ELOPEMENT RISK Provide supervision and redirection to avoid and prevent elopement. Provide checks throughout day/night and document whereabouts..." The document included four time slots, "Night", "Morning", "Afternoon", and "Evening". The document stated the aforementioned service was provided on July 17, 2023 in the "morning" and "afternoon". However, documentation to indicate R1 was provided the aforementioned service in the "evening" of July 17, 2023 through July 23, 2023 and in the morning of July 24, 2023 was not available for review.

3. In an interview, E1 reported caregivers provided the aforementioned service, however, the caregivers forgot to document the aforementioned service. E1 acknowledged the aforementioned service was not documented on R1's ADL as provided.

Based on documentation review and interview, the manager of an assisted living facility authorized to provide directed care services failed to implement policies and procedures to ensure the safety of a resident who may wander.

Findings include:

1. A review of Department documentation revealed AL10165 was authorized to provide directed care services.

2. A review of facility documentation revealed an incident report dated July 12, 2023. The incident report stated "On 7/12 around dinner time...[R1] (dx dementia), completed [R1's] meals, then excused [R1] to go to the bathroom. Few minutes passed when the staff noticed [R1] was not back. When they investigated [R1's] whereabout, they noticed [R1] pushed and propped open a window in another resident's room, and escaped...Quarter of an hour later, the resident was found less than 300 ft from the property and fire department assessed [R1] and took [R1] to the ER...The resident was assessed and cleared around 2AM back to the facility. In the aftermath of the incident, the facility added security cameras, sensors to all entries and window to prevent future elopements."

3. A review of the facility's policies and procedures revealed a policy titled "WANDERING" dated January 14, 2019. The policy stated "...1. When an initial assessment is conducted on a prospective resident, his or her potential tendency to wander should be assessed. If an applicant has a demonstrated pattern of wandering from the location where the prospective resident is currently residing, he or she would not be considered appropriate for admission to the facility..."

4. In an interview, the Compliance Officer asked E1 for documentation for R1 of an initial assessment per the aforementioned policy, however, the documentation was not available for review.

5. In an interview, E1 reported the resident's windows are alarmed, security cameras were installed in the main areas of the facility, and the front and back door are locked to control egress. E1 acknowledged policies and procedures were not implemented that ensure the safety of a resident who may wander.

Based on record review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. A review of E2's personnel record revealed a cardiopulmonary resuscitation (CPR) and first aid training card with an issue date of December 27, 2020. The CPR and first aid training card stated "...Valid for 2 Years", and documentation of current CPR and first aid training for E2 was not available for review.

2. In an interview, E1 acknowledged documentation indicating compliance with the aforementioned requirements was not provided within two hours after a Department request

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for one of three caregivers sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the personnel record did not include the documentation, and the documentation was not provided to the Department within two hours after a Department request.

Findings include:

1. The Compliance Officer observed E2 to be the only staff working on-site when the Compliance Officer arrived at the facility.

2. A review of the facility's policies and procedures revealed a policy titled "FIRST AID/CPR TRAINING REQUIREMENTS" dated December 14, 2019. The policy stated "POLICY: Assisted living facilities are required that facility staff members who provide care for residents, should have completed courses in First Aid and CPR and hold a currently valid card documenting completion of such courses in the facility at all times."

3. A review of E2's personnel record revealed a CPR and first aid training card with an issue date of December 27, 2020. The CPR and first aid training card stated "...Valid for 2 Years", and documentation of current CPR and first aid training for E2 was not available for review.

4. In an interview, E1 reported E2 had current CPR and first aid training, however, E1 and E2 could not locate the documentation. E1 acknowledged E2's current CPR and first aid training was not included in E2's personnel record.

Based on observation and interview, the manager failed to ensure food stored by the facility was free from spoilage and was safe for human consumption.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed thirty (30) eggs in a carton in a cabinet in the kitchen.

2. According to the United States Food and Drug Administration (FDA) guidelines, eggs should be stored at a temperature of 40 \'b0F or below.

3. In an interview, E2 reported the eggs are served for breakfast to the residents.

4. In an interview, E1 acknowledged food served to the residents was not protected from spoilage.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were 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. The Compliance Officer observed one ambulatory resident on the premises.

2. The Compliance Officer observed one container of "Lysol toilet bowl cleaner" in an unlocked cabinet in a hallway bathroom. The cabinet did not contain a locking device. The item contained a toxic warning label.

3. In an interview, E1 acknowledged the poisonous or toxic materials stored by the facility were not locked and were accessible to residents.