DESERT SANCTUARY ASSISTED LIVING LLC

Based upon record review and interview, the manager failed to ensure that employees had competency and continued competency in regards to fall prevention and fall recovery. The deficient practice posed a potential risk to the safety of the residents.

Findings include:

1. Record review revealed that E2 and E3 had no documentation of fall prevention and fall recovery training.

2. A review of documentation revealed a policy titled "Fall prevention and recovery training" with a subsection that read: "All employees hired by the care facility will either supply that they have had training or complete the care home training provided by the care home."

3. In an interview, E1 acknowledged that E2 and E3 did not have documented fall prevention and fall recovery training.

This is a repeat deficiency from the compliance inspection conducted on July 1, 2022.

Based upon record review and interview, the manager failed to ensure that two of three employees' fingerprint clearance cards were verified with the Department of Public Safety (DPS). The deficient practice posed a potential risk to the safety of the residents.

Findings include:

1. Record review revealed that fingerprint verification documentation was missing for two of three employees.

2. Record review of E2's and E3's personnel records revealed that E2 and E3 had fingerprint clearance cards; however, there was no documentation that these fingerprint clearance cards had been verified with DPS.

3. A review of documentation revealed a policy titled "Employee Records" and an additional section titled "Maintain a personnel file for each staff member that includes". Within this subsection was a subsection titled: "Compliance with fingerprint requirements".

4. A review of documentation revealed a policy titled "Fingerprint Documentation" and an additional section containing the following: "All new employees with existing DPS fingerprint card must be verified by phone. The standard requires the employee to call DPS and have them confirm that the applicant is still okay to work in Arizona. Document the date, time and badge number of officer that checks records".

5. In an interview, E1 acknowledged that E2 and E3 did not have fingerprint card verification documentation in their employee files as was evidenced in E2 and E3's "Fingerprint Documentation" forms not being filled out and signed by E1.

This is a repeat deficiency from the compliance inspection conducted on July 1, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included the requisite component of skills and knowledge, for two of three employees with a personnel record. The deficient practice posed a risk as required information could not be verified for E2 and E3's employment records.

Findings include:

1. A review of documentation revealed a policy titled "Employment Orientation Acknowledge" and an additional section titled "A caregivers or assistant caregiver's skills and knowledge are verified and documented". On the policy form titled "Employment Orientation Acknowledge" items two through twenty-one were not signed off by the manager.

2. A review of E2's and E3's personnel records revealed no documentation E2's and E3's skills and knowledge were verified and documented.

3. In an interview, E1 confirmed that E2 and E3 were missing the requisite component of skills and knowledge in their employment records.

Based upon documentation review and interview, the manager failed to ensure that documentation was maintained for at least twelve months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each for three of three employees. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents.

Findings include:

1. A documentation review revealed no April employee work schedule.

2. In an interview, E1 acknowledged that there was not an April employee work schedule.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included the requisite component of starting date, for two of three employees. The deficient practice posed a risk as required information could not be verified for E2 and E3's employment records.

Findings include:

1.A review of documentation revealed a policy titled "Employee Records" and an additional section titled "Maintain a personnel file for each staff member starting date". Within this section was a subsection titled "Employee starting date".

2. A review of E2's and E3's personnel records revealed no documentation of E2's and E3's start dates.

3. In an interview, E1 confirmed that E2 and E3 were missing their dates of hire in their personnel records.

Based upon record review and interview, the manager failed to ensure that services provided to two of three residents were documented in the residents' record. The deficient practice posed a risk as services could not be verified as provided against a service plan, and the Department was provided false and misleading information.

Findings include:

1. A review of documentation revealed a form titled "Activities of Daily Living Flow Chart" which was filled out beyond the time the Compliance Officers inspected the facility. The chart was filled out for the entire day of April 8, 2024. The Compliance Officers conducted their inspection on April 8, 2024 and observed the form at 10:00 am. The "Activities of Daily Living Flow Chart" was filled out for the entire day of April 8, 2024 for two of three residents.

2. The services documented as provided but had not yet been provided for R1 and R2 were:

-Fluid Intake at ten pm.
-Urine Output at ten pm.
-Night Checks at ten pm.

3. In an interview, E1 acknowledged that the "Activities of Daily Living Flow Chart" for R1 and R2 was filled out for the entire day of April 8, 2024. E1 acknowledged that "Fluid Intake", "Urine Output" and "Night Checks" had all been prechecked as completed.

Based on documentation review, record review, and interview, the manager failed to ensure that tuberculosis infection control activities were implemented for one of three employees including annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis (TB). The deficient practice posed a potential threat to the health and safety of residents.

Findings include:

1. Review of facility documentation revealed a policy titled "TB- Tuberculosis Screening and Risk Assessment Form (Infection Control Policy and Procedures)". A subsection to "TB-Tuberculosks Screening and Risk Assessment Form (Infection Control Policy and Procedures)" reveals that the facility did have a subpolicy titled "The facility will be assessed on an annual basis to determine TB risk". This policy includes the annual screening form. The manager failed to implement this portion of the policy.

2. Review of a personnel record revealed that the annual TB screening form had not been conducted for E3. E3 has had a history of positive TB skin tests.

3. In an interview, E1 acknowledged that the annual TB screening form had not been conducted for E3.