ROSEWOOD CARE HOME LLC

<p>Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for one of two residents sampled. </p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1 . A review of R2's medical record revealed documentation of an orientation completed was not available for review at the time of inspection. </p><p><br></p><p><br></p><p><br></p><p>2 . In an exit interview, the findings were discussed with E3 and no additional information was provided. </p>

<p>Based on observation and interview, the manager failed to ensure medication was stored in a separate <span style="background-color: rgb(255, 255, 255);">locked room, closet, cabinet, or self-contained unit used only for medication storage.</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">Findings include:</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">1 . During an environmental inspection of the facility, the Compliance Officer observed the refrigerator located by the front door of the facility. When the Compliance Officer opened the refrigerator, the bottom compartment had a lock, but was unlocked at the time of inspection. Inside the compartment, the Compliance Officer observed loose insulin and an unlocked blue lock box which contained more insulin. </span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">2 . In an exit interview, the findings were discussed with E3 and no additional information was provided. </span></p>

<p>Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1 . During an environmental inspection of the facility, the Compliance Officer observed a food menu posted. However, the food menu was dated September 1, 2025 through September 7, 2025.</p><p><br></p><p><br></p><p><br></p><p>2 . In an exit interview, the findings were discussed with E3 and no additional information was provided.</p>

Based on documentation review and interview, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager failed to comply with all of the requirements of this rule, which posed a health and safety risk.

Findings include:

1. A review of facility documentation revealed no documentation showing any allegations of abuse, neglect, or exploitation.

2. In an interview, E3 reported APS came to talk to E2 on July 25, 2023. E3 reported APS had not mentioned a resident name as one wasn't given, and the facility conducted an investigation on E2. However, E3 reported E3 had not documented the investigation.

3. In an interview, E3 acknowledged the facility had not documented the investigation.

Based on record review and interview, the manager failed to ensure a personnel record for each employee or volunteer was maintained for at least 24 months after the last date the individual provided services in or for the assisted living facility, for one of one former caregivers sampled The deficient practice posed a risk as required information could not be verified for E2.

Findings include:

1. A review of personnel records revealed a personnel record for E2 was not available for review at the time of inspection.

2. In an interview, E3 reported E1 had a personnel record for E2 but was unable to locate it.

3. In an interview, E3 acknowledged a personnel record for E2 was not maintained for at least 24 months after the last date the individual provided services in or for the assisted living facility.

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if employees or volunteers did not possess the skills and knowledge to ensure the health and safety of residents.

Findings include:

1. A review of the facility's policies and procedures revealed no documentation of a policy covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented.

2. In an interview, E2 acknowledged a policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented was not available for review at the time of the inspection.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for one of three sampled personnel members. The deficient practice posed a risk if an employee did not possess the skills and knowledge to meet the needs of residents.

Findings include:

1. A review of E3's personnel record revealed documentation of verification of skills and knowledge was not available for review at the time of inspection.

2. In an interview, E2 acknowledged E3's personnel record did not include documented verification of E3's skills and knowledge at the time of the inspection.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for two of three sampled personnel members. The deficient practice posed a potential TB exposure risk to residents.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(2)(a-b) states: "B. A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101."

2. A review of E1's and E3's personnel records revealed documentation of freedom from TB. However, documentation of TB screening was not available for review at the time of inspection.

3. In an interview, E1 acknowledged E1's and E3's personnel records did not contain documentation of TB screening at the time of the inspection.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a potential for physical injury and psychological distress.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-101(201) states: "Restraint" means "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body."

2. During the environmental inspection of the facility, the Compliance Officer observed R1's bed was pushed against the wall on one side and a bed rail, the length of the top half of the bed, was observed on the other side of the bed.

3. A review of R1's medical record revealed a document titled "Authorization for continued residency." The document stated "The resident is considered to be bedbound..."

4. In an interview, E2 reported the half rail bedrail was up to prevent R1 from falling out of bed. E2 acknowledged R1 was subjected to restraint.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for two of two sampled residents. The deficient practice posed a potential TB exposure risk to residents.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(2)(a-b) states: "B. A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101."

2. A review of R1's and R2's medical records revealed documentation of freedom from TB. However, documentation of TB screening was not available for review at the time of inspection.

3. In an interview, E1 acknowledged failure to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility.

Findings include:

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

2. During the environmental inspection of the facility, the Compliance Officer observed alerts placed on the front door and a door leading to the back yard. However, the alerts on each door were either turned off or not operational at the time of the inspection.

3. In an interview, E1 acknowledged means of exiting the facility did not control or alert employees of the egress of a resident from the facility at the time of the inspection.

Based on documentation review, observation, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident covering assistance in the self administration of medication and medication administration.

Findings include:

1. A review of the facility's polices and procedures revealed a document titled, "Medications," dated January 24, 2021. The policy stated, "...3. Whenever possible, written medication orders will be obtained prior to admission or by verbal order the day of admission:...d. The manager will obtain written...orders to verify the verbal orders within 14 working days. e. The unsigned copy of the verbal order shall be disposed of once the signed copy is obtained. 4. All resident medications must be secured in a locked storage area. Only the manager and trained caregivers shall be in possession of the keys to the facility's medication storage area...13. Any resident medications which is discontinued or expired by physician's order shall be offered back..., returned to the pharmacy or disposed of by flushing down the toilet..."

2. During a facility tour, the Compliance Officers observed the following medication in an unlocked kitchen cabinet:
-"Ciproflaxin 500 MG...Take 1 tablet by mouth twice daily for 7 days...;"
-Two bottles of "Polyeth Glyc Pow 3350 NF...Mix 17 GM...in 8 oz. of water and drink daily...;"
-"Klor-Con Powder...20 mEq...;"

3. During a facility tour, the Compliance Officers observed an unlabeled prescription bottle containing yellow capsules in another unlocked kitchen cabinet.

4. During a facility tour, the Compliance Officers observed the following medication in an unlocked kitchen refrigerator:
-"Lorazepam...2 mg per ml...;"
-"Morphine Sulfate Oral Solution...100 mg per 5 ml..."
-"Morphine 20mg/ml..."

5. During a facility tour, the Compliance Officers observed a prescription bottle, for R1, filled with white, round pills labeled "Midodrine HCL 5 MG Tablet..." .

6. A review of R1's medical record revealed a medication administration record (MAR) for the month of November 2022. The MAR revealed R1 was not administered "Midodrine HCL 5 MG Tablet..."

7. A review of R1's medical record revealed a document titled, "Resident Status Report," signed and dated by a medical practitioner on October 12, 2022. The report revealed R1 was not prescribed "Midodrine HCL 5 MG Tablet..."

8. A review of R2's medical record revealed a MAR for the month of November 2022. The MAR revealed R2 had been administered the following medications:
-"Aricept 10MG take 1 tab QD P.O. at bedtime;"
-"Aspirin 81MG take 1 tab chewable QD PO;"
-"Venlafaxine 75MG take 1 tab P.O. QD;"
-"Clonidine HCI 0.1MG Take 1 tab PO every 6 hours...PRN;"
-"Cyclobenzaprine HCI 5MG take 1 tab TID...;"
-"Dulcolax 10MG...PRN;"
-"Atorvastatin 40MG Take 1 tab QD PO at bedtime;"
-"Levatiraceta (sic) 100MG Take 15ml every 12 hours PO;"
-"Levothyroxin (sic) 150MCG Take 1 cap PO QD;"
-"Potassium Chloride 20 MEQ Take 1 tab BID PO;"
-"Lorazepam 0.5MG take 1 take every 4hr PRN PO;"
-"Tylenol 500MG Take 1 tab TID PO PRN"

9. A review of R2's medical record revealed a list of medications R2 received, signed and dated by an registered nurse on November 22, 2022. However, medication orders signed and dated by a medical practitioner were not available for review.

10. In an interview, E1 and E2 acknowledged the unlocked medications were accessible to residents. E1 reported a resident had passed away the morning of the inspection and that was why the "Lorazepam...2 mg per ml..., Morphine Sulfate Oral Solution...100 mg per 5 ml...," and "Morphine 20mg/ml..." were left unlocked.

11. In an interview, E1 reported the medication in the unlabeled bottle was Vitamin D and belonged to E1. E1 reported R1's "Midodrine HCL 5 MG Tablet..." was a medication R1 was admitted with but R1 did not receive. E1 reported this medication should have been discarded according to policies and procedures.

12. In an interview, E1 and E2 acknowledged medication orders for R2, signed by a medical practitioner, were not in R2's medical record.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the licensee did not provide the documentation at the exit interview.

Findings include:

1. A review of facility documentation revealed a policy and procedure for fall prevention and fall recovery was not available for review.

2. A review of facility documentation revealed a training program for fall prevention and fall recovery was not available for review.

3. A review of E1's and E2's personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review.

4. In an interview, E2 acknowledged a fall prevention and recovery training program had not been developed and administered to all staff.

Based on documentation review, observation, record review, and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education and experience for a caregiver. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the licensee did not provide the documentation at the exit interview.

Findings include:

1. A review of Department documentation revealed a license effective date of November 17, 2021 for AL12047.

2. The Compliance Officers observed E1 working alone at 9 AM.

3. A review of E1's personnel record revealed E1 was hired as a caregiver.

4. A review of the facility's policies and procedures revealed policies and procedures to cover qualifications, including required skills and knowledge, education and experience for a caregiver were not available for review.

5. In an interview, E2 acknowledged the policies and procedures to cover qualifications, including required skills and knowledge, education and experience required for a caregiver was not available for review.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for two of two personnel records sampled. The deficient practice posed a risk if E1 and E2 were unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the licensee did not provide the documentation at the exit interview.

Findings include:

R9-10-806.B.4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented before the caregiver or assistant caregiver provides physical health services or behavioral health services, and according to policies and procedures.

1. A review of E1's (hired in 2021) personnel record revealed the record did not include evidence of E1's qualifications, including skills and knowledge applicable to E1's job duties.

2. A review of E2's (hired in 2021) personnel record revealed the record did not include evidence of E2's qualifications, including skills and knowledge applicable to E2's job duties.

3. In an interview, E1 and E2 acknowledged E1's and E2's personnel records did not contain verification of E1's and E2's qualifications, including skills and knowledge, applicable to E1's and E2's job duties.

Based on observation, documentation review, record review, and interview, the manager accepted an individual without the ability to provide the assisted living services needed by the individual, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. The Compliance Officers observed E1 working alone at 9 AM.

2. The Compliance Officers observed E2 arrive at the facility at approximately 11 AM.

3. A review of documentation revealed the facility's employee shift schedule. The schedule revealed only two employees were scheduled for the full month of November 2022; E2 worked the 7am to 7pm shift, and E1 worked 7pm to 7am shift.

4. A review of R1's medical record revealed a discharge report from a hospital. The report stated "Physical Therapy: Have two staff members present to assist you with transfers and bed mobility."

5. In an interview, E1 reported E1 and E2 were both on the premises to assist as needed, despite the posted schedule documenting only one caregiver was working per shift.

Based on observation, record review and interview, the manager failed to ensure a resident was not subjected to restraint, for one of two residents sampled. The deficient practice posed an injury risk to R1.

Findings include:

1. The Compliance Officers observed R1's bed to have two bedrails, combined, measured the length of the bed.

2. A review of R1's medical record revealed a discharge report from a hospital. The report stated "Physical Therapy: Have two staff members present to assist you with transfers and bed mobility."

3. In an interview, E1 and E2 acknowledged the full bedrails on R1's bed, and reported R1 had recently been discharged from the hospital from having kidney and gall bladder surgery. E1 and E2 stated R1 was "full code," R1 could not move or get out of bed, and the bed rails were being used to ensure R1 didn't fall or move and rupture R1's incision.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the 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 Officers observed an unlocked cabinet under the kitchen sink. The cabinet did not contain a locking device. The cabinet contained "Clorox" spray, "Windex" spray, "Febreze" spray, "Pledge" spray, and "Kirkland" dishwasher pacs. The items contained toxic warning labels.

2. The Compliance Officers observed an unlocked cabinet under the common bathroom sink. The lock on the cabinet was broken. The cabinet contained "Lysol" toilet bowl cleaner. The item contained a toxic warning label.

3. The Compliance Officers observed "Clorox" spray and "Febreze" in a hallway bathroom, on a counter. The items contained toxic warning labels.

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