Baraka at Rosegarden Assisted Living

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for two of two residents sampled. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. A review of R1's medical record revealed a written service plan for personal care services dated May 19, 2025. However, the service plan did not include a signature and date from the resident or representative. 2. A review of R2's medical record revealed a written service plan for directed care services dated June 04, 2025. However, the service plan did not include a signature and date from the resident or representative. 3. In an interview, E1 acknowledged that R1's and R2's service plans did not include a signature and date from the resident or representative.

Based on the documentation review, record review, and interview the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9) for two of two residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: -1. The reason or reasons the emergency responder was requested on behalf of the resident. -2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. -3. The name, address and telephone number of the resident's current pharmacy. -4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. -5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. -6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. -7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. -8. A copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. -9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of the medical records for R1 and R2 did not include a standardized form for each resident that included the information as required in A.R.S. 36-420.04(A)(1) through (9). 3. In an interview, E1 acknowledged that the documentation provided to the Compliance Officers was blank and not prefilled with the required information as prescribed in A.R.S. § 36-420.04(A).

Based on documentation review and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented and implemented tuberculosis (TB) infection control activities required in R9-10-113(A)(2)(d). Findings include: 1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis per R9-10-113(A)(2)(d) was available for review. 2. In an interview, E1 acknowledged that the health care institution had no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis per R9-10-113(A)(2)(d) available for review.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver, for two of three assistant caregivers reviewed. The deficient practice posed a risk as the individuals were not qualified to provide the required services, and the department was provided false and misleading documentation. Findings include: 1. A review of Department records revealed the facility is licensed at the directed care level. 2. A review of A.R.S. § 36-401.A.49 revealed "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 3. When the Compliance Officers arrived at the facility on June 26, 2025, the manager was not present. E3 and E4 were the only personnel at the facility providing services to residents. E1 arrived at the facility a few minutes after. 4. In an interview, E1 reported E3 and E4 were all licensed caregivers. 5. A review of department documentation revealed a police report received on July 07, 2025. The police report reported that E3 and E5 had provided false identification to the Police Officer, and E3’s and E5’s real identities were E6 and E8. 6. On July 14, 2025, the Compliance Officers conducted a follow-up inspection. When the Compliance Officers arrived at the facility, E3 and E4 were the only personnel at the facility. 7. In an interview, E3 and E4 reported that their actual identities were E6 and E7. 8. A few minutes after the Compliance Officers arrived, E2 arrived and reported that on June 26, 2025, E1 had provided fake personnel files for E6 and E7, and E6 and E7 were assistant caregivers. 9. A review of the personnel records revealed no personnel records for E6 and E7. 10. In an interview on July 14, 2025, E2 acknowledged that E6 and E7 interacted with residents without the supervision of a manager or caregiver. E2 also acknowledged that E1 had provided false and misleading documentation by providing fake personnel files for E6 and E7 as licensed caregivers.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents, and the department was provided with false and misleading documentation. Findings include: 1. When the Compliance Officers arrived at the facility on June 26, 2025, the manager was not present. E3 and E4 were the only personnel at the facility providing services to residents. E1 arrived at the facility a few minutes after. 2. During the environmental tour, the Compliance Officers observed that there was a work schedule posted for the month of June. However, E3, E4, and E5 were on the posted work schedule. 3. A review of department documentation revealed a police report received on July 07, 2025. The police report reported that E3 and E5 had provided false identification to the Police Officer, and E3’s and E5’s real identities were E6 and E8. 6. On July 14, 2025, the Compliance Officers conducted a follow-up inspection. When the Compliance Officers arrived at the facility, E3 and E4 were the only personnel at the facility. 7. In an interview, E3 and E4 reported that their actual identities were E6 and E7, and that E5 was actually E8. 8. A few minutes after the Compliance Officers arrived, E2 arrived and reported that on June 26, 2025, E1 had provided fake personnel files for E6, E7, and E8, and E6 and E7 were assistant caregivers. 9. A review of the work schedule posted for June 2025 was false, and E6, E7, and E8 were not on the work schedule posted for June. 10. In an interview, E2 acknowledged that documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked, and the department was provided false and misleading documentation.

Based on observation, record review, and interview, the manager failed to ensure that a trained caregiver was present on the assisted living facility's premises when the manager was not present. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs, and the department was provided false and misleading documentation. Findings include: 1. When the Compliance Officers arrived at the facility on June 26, 2025, the manager was not present. E3 and E4 were the only personnel at the facility providing services to residents. E1 arrived at the facility a few minutes after. 2. In an interview, E1 reported E3 and E4 were all licensed caregivers. 3. A review of department documentation revealed a police report received on July 07, 2025. The police report reported that E3 and E5 had provided false identification to the Police Officer, and E3’s and E5’s real identities were E6 and E8. 4. On July 14, 2025, the Compliance Officers conducted a follow-up inspection. When the Compliance Officers arrived at the facility, E3 and E4 were the only personnel at the facility. 5. In an interview, E3 and E4 reported that their actual identities were E6 and E7. 6. A few minutes after the Compliance Officers arrived, E2 arrived and reported that on June 26, 2025, E1 had provided false personnel files for E6, E7, and E8, and E6 and E7 were assistant caregivers. 7. A review of E6's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. In addition, E6's record did not include documentation that showed an administrator's license, a nursing license, or employment as a caregiver prior to November 1, 1998. Therefore, E6 was not qualified to be left alone with the residents based on the lack of caregiver training. 8. A review of E7's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. In addition, E7's record did not include documentation that showed an administrator's license, a nursing license, or employment as a caregiver prior to November 1, 1998. Therefore, E7 was not qualified to be left alone with the residents based on the lack of caregiver training. 9. In an interview on July 14, 2025, E2 stated E6 and E7 were not caregivers and worked as assistant caregivers, and E2 acknowledged neither a manager nor a caregiver was present at the facility when the Compliance Officers arrived on June 26, 2025, and July 14, 2025.

Based on observation, record review, and interview, the manager failed to ensure a complete personnel record was available for three of eight personnel sampled. The deficient practice posed a risk as required information could not be verified, and the department was provided false and misleading documentation. Findings include: 1. When the Compliance Officers arrived at the facility on June 26, 2025, the manager was not present. E3 and E4 were the only personnel at the facility providing services to residents. E1 arrived at the facility a few minutes after. The Compliance Officers requested to review E1, E3, E4, and E5's personnel records. 2. In an interview, E1 reported E3, E4 and E5 were all licensed caregivers. 3. A review of department documentation revealed a police report received on July 07, 2025. The police report reported that E3 and E5 had provided false identification to the Police Officer, and E3’s and E5’s real identities were E6 and E8. 4. On July 14, 2025, the Compliance Officers conducted a follow-up inspection. When the Compliance Officers arrived at the facility, E3 and E4 were the only personnel at the facility. The Compliance Officers requested to review E3, E4, E5, E6, E7, and E8's personnel records. 5. In an interview, E3 and E4 reported that their actual identities were E6 and E7. 6. A few minutes after the Compliance Officers arrived, E2 arrived and reported that on June 26, 2025, E1 had provided fake personnel files for E6, E7, and E8. In an interview, E2 also reported that E3 was terminated in January 2024, E4 was terminated in December 2024, and E5 was terminated in June 2024. 7. A review of the personnel records revealed no personnel records for E6, E7, and E8. 8. In an interview on July 14, 2025, E2 acknowledged that there were no personnel records available for E6, E7, and E8. E2 also acknowledged that E1 had provided false and misleading documentation by providing fake personnel files for E6, E7, and E8.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the manager, for two of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a written service plan for personal care services dated May 19, 2025. However, this service plan did not include a signature and date from the manager. 2. A review of R2's medical record revealed a written service plan for directed care services dated June 04, 2025. However, this service plan did not include a signature and date from the manager. 3. In an interview, E1 acknowledged that R1's and R2's service plans did not include a signature and date from the manager.

Based on observation, documentation review, and record review, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. When the Compliance Officers arrived at the facility on June 26, 2025, the manager was not present, and E3 and E4 were the only personnel providing services to residents. 2. A review of department documentation revealed a police report received on July 7, 2025, which stated that E3 and E5 had provided false identification to the responding officer. The report identified E3 and E5’s actual identities as E6 and E8. 3. On July 14, 2025, during a follow-up inspection, the Compliance Officers again observed that E3 and E4 were the only personnel present at the facility. The Compliance Officers later determined that E3, E4, and E5 were actually E6, E7, and E8 using false identities. 4. A review of the personnel records revealed no personnel records for E6, E7, and E8. E6 and E7 were assistant caregivers. 5. In an interview, E2 reported that both E1 and E2 were aware that false identifications were provided to E6, E7, and E8. 6. The Compliance Officers determined that allowing assistant caregivers to provide care under false identities, and E1 and E2’s involvement in providing those false identifications to E6, E7, and E8, failed to ensure the residents’ right to be treated with dignity, respect, and consideration.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual administering medication, for two of two residents sampled. The deficient practice posed a risk as the required information could not be verified, and the Department was provided false or misleading information. Findings include: 1. When the Compliance Officers arrived at the facility on June 26, 2025, the manager was not present, and E3 and E4 were the only personnel providing services to residents. A review of department documentation revealed a police report received on July 7, 2025, which stated that E3 and E5 had provided false identification to the responding officer. The report identified E3 and E5’s actual identities as E6 and E8. On July 14, 2025, during a follow-up inspection, the Compliance Officers again observed that E3 and E4 were the only personnel present at the facility. The Compliance Officers later determined that E3, E4, and E5 were actually E6, E7, and E8 using fake identities. 2. A review of the personnel records revealed no personnel records for E6 and E8; however, E6 and E8 were assistant caregivers. 3. A review of R1's and R2's service plans revealed that they received medication administration. 4. A review of R1's and R2's medical records revealed medication administration records (MAR) for May and June 2025. The Compliance Officers observed that all medications documented as administered to R1 and R2 in May and June 2025 were documented using the same initials, indicating the same personnel member administered all medications, which were E3 and E5. However, E3 was terminated in January 2024, and E5 was terminated in June 2024. 5. In an interview, E2 acknowledged that R1's and R2's MARs did not contain documentation of medication administered that included the name and signature of the individual who actually administered the medication, and the Department was provided false or misleading information.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R2's medical record revealed R2 was offered the flu and pneumonia vaccines in 2022 and 2023. However, documentation of additional offers was not available for review. 3. In an interview, E1 acknowledged R2's medical record did not contain documentation of R2's notification of the availability of vaccinations according to A.R.S. § 36-406(1)(d).

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, every six months, 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 one resident reviewed who was 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 reported R2 was non-ambulatory and received Directed Care Services. 2. A review of R2's medical record revealed a service plan dated June 04, 2025. The service plan stated R2 was "Non-Ambulatory, Can't Self-propel, Exempt from evacuation drill/order by PCP." 3. A review of R2's medical record revealed a written determination from R2's medical practitioner, signed and dated May 26, 2023, and November 26, 2023. However, no additional documentation stating R2's medical practitioner examined R2 every six months, signed and dated a determination that stated R2's needs could be met by the facility, and reviewed the facility's scope of services. 4. In an interview, E1 acknowledged that R2's medical practitioner did not provide a written determination at least once every six months.

Based on observation and interview, the manager failed to ensure there was a current drug reference guide that was available for use by personnel members. This posed a health and safety risk to the resident if the caregiver was unable to reference a medication a resident was taking. Findings include: 1. During the environmental tour, the Compliance Officers observed that the facility was providing medication administration services. 2. The Compliance Officers requested the current drug reference guide. However, the drug reference guide was not provided for the department to review. 3. In an interview, E1 acknowledged that the facility did not have a drug reference guide available for use by personnel members.

Based on observation, record review, documentation review and interview, for one of two residents sampled, who received a controlled substance, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility. Findings include: 1. During an observation of R2’s medications, the Compliance Officer observed that the medications included controlled substances. 2. A review of R2's medical record revealed medication orders that included the following prescribed medication: - Lorazepam – 1 mg, take ½ tab PO three times daily (8 AM, 1 PM, 7 PM) 3. In an interview, E1 reported that the facility does not inventory controlled substances. 4. A review of the facility's policies and procedures revealed a policy titled "26. Medications - E. Controlled Substances - 3) Inventorying." The policy stated: "a. There are no additional rules required for inventorying narcotic medications other than R9-10-816(E) item (3) above. Some facilities elect to have narcotic medication counted with at least two individuals present. b. This facility [blank box] elects to have two individuals present or [blank box] does not elect to have two individuals present for counting narcotic medication." Additionally, a handwritten note on the policy read, "Do not count narcotics." 5. In an interview, E1 acknowledged that the policies and procedures were not implemented for inventorying controlled substances.

Based on observation, documentation review, and interview, the manager failed to ensure a resident bedroom was not used as a passageway to a common area or another sleeping area. The deficient practice posed a potential privacy rights violation to the resident. Findings include: 1. During the environmental inspection, the Compliance Officers observed the master bedroom, bathroom, and closet occupied by two residents. The Compliance Officers observed a bed, luggage, and personal belongings in the closet. 2. In an interview, E1 and E6 reported that E6 slept in the master bedroom closet. 3. A review of Department documentation revealed AL7402 was licensed in 2017. 4. In an interview, E1 acknowledged that E6 slept in the master bedroom closet, and a resident bedroom was used as a passageway to another sleeping area.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled or alerted employees of 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. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the facility tour, the Compliance Officer observed the door leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard did not control or alert employees of the egress of a resident from the facility. 3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated June 7, 2024. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders for the following medications: -Polyethylene Glycol 3350 (Miralax OTC Powder), mix one capful (17 grams) in 8 oz of fluid and drink by mouth once daily; -Aspercreme Lidocaine 4%, apply topically to bilateral feet twice daily; -Ear drops 6.5% drops, instill 5 drops into both ears twice daily x4 days every month; -Morphine Sulf ER 15 MG TA, take one tablet by mouth twice daily; -Senna 8.6 MG tablet, take one tablet by mouth twice daily; -Tizanidine HCL 4 MG, take one tablet by mouth twice daily in the morning and noon...; and -Carbidopa-Levodopa 25-100, take one tablet by mouth four times daily. However, the September 2024 medication administration record (MAR) did not indicate the aforementioned medications had been administered at 8 pm on September 1st - present. 3. Review of R2's medical record revealed a current written service plan dated June 7, 2024. This service plan indicated R2 received medication administration. 4. Review of R2's medical record revealed a signed medication order for the following: -Aripiprazole 10 MG, take one tablet by mouth daily in the morning; -Polyethylene Glycol 3350, mix one capful (17 grams) in 8 OZ of water and drink by mouth once daily; -Divalproex Delayed 125 MG, take 1 tablet by mouth twice daily; -Lorazepam 1 MG, take 1/2 tablet by mouth twice daily; -Methenamine HIPP 1 GM, take 1 tablet by mouth ever 12 hours; -Risperidone 1 mg, take 1 tablet by mouth twice daily; -Trazodone 50 MG, take 1 tablet by mouth twice daily at 2 PM and at bedtime; -Mirtazapine 15 MG, take 1/2 tablet by mouth at bedtime; -Senna 8.6 mg, take 1 tablet by mouth at bedtime; and -Quetiapine 50 mg, take one and a half by mouth 3 times daily. However, the September 2024 MAR did not indicate the aforementioned medications had been administered at 8 pm on September 1st - present. 5. In an interview, E1 reported the medications were administered per the medication orders and acknowledged R1's and R2's medical record did not include documentation the medications were administered.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer. The deficient practice posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a refrigerator in the kitchen which stored food and medication. However, the refrigerator did not contain a thermometer. 2. In an interview, E1 acknowledged the kitchen refrigerator did not contain a thermometer.

Based on observation and interview, the manager failed to ensure a bathroom accessible from the common area contained paper towels or a mechanical air dryer. The deficient practice posed a potential risk to infection control. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed no paper towel dispenser or mechanical air dryer in the common area bathroom used by residents. 2. During an interview, E1 acknowledged there were no paper towels or mechanical air dryer in the bathroom.