Desert Rose Assisted Living LLC

Based on record review and interview, the assisted living home failed to maintain written documentation of emergency responder (EMS) documentation that included the items listed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R1’s medical record revealed no copy of the document provided to EMS for the incident on September 12, 2025. 2. A review of R2’s medical record revealed no standardized EMS documentation. 3. In an interview, E1 acknowledged that R1 did not have EMS documentation for the incident on September 12, 2025. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment. 2. In an interview, E1 acknowledged that the annual assessment of the facility's TB risk assessment was not completed. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for three of the three employees sampled. The deficient practice posed a potential TB exposure risk to residents and false or misleading information was provided to the Department. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) test is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of the facility’s policies and procedures revealed a blank copy of “Annual Tuberculosis Symptom Screen” prefilled with a digital signature of O1 with no dates. 4. The Compliance Officer observed E1 and E2 providing services to the resident during the inspection. 5. A review of the facility’s scheduled work hours revealed the following: E1 was listed to work Monday to Saturday, all day. E2 was listed to work Sunday to Friday, all day. E3 was listed to work Saturday to Sunday, all day. 6. A review of E1's personnel record revealed E1’s hire date of February 1, 2023. In addition, the following was revealed: No documentation of TB risk assessment. An “Annual Tuberculosis Symptom Screen” dated March 10, 2025. However, the signatures of E1’s and O1’s appeared falsified as they were not original, the same as the one prefilled “Annual Tuberculosis Symptom Screen” in the policies and procedures, and the same in all the employee records reviewed. The date of May 10, 2025 was written in a pen. 7. A review of E2's personnel record revealed E2’s hire date of February 1, 2023. In addition, the following was revealed: One negative TB test dated after E2's date of hire. No documentation of TB risk assessment. An “Annual Tuberculosis Symptom Screen” dated February 1, 2025

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a TB exposure risk to residents and false or misleading information was provided to the Department.  Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the facility’s policies and procedures revealed a blank copy of “Annual Tuberculosis Symptom Screen” prefilled with a digital signature of O1 with no dates. 3. A review of R1’s medical record revealed “Annual Tuberculosis Symptom Screen” signed by R1. However, the signature of O1 appeared falsified as it was not original, the same as the one prefilled “Annual Tuberculosis Symptom Screen” in the policies and procedures. 4. In an interview, E1 acknowledged that the document titled "Annual Tuberculosis Symptom Screen" for R1 was not original and contained a prefilled photocopied signature. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that, when initially developed, was signed and dated by the resident or the resident's representative, the manager, and the nurse who reviewed the service plan, for one of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements and false or misleading information was provided to the Department. Findings include: 1. A review of R2’s medical record revealed the following: A current service plan dated May 27, 2025. The service plan indicated that R2 received medication administration. On the service plan signature page, O1, E1, and R2’s representative signatures appeared to be photocopied and appeared to be identical to those on the November 27, 2024 service plan. The signatures did not show any new ink marks. The previous service plan was dated November 27, 2024. The service plan indicated that R2 received medication administration. On the service plan signature page, O1, E1, and R2’s representative signatures appeared to be photocopied. The signatures did not show any new ink marks. 2. In an interview, R2 reported that R2 had not seen the doctor since R2 had moved in. R2 also reported that R2’s family member visits every Wednesday. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2), 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. A review of R2's medical record revealed the following: A current written service plan dated May 27, 2025. The service plan indicated that R2 was bedbound/Hoyer lift. A document “Certification for Non-ambulatory residents to reside in the group home” dated 1/29/2024 and signed by O1. In addition, E1 signed for R2’s representative. No further documentation for continued residency. 2. In an interview, E1 acknowledged that E1 signed for R2’s representative on “Certification for Non-ambulatory residents to reside in the group home.” In addition, E1 acknowledged that R2 did not have any further documentation for continued residency. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider for one of two residents sampled. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1’s medical record revealed a progress note for September 12, 2025 that stated, “Had to call 911 for [R1]. [R1] was very weak to stand and disoriented. Was confined to Dignity Health.” 2. In an interview, E1 reported that the primary care provider was contacted the week of October 6, 2025. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of two resident. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1’s medical record revealed a progress note for September 12, 2025 that stated, “Had to call 911 for R1. [R1] was very weak to stand and disoriented. Was confined to Dignity Health.” 2. In an interview, E1 acknowledged that the only documentation of the emergency was in the progress note and was missing the time of the incident, the names of individuals who observed, and any action taken to prevent the incident from occurring in the future. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.