Haven at Rose Garden LLC

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for two of three sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of Department documentation revealed a Settlement Agreement with an execution date of December 23, 2024. Term #13 of the agreement stated, “Applicant shall…ensure that all signatures on TB documentation are wet signatures for the next two (2) years." 2. A review of facility documentation revealed a policy and procedure (P&P) titled “TUBERCULOSIS (TB) TESTING.” The P&P stated, “The manager or manager designee shall…document this facility’s annual assessment of the risk of exposure to infectious TB, including documentation for each individual required to be screened for infectious TB that indicates the individual’s freedom from symptoms of infectious TB, and has a wet signature by a MP or LHP.” 3. A review of E1’s, E4’s, E5’s, E6’s, E7’s, and E8’s personnel records revealed copies of TB documentation instead of originals with wet ink signatures. 4. In an interview, E2 reported having requested and received the original TB documents from the individual(s) who created the documents. E2 reported E2 received some of the original documents with the wet ink signatures. However, E2 confirmed E2 did not verify E2 received all of the requested documents. 5. A review of R2’s and R3’s medical records revealed R2 and R3 were accepted into the facility more than seven days before the date of the inspection. However, the review revealed copies of TB documentation instead of originals with wet ink signatures. The review further revealed no baseline screening consisting of assessing risks of prior exposure to infectious tuberculosis and determining if R2 and R3 had signs or symptoms of tuberculosis. 6. In an interview, E1 reported R2 and R3 did not have documentation of baseline screening consisting of assessing risks of prior exposure to infectious tuberculosis and determining if R2 and R3 had signs or symptoms of tuberculosis.

Based on documentation review, record review, observation, and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as residents were alone with an individual who was not a certified caregiver. Findings include: 1. Arizona Revised Statutes § 36-401(A)(49) states, "'Supervision' means directly overseeing and inspecting the act of accomplishing a function or activity." 2. A review of E8’s personnel records revealed E8 was hired as an assistant caregiver. The review further revealed no documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). 3. A review of the caregiver certificate verification website (azcg.tmutest.com) revealed no valid caregiver certificate under E8's name. 4. On several occasions during the inspection, the Compliance Officer observed E8 interacting with residents while not under the supervision of a manager or caregiver. 5. In an interview, the Compliance Officer brought the issue to E1’s attention and E1 stated, “Okay.” 6. On several occasions after the interview, the Compliance Officer observed E8 again interacting with residents while not under the supervision of a manager or caregiver. 7. In an interview, E2 reported R3 often had sudden loud outbursts at night that required the attention of the caregiver. E2 reported the assistant caregivers would then check on and attend to the other residents while the caregiver was with R3.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for two of three sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. A review of R2’s medical record revealed a service plan dated July 18, 2025, which indicated R2 was to receive showers two times weekly. The review revealed two sets of documentation of assisted living services provided to R2 (ADLs) dated July 2025. The first set of July ADLs revealed documentation demonstrating R2 received showers on July 6-7, 2025. The second set revealed documentation demonstrating R2 received showers on July 10, 14, 18, and 22, 2025. The review revealed no ADLs dated August 2025. 2. In an interview, when the Compliance Officer asked how many showers R2 received in July 2025, E1 stated, “Two.” E1 reported R2 received two showers in early July then wanted sponge baths in bed instead. When the Compliance Officer asked why the service plan included showers even after R2 wanted to switch to sponge baths, E1 offered no comment. 3. A review of R3’s medical record revealed a service plan dated May 18, 2025, which indicated R3 was to receive bed baths every day. The review revealed ADLs dated August 2025. However, the ADLs revealed documentation demonstrating R3 received no bed baths in August 2025. 4. In an interview, E1 reported R3 received a shower on August 2, 2025, and a bed bath on August 5, 2025. When the Compliance Officer asked if R3 had received bed baths on any other days in August, E1 stated, “No.”

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of three sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R3's medical record conducted at approximately 12:30 PM revealed documentation of assisted living services provided to R3 (ADLs) dated August 2025. However, the ADLs revealed no documentation demonstrating whether R3 received any services on August 6, 2025, other than group exercises in the morning and afternoon. The ADLs further revealed no documentation of R3 having received a bed bath on any day in August. 2. In an interview, E1 confirmed facility personnel had not yet documented the services provided to R3 on August 6, 2025. E1 further reported R3 had received a bed bath on August 5, 2025. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on June 5, 2025.

Based on record review, interview, and observation, the manager failed to ensure a resident’s medical record contained documentation of assisted living services provided to the resident, for two of three sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a current service plan. The service plan indicated hospice was to give R1 a bed bath every day. The review revealed documentation of assisted living services provided to R1 (ADLs) dated July 2025. The ADLs revealed documentation demonstrating facility personnel gave R1 bed baths on July 1-31, 2025, contrary to the service plan stating R1’s bed baths were to be given by hospice. The review further revealed ADLs dated August 2025. The ADLs stated R1 “Moved out…[at] 4:30 PM” on R1’s date of termination of residency. However, the ADLs revealed documentation demonstrating R1 received “Oral Care-Brush Teeth PM,” dinner, and an after-dinner snack on the date of R1’s termination of residency. 2. In an interview, when the Compliance Officer asked who gave R1’s bed baths, E1 stated, “Hospice.” E1 confirmed facility personnel were documenting the bed baths on the ADLs though facility personnel did not give them. E1 reported hospice came three times a week to give R1 bed baths. When the Compliance Officer mentioned bed baths having been documented daily on the ADLs and not three times a week, E1 offered no comment. E1 reported R1 left the facility on the date of R1’s termination of residency before evening oral care, dinner, and the after-dinner snack. 3. A review of R3's medical record conducted at approximately 11:00 AM revealed ADLs dated August 2025. The ADLs revealed documentation demonstrating R3 participated in “GROUP EXERCISES” in the morning and afternoon on August 1-6, 2025, even though the review took place before the afternoon of August 6, 2025. The ADLs further revealed documentation R3 received showers on August 2 and 5, 2025, but no bed baths at all in August. 4. In an interview, when the Compliance Officer asked what type of group activities the facility put on, E1 reported the residents sat at the dining room table and talked. When the Compliance Officer explained talking was not a group exercise, E1 offered no comment. When the Compliance Officer asked if R3 participated in a group exercise or group activity the morning of the inspection, E1 stated, “No.” E2 then reported the last activity that E1 considered a group exercise occurred on August 4, 2025. When the Compliance Officer pointed out the group exercise for the afternoon of August 6, 2025, being documented for a future time, E1 offered no comment. E1 reported R3 last received a shower on August 2, 2025, and not on August 5, 2025, as stated on the ADLs. E1 further reported R3 received a bed bath on August 5, 2025, even though facility personnel had not documented the service. 5. The Compliance Officer obser

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and incontinence care that ensured a resident maintained the highest practicable level of independence when toileting, for one of one sampled resident receiving personal care services. Findings include: 1. A review of R2’s medical record revealed a service plan dated July 18, 2025, which indicated R2 was to receive personal care services. The service plan included sections regarding “Skin condition” and “Elimination.” However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and incontinence care that ensured R2 maintained the highest practicable level of independence when toileting. 2. In an interview, E1 and E2 confirmed R2’s service plan did not include all items required by this rule.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and incontinence care that ensured a resident maintained the highest practicable level of independence when toileting, for two of two sampled residents receiving directed care services. Findings include: 1. A review of R1’s medical record revealed a service plan dated May 12, 2025, which indicated R1 was to receive directed care services. The service plan included sections regarding “Skin condition” and “Elimination.” However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and incontinence care that ensured R1 maintained the highest practicable level of independence when toileting. 2. A review of R3’s medical record revealed a service plan dated May 18, 2025, which indicated R3 was to receive directed care services. The service plan included sections regarding “Skin condition” and “Elimination.” However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and incontinence care that ensured R3 maintained the highest practicable level of independence when toileting. 3. In an interview, when the Compliance Officer asked if R1’s and R3’s service plans included all items required by this rule, E1 stated, “No.” E2 confirmed R1’s and R3’s service plans did not include all items required by this rule.

Based on documentation review, observation, and interview, the manager failed to ensure 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 monitored 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 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. The Compliance Officer observed a sliding glass door leading from the living room to the back yard. However, the Compliance Officer observed no alert or monitoring method present. During the course of the inspection, the Compliance Officer observed several instances of residents going out the door with no personnel present. 3. In an interview, E2 reported the door had an alert installed, but stated, “It fell off the door.”

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for three of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a current service plan which indicated R1 received medication administration. The review revealed a medication order for “IPRAT_ALBUT 0.5-3(2.5) MG/3 ML…1 Solution RESPIRATORY (INHALATION)...every 12 hours scheduled” dated June 11, 2025. The review further revealed a medication administration record (MAR) dated July 2025. However, the MAR revealed no documentation demonstrating facility personnel administered R1’s “IPRAT-ALBUT” on July 1-31, 2025. 2. In an interview, E1 confirmed facility personnel did not administer R1’s “IPRAT-ALBUT” in July, stating, “[R1] didn’t want it.” 3. A review of R2’s medical record revealed a current service plan which indicated R2 received medication administration. The review revealed the following medication orders: - “Amoxicillin-clavulanate 875 mg-125 mg oral tablet…1 tab Oral Q12H,x10 days” dated July 15, 2025; - “Gabapentin 100 mg oral capsule…1 cap Oral QBedtime, x30 days” dated July 4, 2025; - “Gabapentin 300 mg capsule 1 PO QHS” with a “Date Started” of July 15, 2025; - “Metronidazole 500 mg tabletQ12H” with a “Date Started” of July 15, 2025; - “Miralax [polyethylene glycol] 17 gram oral powder Daily” with a “Date Started” of July 15, 2025; and - “Pepcid [famotidine] 20 mg oral tablet…1 tab Oral BID,x7 days” dated July 15, 2025. The review revealed a series of MARs dated July 2025 which revealed the following: - R2 received amoxicillin-clavulanate at 8:00 AM on July 16-22, 2025, and at 8:00 PM on July 15-22, 2025, instead of for ten days as ordered; - R2 did not receive gabapentin 100 mg in July 2025; - R2 received gabapentin 300 mg on July 5-14, 2025, without an order; - R2 did not receive gabapentin 300 mg on July 31, 2025; - R2 did not receive metronidazole in July 2025; - R2 did not receive polyethylene glycol in July 2025; and - R2 received amoxicillin-clavulanate at 8:00 AM on July 16-20 and 22, 2025, and at 8:00 PM on July 15-22, 2025, instead of for seven days as ordered. 5. A review of R3’s medical record conducted at approximately 11:00 AM revealed a current service plan which indicated R3 received medication administration. The review revealed a medication order for “Acetaminophen 500 MG tablet…1 Tablet ORAL every 6 hours” with an “Order Date” of July 2, 2025, as well as medications orders for scheduled amlodipine, aspirin, insulin, lorazepam, metoprolol, morphine, pantoprazole, quetiapine, senna, and trazodone. The review revealed a MAR dated August 2025. The MAR revealed R3 received acetaminophen at 8:00 AM, 2:00 PM, and 8:00 PM on August 1-5, 2025. However, the MAR revealed R3 received no medications on August

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of three sampled residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency. Findings include: 1. A review of R1's medical record revealed a current service plan which indicated R1 was to receive medication administration. The review further revealed several medication orders. However, the review revealed no medication administration record (MAR) dated August 2025. 2. In an interview, E1 confirmed R1 received medication administration. E1 reported R1’s physician had been in the process of changing R1’s medication regimen near the end of July so E1 did not create a MAR for August 2025. E1 reported R1 facility personnel administered R1’s medication in August but did not document it. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on June 5, 2025.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. The Compliance Officer observed an unlocked door leading into the laundry room. Inside the laundry room, the Compliance Officer observed an unlocked refrigerator with a medication lock box inside. However, the lock was set to the code and the box was unlocked. Inside the box, the Compliance Officer observed a variety of resident medications, including acetaminophen, bisacodyl, insulin, lorazepam, and morphine. 2. In an interview, E2 confirmed the medication lock box was set to the code and was unlocked.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to residents with access to the poisonous or toxic materials. Findings include: 1. The Compliance Officer observed an unlocked cabinet above the toilet in an unlocked bathroom accessible to residents. Inside the cabinet, the Compliance Officer observed a magnet used to unlock cabinets. Next to the sink, the Compliance Officer observed a locked cabinet. However, upon unlocking the cabinet with the accessible magnet key and opening the cabinet, the Compliance Officer observed a spray can of air freshener. 2. In an interview, E2 acknowledged the magnet key and air freshener were accessible to residents. 3. The Compliance Officer observed an unlocked door leading into the laundry room. The Compliance Officer observed an unlocked cabinet in the laundry room. Inside the cabinet, the Compliance Officer observed air freshener, laundry whitener, and stain remover. The Compliance Officer further observed air freshener on the washer and dryer units as well as on an end table. 4. In an interview, E2 reported the laundry room should have been locked. E2 reported E2 had been having troubles with the lock on the door recently and needed to replace it. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on June 5, 2025.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for one of six sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(1) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency.” 2. A review of E5's personnel record revealed E5 was hired as a caregiver. The review revealed documentation of previous employers. However, the review revealed documentation demonstrating facility personnel only contacted one previous employer and not more than one as required by statute. 3. In an interview, E1 reported E1 contacted two of E5’s previous employers but only documented one.

Based on observation, record review, and interview, the manager failed to ensure a resident’s medical record contained documentation of assisted living services provided to the resident, for one of eight sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. Shortly after entering the home, the Compliance Officer observed E1 documenting in a binder containing documentation of assisted living services provided to the residents (ADLs). 2. A review of R5's medical record conducted at approximately 5:00 PM revealed ADLs dated June 2025. The ADLs revealed documentation demonstrating R5 had already received dinner, an after-dinner snack, PM oral care, and night checks at 9:00 PM and 11:00 PM on the date of the inspection, even though all such events were in the future. 3. In an interview conducted at approximately 5:00 PM, when the Compliance Officer asked whether the residents had eaten dinner, E1 stated, “No.” When the Compliance brought the aforementioned documentation issues to E1’s and E2’s attention, E2 turned to E1 and stated, “You can’t sign off saying you did something if you didn’t do it,” to which E1 replied, “I’m already here.” E1 reported E1 had signed off on all PM care for R5 since E1 was planning on providing those services. E1 reported the Compliance Officer entered the home in the middle of E1 documenting ADLs for all residents.

Based on observation, 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 date and time of administration or assistance, for three of eight sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. Shortly after entering the home, the Compliance Officer observed E1 documenting in a binder containing medication administration records (MARs). 2. A review of R5's medical record conducted at approximately 5:00 PM revealed MARs dated June 2025. The MARs revealed documentation demonstrating R5 had already been administered medication at 8:00 PM on the date of the inspection, several hours in the future. 3. In an interview, when the Compliance Officer asked if facility staff had already administered the medication, E1 stated, “No.” 4. A review of R6's medical record conducted at approximately 5:40 PM revealed MARs dated June 2025. The MARs revealed documentation demonstrating R6 had already been administered medication at 8:00 PM on the date of the inspection, several hours in the future. 5. A review of R8's medical record revealed MARs dated June 2025. The MARs revealed documentation demonstrating R8 had been administered oxycodone at 9:45 PM and 10:00 PM on June 3, 2025. 6. In an interview, E1 reported the time of the first administration was incorrect. E1 reported facility staff administered the oxycodone 9:45 AM and not at 9:45 PM. 7. In a separate interview, when the Compliance brought the aforementioned documentation issues to E1’s and E2’s attention, E2 turned to E1 and stated, “You can’t sign off saying you did something if you didn’t do it,” to which E1 replied, “I’m already here.” E1 reported E1 had signed off on the aforementioned medications since E1 was planning on administering them. E1 reported the Compliance Officer entered the home in the middle of E1 documenting medications for all residents.