Majestic Rose Llc-pr

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 that included initial training and continued competency training for three of three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Fall Prevention and Recovery Training." The policy stated, "6. All employees hired by the facility will either: supply evidence of completion of a comparable fall prevention and recovery training provider meeting this policy requirement or attend training with the facility's provider. 7. All employees of the facility will attend refresher training on an annual basis on Fall Prevention and Fall Recovery that meets the same guidelines as initial training." 2. A review of E2's personnel record revealed documentation of completed training on fall prevention and fall recovery on February 26, 2024. However, documentation of additional training was not available for review. 3. A review of E3's personnel record revealed documentation of completed training on fall prevention and fall recovery on August 20, 2024. However, documentation of additional training was not available for review. 4. A review of E4’s personnel record did not include documentation of completed initial training on fall prevention and fall recovery. 5. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the health care institution’s chief administrative officer failed to annually provide training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed and conduct an annual assessment of the health care institution's risk of exposure to infectious TB. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff. Findings include: 1. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 2. A review of E2's, E3's, and E4's personnel records did not include documentation of training related to recognizing the signs and symptoms of TB. Based on E2's, E3's, and E4's dates of hire, this documentation was required. 3. A review of the facility’s TB risk assessment documentation revealed an August 2024 risk assessment. After further review, it was revealed that there was no other documentation of a TB risk assessment. 4. In an interview, E1 reported being unable to produce a current TB risk assessment. 5. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for three of three personnel sampled. The deficient practice posed a risk if E2, E3, and E4 were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(A) states, "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.." 2. A review of the E4's personnel record revealed documentation of an application for a fingerprint clearance card (FPCC) dated October 17, 2025. However, E4's FPCC application was not dated within 20 days of E4's date of hire. 3. A.R.S. § 36-411(C) states, "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...4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee." 4. A review of E4's personnel record revealed documentation of professional references; however, documentation of the facility's good faith effort to contact previous employers was not available. 5. A review of E3's personnel record did not include documentation of verification that E3 was not on the adult protective services registry. 6. A review of E4's personnel record did not include documentation of verification that E4 was not on the adult protective services registry. 7. 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 that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. A.R.S. § 36-401.A.49. "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 2. During an environmental tour, the Compliance Officers observed E4 providing direct care to residents upon entering the facility without E3 or a manager’s supervision. After further observation, the Compliance Officers observed E4 enter the residents’ room to provide care without E3 or a manager’s supervision. 3. A review of E4'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. 4. In an interview, E4 reported E3 was in the shower. 5. In an interview, E1 reported all personnel other than E3 were assistant caregivers. E1 reported being unaware of assistant caregivers needing supervision. 6. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of three personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. While on-site for the complaint inspection, the Compliance Officers observed E3 on-site and providing services to residents. 2. A review of E3's personnel record revealed a CPR and First Aid certification with an expiration date of November 29, 2025. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure medication 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 residents who were unable to self-administer medications. Findings include: 1. During an environmental tour, the Compliance Officers observed four unattended and unlocked, clear bins that contained medication. The bins were stacked on the recliner. After further observation, the Compliance Officers observed residents sitting on the other recliners near the medication. 2. During an environmental tour, the Compliance Officers observed two bottles of Polyethylene Glycol 3350 on the kitchen island. 3. During an environmental tour, the Compliance Officers observed an inhaler and Wixela on the countertop in a common bathroom. 4. A review of the facility’s policies and procedures revealed a policy titled “Medications”. The policy stated, “All resident medications must be secured in a locked storage area. Only individuals authorized may have access to the facility’s medication storage area. ” 5. In an interview, E4 reported E3 was in the shower. 6. In an interview, E1 reported E3 had just finished dispensing medication. 7. In an exit interview, the findings were discussed with E1, and no additional information was provided. 8. This is a repeat deficiency from the compliance inspection conducted on June 10, 2024.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. A review of the facility’s evacuation drills revealed documentation of an evacuation drill being conducted in June 2024 and November 2024. After further review, it was revealed there was no other documentation of evacuation drills. 2. A review of the facility’s policies and procedures revealed a policy titled "Evacuation Plan”. The policy stated, “An evacuation drill for employees and residents is conducted at least once every six months. Documentation of each evacuation drill is created, and maintained for 12 months after the date of the evacuation drill.” 3. In an interview, E1 reported being behind on drill documentation. 4. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour, the Compliance Officers checked the water temperature in a common bathroom and observed a hot water temperature of 128º F. 2. A review of the facility’s policies and procedures revealed a policy titled "Environmental Safety”. The policy stated, “Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents.” 3. In an interview, E1 reported the facility just replaced the water heater and would cut it down. 4. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on 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. Findings include: 1. Review of the posted personnel schedule dated June 2024 revealed no documentation of the hours worked by each caregiver. 2. During an interview, E1 and E3 acknowledged documentation was not maintained of the caregivers working each day, including the hours worked. 3. This is a repeat deficiency from the compliance inspection conducted September 7, 2022.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a service plan for personal care dated March 14, 2024, which reported that R1 required the following assisted living services: -"Cleans nails PRN"; -"Comb hair daily"; -"Foot care"; and -"Skin care PRN". However, review of R1's "ADL [Activities of Daily Living] Documentation Sheet" revealed that these services were not documented. 2. Review of R's medical record revealed a service plan for directed care dated May 19, 2024, which reported that R2 required the following assisted living services: -"Cleans nails PRN"; -"Comb hair daily"; -"Foot care"; and -"Skin care PRN". However, review of R2's "ADL Documentation Sheet" revealed that these services were not documented. 3. In an interview, E1 reported that the services were provided to R1 and R2, but did not realize they needed to be documented. E1 and E3 acknowledged that R1's and R2's medical records did not contain documentation of assisted living services provided to the residents.

Based on observation and interview, the manager failed to ensure a resident received privacy in care for personal needs. The deficient practice posed a risk of a privacy rights violation to the residents. Findings include: 1. During the facility tour, the Compliance Officer observed a television screen in the common area which showed a live view from cameras in each occupied resident bedroom simultaneously. The cameras provided a view of the residents beds. 2. The Compliance Officer observed that the view of one resident receiving care for personal needs from a caregiver was visible on the screen in the common area. 3. In an interview, E2 reported that only caregivers look at the screen, however the screen was in view of residents sitting in the common area. 4. In an interview, E3 reported that residents signed documentation of consent to be videotaped. E1 and E3 acknowledged the resident's right to receive privacy in care for personal needs was not ensured at the time of the inspection.

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. Review of facility policies and procedures revealed a document titled "Wandering Residents", which stated: "If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security." 3. During the facility tour with E2, the Compliance Officer observed two doors leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The doors leading out to the backyard each had a device that was intended to alert employees to the egress of a resident to the outside area. However, the devices were not functioning. 4. During the facility tour with E2, the Compliance Officer observed a door in an unlocked garage that led to the back yard. This door was not equipped with a device to alert caregivers to the egress of a resident. 5. 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. 6. This is a repeat deficiency from the compliance inspection conducted on September 7, 2022.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered. Findings include: 1. Review of R2's June 2024 medication administration record (MAR) revealed the following medications were not documented as administered to R2 on June 2, 2024: -Raloxifene 60mg; -Sertraline 25mg; 2. Review of R2's medical record revealed a medication order that stated the following: -"raloxifene 60 mg tablet GIVE [R2] 1 TABLET BY MOUTH EVERY MORNING"; -"sertraline 25mg tablet TAKE 1 TABLET BY MOUTH EVERY MORNING". 3. In an interview, E1 reported that E2 had administered the medication, but forgot to document them. E1 and E3 acknowledged R2's medication administration was not documented in R2's medical record. 4. This is a repeat deficiency from the compliance inspection conducted on September 7, 2022.

Based on observation and interview, the manager failed to ensure medication stored by the 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 residents who could access the medication. Findings include: 1. During the facility tour with E2, the Compliance Officer observed the following: In a refrigerator in an unlocked laundry room: -Lorazepam prefilled syringes; -Calcitonin salmon nasal spray; and -Morphine Sulfate prefilled syringes. In a drawer in the kitchen: -Docusate softgel In an unlocked caregiver room: -Motrin IB; and -a bottle of 70% Isopropyl alcohol. 2. During an observation, the caregivers were not accessing the medications at the time of arrival. 3. In an interview, E1 and E3 acknowledged the medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During the facility tour with E2, the Compliance Officer observed an unsecured oxygen container in the garage. 2. In an interview, E1 and E3 acknowledged that an oxygen container was not secured in an upright position.

Based on observation, documentation review, 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 the physical health and safety of a resident. Findings include: 1. During the facility tour with E2, the Compliance Officer observed the following: In an unlocked laundry room: -"Chase home value spray" which stated "Caution keep out of reach of children"; -"Spic and span everyday cleaner" which stated "Caution keep out of reach of children"; - "Kroger pro strength drain cleaner gel" which stated "Danger: keep out of reach of children causes burns to eyes, skin, and mucus membranes. Harmful if swallowed"; and -"Pledge wood oil" which stated "Caution may be harmful if swallowed". In a cabinet in an unlocked garage, stored next to beverages: -six bottles of "Pine-sol multi-surface cleaner" which stated "Caution: keep out of reach of children"; and -two bottles of "Lysol advanced power cleaning gel" which stated "Danger: keep out of reach of children". In an unlocked cabinet under the kitchen sink: -"Easy off oven and grill cleaner" which stated "Keep out of reach of children. danger: corrosive. contains sodium hydroxide (lye). will burn eyes and skin. harmful if swallowed." 2. Review of facility documentation revealed a policy titled "Environmental safety". The policy stated "All poisonous and toxic materials will be in labeled containers, locked area separate from food preparation and storage areas, dining areas, and medications such that they are inaccessible to residents." 3. In an interview, E1 and E3 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.