Rosa's Chante Assisted Living Home

Based on record review, documentation review, and interview, the assisted living home failed to maintain a standardized form for each resident which included the information prescribed in subsection A of this section, and failed to periodically update the form as necessary. The deficient practice posed a risk to resident health as an out of date list of medications was provided to emergency responders. Findings include: 1. A review of R2's medical record revealed an incident report, dated December 20, 2025 at 12:35 PM. The incident report form stated, "pt coughing at table...called 911, difficulty breathing- presented DNR, pt had a pulse, EMS placed on floor patio, begin CPR then stopped. TPD responded / OME responded, OME took body." 2. A review of facility documentation revealed a copy of an emergency responder packet for R2 which consisted of a face sheet, a DNR form, and a medication list. However, the document did not include the reason for contacting emergency medical services, and did not include the pharmacy address or a statement whether R2 required medication services. Additionally, the attached list of medications was dated June 12, 2024 and included the following medications: "Zyprexa 5 MG PO BID, Lisinopril 20 MG PO QD, Buspirone 10 MG PO BID, Eliquis 2.5 MG PO BID, and Tylenlol, 325 MG PO 4HRS/PRN." 3. A review of R2's medical record revealed a list of medication orders, dated September 30, 2025, which included the following medications, "Olanzapine 7.5 MG PO BID, Lisinopril 20 MG PO BID, Buspirone 10 MG PO TID, Low Dose Aspirin 81 MG, PO QD, Tylenol 325 MG PO 4 HRS/PRN, Mirtazapine 30 MG PO QD, and Depakote 125 MG PO BID." 4. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident’s needs required in R9-10-807(B), documentation of freedom from infectious tuberculosis as required in R9-10-807(A), or documentation of the determination in R9-10-812(3), for one of two sampled residents. The deficient practice posed a risk if the facility was unable to meet a resident's needs and false or misleading information was provided to the Department. Findings include: 1. A review of R1's medical record revealed a baseline screening for Tuberculosis form. The form was dated one day prior to R1's date of acceptance. However, the form had a photocopied signature of a medical practitioner, and the rest of the form, including the date of the medical practitioner's signature, was filled out with a blue pen. 2. A review of R1's medical record revealed a form titled "Determination for Admission," which covered R9-10-807(B). The form was dated one day prior to R1's date of acceptance. However, the form had a photocopied signature of a medical practitioner, and the rest of the form, including the date of the medical practitioner's signature, was filled out with a blue pen. 3. A review of R1's medical record revealed a form titled "Approval for Behavioral Care," which covered R9-10-812(3). The form was dated one day prior to R1's date of acceptance. However, the form had a photocopied signature of a medical practitioner, and the rest of the form, including the date of the medical practitioner's signature, was filled out with a blue pen. Additionally, the date the medical practitioner had allegedly examined R1 had been left blank. 4. A review of R1's medical record revealed a second set of all three aforementioned documents which appeared to have an original signature and date by the same medical practitioner, except for the Determination for Admission, which was signed but not dated. However, all three documents were dated 14 days after R1's date of acceptance. 5. In an exit interview with E1, the findings were reviewed and no additional information was provided.