Rose Court Senior Living

Based on record review, documentation review, and interview, the manager failed to ensure that a manager, a caregiver, assistant caregiver, or a volunteer provide documentation of freedom from infectious Tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in R9-10-113. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A record review of E1's personnel record revealed, a negative TB test was provided in July 2025. A second negative TB test was not available for review. 2. A record review of E2's personnel record revealed, a negative TB test was provided in November 2022. A second negative TB test was not available for review. 3. A documentation review of the facility's Policies and Procedure titled, "Tuberculosis Screening" stated, “1. All staff and volunteers who work in the assisted living facility: 1. Will have documented at the starting of employment (or service) as stated per state regulations, evidence of freedom from pulmonary tuberculosis. The following are acceptable: a. A report of a two negative Mantoux skin tests administered within six months of submitting the report." 4. In an interview, E1 acknowledged the manager failed to ensure documentation of freedom from infectious Tuberculosis (TB) was provided for E1 and E2 on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in R9-10-113.

Based on record review, documentation review and interview, the manager retained a resident confined to a bed or chair without meeting the requirements in R9-10-814.B.2.a.b.i-iii., including documentation of the resident's or the resident's representative's request the resident remain in the facility; documentation to demonstrate the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A record review of R6's medical records revealed, the ”Medical Provider's Examination Report" stated, "The resident/resident's representative request this resident be accepted by the community or remains in the community because of one or more of the following conditions: The inability to ambulate even with assistance and is confined to a bed or a chair." The statement was last completed and signed by a physician on February 27, 2025. An updated "Medical Provider's Examination Report" was not available for review. 2. A record review of R6's medical records revealed, an updated Service Plan dated May 1, 2025. 3. A review of the facility's “Medical Provider's Examination Report” stated, "As per Arizona State Regulation R-9-10-814.B., requires that the Physician review the facility's scope of services and agrees that the resident's needs can be met by the Assisted Living Facility's scope of services. The physician is required to examine the resident at the onset of the condition or within 30 calendars of acceptance and at least once every 6 months throughout the duration of the resident's condition." 4. In an interview, E1 acknowledged the manager did not obtain documentation to demonstrate R6's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility.

Based on documentation review and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A documentation review of the facility’s Policy & Procedures section titled “Disaster Plan Review and signature page”, showed the Disaster Plan was lasted reviewed on January 9, 2024. 2. A documentation review of the facility's Policies and Procedures titled, "Disaster Plan and Evacuation Drill” stated, "The disaster plan is reviewed and the review is documented at least once every 12 months and includes the date and time of the disaster plan review, the names of each employee or volunteer participating in the disaster plan review, a critique of the disaster plan view, and if applicable, recommendations for improvement.” 3. In an interview, E1 acknowledged the manager did not ensure the Disaster Plan was reviewed every 12 months as required.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident’s medical record, for three and three sampled residents. Findings include: 1. A review of R1's medical record contained a service plan dated July 17, 2025 . R1's service plan reported R1 would be provided assistance with dressing twice daily, transfer assistance in and out of bed, toileting assistance every shift, personal hygiene of oral, skin and daily grooming twice daily, wellness and safety checks every shift. 2. A review of R1's medical record contained a document titled "Documentation Survey Report" dated August 2025 which reflected R1 was not provided assistance with following: Wellness checks on the day shift of August 1, 2025 and August 2, 2025 and night shift of August 15, 2025; Dressing assistance the day shift of August 1, 2025 and August 2, 2025; Mobility and transfer the day shift of August 1, 2025, August 2, 2025 and night shift of August 15, 2025; Grooming personal hygiene/oral care the day shift of August 1, 2025, August 2, 2025; and Toileting not provided on the day shift of August 1, 2025, August 2, 2025 and night shift of August 15, 2025. 3. A review of R2's medical record contained a service plan dated July 25, 2025 . R2's service plan reported R2 would be provided reminders for dressing twice daily, personal hygiene of oral, skin and daily grooming twice daily, wellness and safety checks every shift. 4. A review of R2's medical record contained a document titled "Documentation Survey Report" dated August 2025 which reflected R2 was not provided assistance with following: Wellness checks on the day shift of August 1, 2025 and August 2, 2025 and night shift of August 15, 2025; Dressing assistance the day shift of August 1, 2025 and August 2, 2025; and Grooming personal hygiene/oral care the day shift of August 1, 2025, August 2, 2025. 5. A review of R3's medical record contained a service plan dated July 18, 2025 . R3's service plan reported R3 would be provided assistance with dressing twice daily, personal hygiene of oral, skin and daily grooming twice daily, wellness and safety checks every shift. 6. A review of R3's medical record contained a document titled "Documentation Survey Report" dated August 2025 which reflected R3 was not provided assistance with following: Wellness checks on the day shift of August 1, 2025 and August 2, 2025 and night shift of August 15, 2025; Dressing assistance the day shift of August 1, 2025 and August 2, 2025; and Grooming personal hygiene/oral care the day shift of August 1, 2025, August 2, 2025. 7. In an interview, E1 acknowledged the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to R1, R2, and R3.

Based on documentation review and interview, the manager failed to ensure when medication is stored by an assisted living facility, policies and procedures were established and documented for inventorying and dispensing controlled substances. Findings include: 1. A review of the facility's documentation of the policies and procedures showed that the medication policies and procedures did not cover inventorying and dispensing controlled substances. 2. In an interview, the E1 reported that the provided medication policies were the only available policies regarding inventorying and dispensing medications, and no other policies and procedures were available for review.

Based on record review and interview, the manager failed to ensure the facility maintained a standardized form for each resident that includes the information prescribed in subsection A of A.R.S. § 36-420.04.A.1-9, for one of one sampled resident. Findings include: 1. A review of R1’s medical record contained an incident report dated May 7, 2025 for an unwitnessed fall that required 911 services. R1's medical record revealed a packet of information to be given to an emergency responder on behalf of the resident, the packet of information and standardized form did not include the reason or reasons the emergency responder would be requested on behalf of the residents’, a list of the residents’ prescription and over-the-counter medications, their dosages and how frequently they would be administered, the name, address and telephone number of the residents’ current pharmacy, the contact information for the residents’ primary care physician, basic information about the residents’ physical conditions and a copy of the residents’ health insurance portability and accountability act release (HIPPA) authorizing the receiving hospital to communicate with the assisted living facility. 2. In an interview, E1 reviewed the information to be given to the emergency responder on behalf of R1 and acknowledged the above information was not included in the packet.