Rose Garden Adult Home Care

Based on observation, record review, and interview, the manager failed to ensure a written notice of termination of residency included all items required by this rule, for one of one applicable sampled resident. Findings include: 1. The Compliance Officer did not observe R2 in the facility at the time of the inspection. 2.A review of R2’s medical record revealed no written notice of termination of residency. 3. In an interview, E1 reported they called EMS to come and get R2 and they had every intention of accepting R2 back into the facility when R2 gets out from the hospital. 4. In an interview, E3 reported the facility did not want R2 back into that facility because of the illegal drugs that were found in R2’s room. E3 reported R2 moved out at the end of December 2025. 5. In an interview, E1 and E3 acknowledged they did not know that finding illegal drugs in a resident's room does not call for an immediate termination of the residency agreement. 6. In an interview, E1 and E3 acknowledged there was no written termination agreement in R2’s medical records. 7. In an exit interview, the findings were reviewed with E1 and E3, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance for two of two residents reviewed. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings Include: 1. A review of R1's and R2’s medical records revealed no documentation of a service plan. Based on R1's and R2’s date of admission, this documentation was required. 2. In an exit interview, the findings were reviewed with E1and E3, and no additional information was provided. 3. This is a repeat deficiency from the complaint and compliance inspection on November 25, 2025.

Based on record review and interview, for one of one applicable resident, the manager failed to ensure a resident's medical record contained the date of termination of residency. Findings include: 1. A review of R2's medical records revealed a date of termination of residency was not available for review. 2. In an interview, E1 reported R2 moved out at the end of December 2025. 3. In an interview, E1 and E3 acknowledged the medical records provided for the one former resident had not included the date of termination of residency.

Based on observation and interview, the manager failed to ensure that a food menu was prepared at least one week in advance and conspicuously posted at least one calendar day before the first meal on the food menu was served. The deficient practice proved a risk as the department was provided false and misleading information. Findings include: 1.During an environmental inspection of the facility, the Compliance Officer did not observe a current food menu posting. There was a whiteboard by the kitchen table that was blank except the food prepared on a Sunday with no date. Later in the inspection the Compliance Officer observed a caregiver write what they served for Monday’s breakfast and dinner and Wednesday's breakfast and lunch. The Compliance Officer was unable to tell what days the food was served on without the date. 2. The Compliance Officer observed E3 typing on the computer. The Compliance Officer observed E3 editing the December 2025’s food menu. 3. In an interview, E3 was questioned on what E3 was doing. E3 reported E3 was printing out the January 2026 food menu and E3 was not editing December 2025’s food menu to be January 2026’s food menu. However the Compliance Officer pointed out that there was no Saturday the 13th in January 2026 that was in December 2025. E3 then acknowledged that E3 was editing the December food menu at the time of the inspection. 4. In an interview, E1 and E3 acknowledged E3 was falsifying documentation at the time of the inspection. E1 and E3 also acknowledged the food menu was not prepared a week in advance. 5. In an exit interview, the findings were reviewed with E1 and E3, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that meals provided by the assisted living facility were served according to posted menus. Findings include: 1.During an environmental inspection of the facility, the Compliance Officer did not observe a current food menu posting. There was a whiteboard by the kitchen table that was blank except the food prepared on a Sunday with no date. Later in the inspection the Compliance Officer observed a caregiver write what they served for Monday’s breakfast and dinner and Wednesday's breakfast and lunch. The Compliance Officer was unable to tell what days the food was served on without the date. 2. In an interview E1 and E3 acknowledged the food menu was not posted and the food could not have been served according to a food menu. 3. In an exit interview, the findings were reviewed with E1 and E3, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident was provided a diet that met the resident’s nutritional needs as specified in the resident’s service plan. The deficient practice posed a risk as R1’s and R2's nutritional needs were not met. Findings include: 1. A review of R1’s and R2’s medical records revealed no service plan that specified the residents’ nutritional needs. 2. In an interview, E1 and E3 acknowledged R1 and R2 did not have a service plan at the time of the inspection. 3. In an exit interview, the findings were reviewed with E1 and E3, and no additional information was provided.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for two of two employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 2. A review of E1's personnel record did not include documentation of the facility's good-faith effort to verify that E1 was not found on the adult protective services registry. 3. A review of E2's personnel record did not include documentation of the facility's good-faith effort to verify that E2 was not found on the adult protective services registry. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three residents reviewed. The deficient practice posed a TB exposure risk to residents. 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 R2's medical record revealed a TB skin test. However, the result of the test was not documented. Based on R2’s date of admission, this documentation was required. 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 a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints for one of three 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 R3’s medical record revealed documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints; however, there was no signature or a date from a medical practitioner or a registered nurse. 2. 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 there was a documented residency agreement with the assisted living facility that included the facility responsibilities for three of three sampled residents. Findings include: 1. Review of R1’s, R2’s, and R3’s medical records revealed residency agreements. However, the residency agreements did not include the facility’s responsibilities. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance for two of three residents reviewed. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings Include: 1. A review of R1's and R3’s medical records revealed no documentation of a service plan. Based on R1's and R3’s date of admission, this documentation was required. 2. 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 a written service plan included documentation of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of three residents reviewed. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings Include: 1. A review of R2’s service plan dated May 2025 revealed no documentation of R2's medical or health problems. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

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 that allowed a resident to be at least 30 feet away from the facility that is secured, and 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 general or specific whereabouts of a resident. Findings Include: 1. The facility was licensed at the directed care level. 2. During an environmental inspection of the facility with E1, the Compliance Officers observed that the front door to enter the facility was equipped with an alarm; however, the alarm was not activated. The front door did not lead to an area that was secured. 3. The Compliance Officers observed that the door in the kitchen leading to the backyard was unlocked and the alarm was inactive. The door was not monitored. 4. In an exit interview. The findings were reviewed with E1, and no additional information was provided.

Based on record review, interview, and documentation review, the manager failed to ensure a medication was administered in compliance with the medication order for one of three resident records reviewed. This deficient practice posed a risk if the resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R2's medical record revealed a current service plan that included personal care services and medication administration. 2. A review of R2’s medical record revealed a written medication order signed and dated September 9, 2025. This medication order stated “Hydralazine 100 mg po Q 8hr” and “Sucralfate 1 gm po BID”. 3. A review of R2’s medication administration record (MAR) for November 2025 revealed Hydralazine 100 mg was administered every six hours. A further review of the MAR revealed there was no documentation of Sucralfate 1 gm. 4. In an interview, E1 acknowledged that Hydralazine 100 mg was not administered every eight hours. Additionally, E1 reported Sucralfate 1 mg never arrived at the facility and R2 never received the medication. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record for one of three residents sampled. The deficient practice posed a risk as the medical record inaccurately indicated a medication was administered. Findings include: 1. A review of R2's medical record revealed a current service plan that included personal care services and medication administration. 2. A review of R2's medical record revealed documentation of a signed medication order dated September 9, 2025. The following medications were prescribed: - Tizanidine 2 mg TID - Gabapentin 100 mg BID - Carvedilol 6.25 mg BID - Benazepril 20 mg QID - Mirtazapine 7.5 mg QHS - Bumetanine 2 mg TID 3. A review of R2’s medical record revealed a medication administration record (MAR) for November 2025. The MAR revealed the following entries not documented as administered: - Tizanidine 2 mg at 12pm and 6 pm on the 22nd - Gabapentin 100 mg at 6 pm on the 22nd - Carvedilol 6.25 mg at 6 pm on the 22nd - Benazepril 20 mg at 6 pm on the 17th and 22nd - Mirtazapine 7.5 mg at 6 pm on the 17th and 22nd - Bumetanine 2 mg at 6 am, 12 pm, and 6 pm on the 17th and 22nd 4. In an interview, E1 reported the medications mentioned above were administered to R2 however, it was not documented as administered. 5. 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 that medication was stored in a separate locked, self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the environmental inspection of the facility with E1, the Compliance Officers observed Children’s Tylenol in an unlocked refrigerator in the kitchen. Additionally, the unlocked refrigerator in the kitchen contained an unlocked storage box storing medications, including: Lorazepam Oral 2mg/mL Morphine Sulfate 100/5mL Haloperidol 2mg/mL Morphine Sulfate 20mg/mL Insulin Lispro 100/mL 2. The Compliance Officers observed a tube of "Phytoplex Z-Guard Paste" in the main bathroom shared by residents. 3. The Compliance Officers observed an unlocked cabinet in the kitchen, located next to the refrigerator contained: Collagenase Santyl Ointment 250 units/g Naloxone HCI Nasal Spray 4mg 4. A review of the facility’s policies and procedures, titled ‘Medication Administration,' reviewed and signed, stated: "3. All medications will be stored by the home in a secure central storage location such as a locked room, closet, cabinet, or self-contained unit used only for medication storage." 5. In an exit interview, findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that 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 an evacuation. Findings include: 1. A review of the facility’s emergency and safety standard documentation revealed no documentation of evacuation drills. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed the following bottles of toxic materials stored under the kitchen sink in an unlocked cabinet: Clorox Disinfectant Bleach Clorox Disinfectant Wipes Three bottles of Comet Bleach Remover Great Value Ultra Dish Liquid 2. The Compliance Officers also observed a spray bottle of "LA's Totally Awesome All Purpose Concentrated Cleaner & Degreaser Spot Remover" on top of the kitchen sink. 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 caregiver documented the services provided in the resident's medical record, for one of three residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2's medical record revealed a service plan dated July 20, 2024. Under the "Bathing, Grooming & Dressing" section, the following was stated, "Resident needs a 1 person assist with ADLs ...". 2. A review of R2's medical record revealed R2's activities of daily living log dated October 2024. However, documentation was not available indicating dressing assistance was provided. 3. In an interview, E3 acknowledged R2 received dressing assistance and documentation was not available showing dressing assistance was provided.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. Review of the staff personnel records revealed that E3, who was hired on February 10, 2024, had no documentation of completing fall prevention and fall recovery training as required. 2. During an interview, E1 and E2 acknowledged that E3 had not completed the required fall prevention and fall recovery training. This is a repeat deficiency from the compliance inspection conducted on March 20, 2023.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver is only assigned to provide the assisted living services the caregiver or assistant caregiver has the documented skills and knowledge to perform; for two of two sampled caregivers which posed a health and safety risk. Findings include: 1. Reviewed the personnel records for E2 (started November 1, 2020), E3 (started February 10, 2024), and E4 (started July 7, 2022). These sampled caregivers' records contained no verified documentation that they had the skills and knowledge to care for R8's colostomy. 2. In an interview, E1 and E2 reported the caregivers are providing colostomy daily care and acknowledged there was no verified documentation available for review of the caregivers' skills and knowledge to provide colostomy care.

Based on records reviewed and interview, the manager failed to ensure at the time of acceptance, a resident or resident's representative received a written copy of all the requirements in subsection (B) and subsection (C), which posed a health and safety risk as the resident or resident's representative could be unaware of these requirements; for one of four sampled residents' records reviewed. Findings include: 1. Review of R1's record revealed no documentation showing the resident or resident's representative received a copy of all of the requirements in subsection (B) and subsection (C). Based on R1's date of acceptance this was required at the time of acceptance. 2. In an interview, E1 and E2 acknowledged there was no evidence this sampled resident or their representative had received a copy of the resident's requirements and rights.

Based on record review and interview during the complaint investigation, the manager failed to ensure that for one of two sampled resident who was unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner signed a determination stating that the resident's needs were being met. This determination was to be completed at the time of acceptance or onset and at least once every six months throughout the duration of the resident's condition to determine if the resident's needs could be met which was based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services. Findings include: 1. In an interview, E2 reported that R4 was accepted to the facility unable to ambulate even with assistance. 2. Review of R4's medical record found no documented determination completed at the date of acceptance or within 30 days prior to acceptance nor anytime since by the resident's medical practitioner. There was no documented determination completed by R4's medical practitioner at least every six months throughout the duration of the resident's condition. Each determination should have been based on a current examination of the resident, the facility's scope of services, and should have included a statement that the resident's needs could be met by the facility. 2. In an interview, E1 and E2 acknowledged there was no documentation of the required determination available for review. E2 reported "not done". This is a repeat deficiency from the compliance inspection conducted on March 20, 2023.

Based on record review and interview, the manager failed to ensure a resident's orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility was completed within 24 hours after the resident's acceptance by the facility and documented; for one of four sampled residents' records reviewed, which posed a safety risk. Findings include: 1. Review of R1's record, based on the date of acceptance, revealed there was no documentation indicating the sampled resident received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after the resident was accepted by the facility. 2. During an interview, E1 and E2 acknowledged there was no documentation to indicate the sampled resident had received evacuation orientation to the exits from the facility within 24 hours after the resident's acceptance, nor anytime since.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were clean according to policies and procedures designed to prevent, minimize, and control illness or infection which could pose a health risk. Findings include: 1. During a facility tour, E2 and the compliance officer observed in a resident's bedroom where the resident was receiving oxygen therapy there was a free standing room floor fan. The fan blades and cover had a thick gray dusty appearing product build up on the fan blades and cover which gave the appearance the fan was not kept clean and could pose a health risk to the resident in that bedroom. 2. During an interview, E1 and E2 acknowledged this floor fan did not appear clean.

Based on observation, record review, and interview, the manager failed to ensure one sampled dog residing at the facility was licensed consistent with local ordinances. Finding include: 1. During a facility tour, E1, E2, and the compliance officer observed a dog, O1, residing at the facility. 2. The compliance officer requested and was not provided with any documentation that O1 had a current license from Yuma County Animal Humane Society. 3. In an interview, E2 acknowledged there was no record that O1 had a current license, as required.