Rosebud Assisted Living Home

Violation cited

Violation cited

Violation cited

Based on documentation review and interview, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. In an interview E1 reported E4 was a live-in caregiver. 2. In an interview E1 reported having a disciplinary interaction with E4. On July 29, 2024, E4 sent E1 a text message advising E1, E4 was no longer at the facility. It is unknown how long E4 was gone from the facility. 3. In an interview, E1 acknowledged no manager or caregiver was present in the facility for an undetermined amount of time.

Based on interview, documentation review, and record review, the manager failed to ensure personnel records included items required in R9-10-806(C)(1), for one of three personnel records reviewed. The deficient practice posed a risk if E4 was unable to meet the needs of residents. Findings included: 1. The Compliance Officer requested to review the personnel record for E4. 2. In an interview, E1 reported E4 was employed as a live-in caregiver when E4 abandoned E4's shift and left the facility. E1 further reported E4 stole E4's personnel record. 3. A review of E4's personnel record revealed no evidence of an application for employment (including name, date of birth, address, phone number), documented skills and knowledge, experience, orientation, or compliance with A.R.S. \'a7 36-411(A) and (C). 4. In an interview, E1 acknowledged the personnel record for E4 did not include items required in R9-10-806(C)(1).

Based on documentation review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a rights violation to the residents. Findings include: 1. A review of facility documentation revealed an incident report documenting an interaction between a E3 and R1. The report stated E3 changed R1's brief in front of other residents and a visitor. The report further stated E3 reported, "R1 is extremely resistant to care and can be manipulative". E3 was immediately replaced and retrained on dealing with resident behaviors. 2. A review of facility documentation revealed three days after the incident, E3 left the facility unannounced and left the residents alone for an undetermined amount of time before notifying the manager. 2. In an interview, E1 acknowledged R1, and the three other residents, were treated without dignity, respect, and consideration. E1 further acknowledged immediate action was taken to retrain E3 and E1 reported to the facility immediately when notified E3 was no longer in the facility.

Based on documentation review, and interview, the manager failed to ensure a resident received privacy in care for personal needs. The deficient practice posed a privacy rights violation to the resident. Findings include: 1. A review of facility documentation revealed an incident report dated July 24, 2024. The incident report stated a resident was provided personal care in the living room in front of other residents and a visitor. 2. In an interview, E1 acknowledged R1 was not provided privacy while receiving personal care. E1 further reported E1 immediately replaced E3, until E3 could be further trained in handling resistant behaviors.

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 one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a signed medication order dated June 23, 2024 for Quetiapine Fumarate 25 MG. The order stated, "Take 1 tablet by mouth 2 times per day in the AM and 1 pm and 2 tablets by mouth at bedtime." 2. A review of R1's medical record revealed Medication Administration Records (MAR) dated June and July 2024. The MAR revealed Quetiapine 25MG was administered as, "Take 1 Tablet (total of 25 mg) - At Bedtime", from June 23, 2024 to July 25, 2024. 3. A review of R1's medical record revealed a signed medication order dated June 26, 2024, for Levofloxacin 250 MG. The order stated, "take 1 tablet by mouth every day for 5 days". 4. A review of R1's MAR for June and July 2024 revealed no evidence the medication was administered to R1 in June or July 2024. 5. In an interview E1 acknowledged the medication administered to R1, was not administered in compliance with a medication order.

Based on record review and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C), for one of two personnel records reviewed. Findings include: 1. A.R.S. \'a7 36-411(C) states, "C. Owners 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. Verify the current status of a person's fingerprint clearance card." 2. A review of E2's personnel record revealed an application for employment, which did not include any previous employer information or documentation of contacting any previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution. 3. In an interview, E1 acknowledged the personnel record for E2 did not include documentation of contact with previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record for two of three resident records reviewed. Findings include: 1. A review of R3's medical record revealed a personal care service plan with medication administration, dated June 14, 2023. The service plan noted the following services were needed by R3: - showering, - dressing, - oral care, - grooming, - skin care, - toileting, - turning, - hydration, and - cognitive stimulation. 2. A review of R3's medical record revealed no documentation that the above services were provided after July 2023. 3. A review of R1's medical record revealed a service plan for directed care level of services with medication administration. No documentation of services provided was available prior to July 2023. 4. In an interview, E1 acknowledged the manager failed to ensure a caregiver documented the services provided in the resident's medical record. E1 reported E2 believed the services provided were recorded in the electronic system.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, and was accurately documented in the resident's medical record, for one of two residents records reviewed. Findings include: 1. A review of R1's medical record revealed an order for "Aripiprazole 10mg tab, one tab PO daily", dated August 12, 2023, and an order for "ATORVASTATIN 40MG TABLET", "TAKE 1 TABLET BY MOUTH DAILY", dated October 29, 2023. 2. A review of R1's medication administration record (MAR) dated November 2023 revealed no documentation of the administration of Atorvastatin or Aripiprazole. 3. A review of R1's medication organizer revealed Atorvastatin was being administered, though no Aripiprazole was located in the medication organizer. 4. A review of documentation revealed no evidence that R1's medical practitioner discontinued the Aripiprazole. 5. In an interview, E1 acknowledged medication was not administered in compliance with a medication order, and was not accurately documented in the resident's medical record, for one of two resident records reviewed.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan and if the Department was provided false or misleading information. Findings include: 1. A review of the facility's work schedule revealed the facility had one shift. 2. A review of facility documentation revealed a disaster drill conducted, on November 6, 2022, June 30, 2023, and November 6, 2023. 3. In an interview, E1 acknowledged disaster drills were not conducted and documented at least once every three months. Upon further review, the documentation from the drill conducted on November 6, 2022, included R1 and R3, who were not admitted into the facility until a later date.

Based on documentation review and interview, the manager failed to ensure an evacuation drill was conducted at least once every six months. Findings include: 1. A review of the facility work schedule revealed the facility had one shift per day. 2. A review of facility documentation revealed evacuation drills were conducted on May, 7, 2023 and on November 7, 2023. There was no documentation of an evacuation drill was conducted prior to May, 7, 2023. 3. In an interview, E1 acknowledged an evacuation drill was not conducted at least once every six months.