Rosewood Care Home LLC

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for one of two residents sampled. Findings include: 1 . A review of R2's medical record revealed documentation of an orientation completed was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on observation 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. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed the refrigerator located by the front door of the facility. When the Compliance Officer opened the refrigerator, the bottom compartment had a lock, but was unlocked at the time of inspection. Inside the compartment, the Compliance Officer observed loose insulin and an unlocked blue lock box which contained more insulin. 2 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a food menu posted. However, the food menu was dated September 1, 2025 through September 7, 2025. 2 . In an exit interview, the findings were discussed with E3 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager failed to comply with all of the requirements of this rule, which posed a health and safety risk. Findings include: 1. A review of facility documentation revealed no documentation showing any allegations of abuse, neglect, or exploitation. 2. In an interview, E3 reported APS came to talk to E2 on July 25, 2023. E3 reported APS had not mentioned a resident name as one wasn't given, and the facility conducted an investigation on E2. However, E3 reported E3 had not documented the investigation. 3. In an interview, E3 acknowledged the facility had not documented the investigation.

Based on record review and interview, the manager failed to ensure a personnel record for each employee or volunteer was maintained for at least 24 months after the last date the individual provided services in or for the assisted living facility, for one of one former caregivers sampled The deficient practice posed a risk as required information could not be verified for E2. Findings include: 1. A review of personnel records revealed a personnel record for E2 was not available for review at the time of inspection. 2. In an interview, E3 reported E1 had a personnel record for E2 but was unable to locate it. 3. In an interview, E3 acknowledged a personnel record for E2 was not maintained for at least 24 months after the last date the individual provided services in or for the assisted living facility.

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if employees or volunteers did not possess the skills and knowledge to ensure the health and safety of residents. Findings include: 1. A review of the facility's policies and procedures revealed no documentation of a policy covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented. 2. In an interview, E2 acknowledged a policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented was not available for review at the time of the inspection.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for one of three sampled personnel members. The deficient practice posed a risk if an employee did not possess the skills and knowledge to meet the needs of residents. Findings include: 1. A review of E3's personnel record revealed documentation of verification of skills and knowledge was not available for review at the time of inspection. 2. In an interview, E2 acknowledged E3's personnel record did not include documented verification of E3's skills and knowledge at the time of the inspection.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for two of three sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(2)(a-b) states: "B. A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101." 2. A review of E1's and E3's personnel records revealed documentation of freedom from TB. However, documentation of TB screening was not available for review at the time of inspection. 3. In an interview, E1 acknowledged E1's and E3's personnel records did not contain documentation of TB screening at the time of the inspection.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a potential for physical injury and psychological distress. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(201) states: "Restraint" means "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body." 2. During the environmental inspection of the facility, the Compliance Officer observed R1's bed was pushed against the wall on one side and a bed rail, the length of the top half of the bed, was observed on the other side of the bed. 3. A review of R1's medical record revealed a document titled "Authorization for continued residency." The document stated "The resident is considered to be bedbound..." 4. In an interview, E2 reported the half rail bedrail was up to prevent R1 from falling out of bed. E2 acknowledged R1 was subjected to restraint.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for two of two sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(2)(a-b) states: "B. A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101." 2. A review of R1's and R2's medical records revealed documentation of freedom from TB. However, documentation of TB screening was not available for review at the time of inspection. 3. In an interview, E1 acknowledged failure to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed alerts placed on the front door and a door leading to the back yard. However, the alerts on each door were either turned off or not operational at the time of the inspection. 3. In an interview, E1 acknowledged means of exiting the facility did not control or alert employees of the egress of a resident from the facility at the time of the inspection.