Tramonto Desert Rose Assisted Living

Based on record review and interview, the manager failed to ensure a resident’s service plan was established, documented, and implemented that contained: a description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; and the amount, type, and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication, for two of two residents sampled. The deficient practice posed a risk if the residents’ needs were not being met. Findings include: 1. A review of R1’s medical record revealed a service plan dated October 10, 2025. The service plan did not specify the frequency for Dressing, Toileting, or Incontinence care for R1. 2. A review of R2’s medical record revealed a service plan dated December 13, 2025. The service plan did not include: A description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; and The amount, type, and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication. 3. In the 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 caregiver or assistant caregiver documented the services provided in the resident’s medical record, for two of two residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. Upon arrival at the facility on February 26, 2026, at approximately 09:10 AM, the Compliance Officers requested records, including Activity of Daily Living (ADL) records for all residents. E3 advised that the records were kept electronically. The Compliance Officers advised E3 not to complete any documentation while the Compliance Officers were on-site. 2. A review of R1’s electronic medical records revealed R1’s ADLs dated February 25, 2026, and February 26, 2026 were completed on February 26, 2026, between 09:45 AM and 09:46 AM by E3. 3. A review of R2’s electronic medical records revealed R2’s ADLs dated February 25, 2026, and February 26, 2026 were completed on February 26, 2026, between 09:46 AM and 09:57 AM by E3. 4. In an interview, E3 acknowledged E3 completed the ADL documentation for R1 and R2 after the Compliance Officers arrived on-site. 5. In the exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance and complaint inspection conducted on October 16, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential illness 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. A review of R2's (admitted 2025) medical record revealed no documentation of a completed TB skin test, as required based on R2's date of admission. 3. In an interview, E1 and E3 reported R2 received a TB skin test dated within 12 months prior to R2's date of occupancy. However, the required TB skin test for R2 was not available for review at the time of the inspection. 4. In the 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 there was a 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 that provides access to an outside area that allows the resident to be at least 30 feet away from the facility or from which a resident may exit to a location at least 30 feet away from the facility that was secure and monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed that the front door lacked a key or special knowledge for egress to an outside area at least 30 feet away from the facility, and the door was not monitored or alerted of egress when the door was opened. 2. During the environmental tour, the Compliance Officers also observed that the rear egress door was secure and contained an interior lock requiring a key to exit to an outside area from which the residents may exit to a location at least 30 feet away from the facility, and the door was not monitored or alerted of egress when the door was opened. The outside area had a gate that was locked. 3. A review of the facility’s policies and procedures revealed a policy titled, “Environmental and Physical Plant Safety, includes Pest Control Program” which stated, “4. Exit doors and windows to the outside that a wandering resident may exit through, will be alarmed to alert employees in the event a resident is wandering.” 4. In an interview, E1 reported both door alarms were functional but they turned them off because the alarms were too loud. E1 also reported they would consider replacing the egress alarms. 5. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation 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 residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2’s current service plan dated December 13, 2025 revealed R2 received medication administration. 2. A review of R2’s medical records revealed a medication order dated December 30, 2025 which stated, “Metoprolol Succinate ER 25mg, Take 1 oral tablet extended release QD one time daily Hold SBP <110 and/or HR <60” 3. A review of R2’s medical records revealed a medication administration record (MAR) dated February 2026 which revealed: one Metoprolol Succinate ER 25mg tablet was administered daily from February 1, 2026 thru February 26, 2026. 4. A review of R2’s medical records revealed a Blood Pressure (BP) log dated February 2026. The log revealed R2’s systolic blood pressure dropped below 110 on February 14, 2026 (99/77) and February 22, 2026 (106/74). However, the medication was not held, as ordered. 5. A review of the facility’s policies and procedures revealed a policy titled, “Medications Including Opioids, Narcotics, and Schedule 2” which stated, “Part III – Medication Regimen, Records and Monitoring: 1. All medications or treatments are administered to the resident only in accordance with the Doctor’s Order and instructions from a Physician or Medical Practitioner.” 6. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation 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 residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2’s current service plan dated December 13, 2025 revealed R2 received medication administration. 2. A review of R2’s medical records revealed a medication order dated December 30, 2025 which stated, “Metoprolol Succinate ER 25mg, Take 1 oral tablet extended release QD one time daily Hold SBP <110 and/or HR <60” 3. A review of R2’s medical records revealed a Blood Pressure (BP) log dated February 2026. The log revealed R2’s blood pressure was not recorded on February 11, 2026 or February 12, 2026. 4. A review of R2’s medical records revealed a medication administration record (MAR) dated February 2026 which revealed: one Metoprolol Succinate ER 25mg tablet was administered daily from February 1, 2026 thru February 26, 2026. However, documentation of R2's vitals was not available for review. 5. A review of the facility’s policies and procedures revealed a policy titled, “Medications Including Opioids, Narcotics, and Schedule 2” which stated, “Part III – Medication Regimen, Records and Monitoring: 1. All medications or treatments are administered to the resident only in accordance with the Doctor’s Order and instructions from a Physician or Medical Practitioner.” 6. In the exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on October 16, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed medications for all residents were stored in an open cabinet inside a small room that was not used only for medication storage, as required. The Compliance Officers observed the following regarding the area where the medications were stored: The room where the open medication cabinet was located was secure. The entire room was used for medication storage. Numerous nonmedication items were stored in the room along with the medication cabinet. These items included several boxes of records stacked near the open medication cabinet, several bags and packages on the floor in front of the medication cabinet, and several files and papers stored in the room adjacent to the medication cabinet. 2. During the environmental tour, the Compliance Officers also observed the following regarding the condition of the medication cabinet: The cabinet did not contain doors that could be secured and separate the medications from other items stored in the room. Medications were not contained to the interior of the cabinet, but were also stored on top of a minifridge next to the cabinet as well as on the outside top of the cabinet. 3. A review of the facility’s policy’s and procedures revealed a policy titled, “Medications Including Opioids, Narcotics, and Schedule 2” which stated, “Part II – Receiving, Storing Medication: 3. Medication stored by the facility must be secured in a locked storage area, closet, cabinet, or self-contained unit used for medication storage only.” 4. In an interview, E1 and E3 reported they were unaware their storage of medications was a problem if the room was kept secure. 5. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of the residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a common area in the backyard where the hard surface formed two circular areas around areas that contained stone. The larger area contained a removable fire pit in the middle of the stone area, and the smaller area contained a hose stemming from the ground. In both areas, the hard edges protruded beyond the stones, leaving an uneven edge that may become a fall hazard for residents using those areas. 2. During the environmental tour, the Compliance Officers observed several ambulatory residents and other residents using walkers throughout the facility. 3. A review of the facility’s policies and procedures revealed a policy titled, “Environmental and Physical Plant Safety, includes Pest Control Program” which stated, “23. Potentially hazardous situations like cracks in the sidewalk, torn or curling carpet or linoleum, plants, bushes or trees growing over and in common traffic areas should be reported to the manager immediately for correction.” 4. In the 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 oxygen containers were secured in an upright position. The deficient practice posed a risk to the health and safety of the residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed several oxygen tanks stored in the garage. There were oxygen tanks stored at the back of the garage in an upright position; however, there was a table resting on top of the tank valves that posed a risk to the integrity of the valves. Additionally, there were oxygen tanks stored immediately inside the overhead door, including several mini tanks, that were leaning due to other miscellaneous items that were pushed against the tanks. 2. During the environmental tour, the Compliance Officers observed an unsecured oxygen tank placed directly on the floor in a resident’s room. The oxygen tank was not in use at the time of the inspection. 3. A review of the facility’s policies and procedures revealed a policy titled, “Environmental and Physical Plant Safety, includes Pest Control Program” which stated, “27. Oxygen safety will be maintained at all times…c. Oxygen tanks will be stored in the upright position at all times, and secured by a chain.” 4. In the 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 poisonous or toxic materials stored by the assisted living facility were in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of the residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed the following items: One 5-gallon bucket of paint stored outside in a common area of the backyard where the residents had access; and One tube of caulk stored on top of the refrigerator in the kitchen where residents had access. 2. A review of the facility’s policies and procedures revealed a policy titled, “Environmental and Physical Plant Safety, includes Pest Control Program” which stated, “16. Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dining areas, and medications and are inaccessible to residents.” 3. In the 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 two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a document titled "Activities of Daily Living Chart" dated October 2023. This document revealed R1 was assisted with bathing, dressing, grooming, and toileting. However, documentation was not available indicating these services were provided October 14th - present. 2. Review of R2's medical record revealed a document titled "Activities of Daily Living Chart" dated October 2023. This document revealed R2 was assisted with bathing, dressing, grooming, and toileting. However, documentation was not available indicating these services were provided October 14th - present. 3. In an interview, E1 acknowledged R1's and R2's medical records did not include documentation of the above listed services and reported the services were provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of two residents reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. Review of R1's medical record revealed no documentation that showed the pneumonia vaccination was offered or received. Based on R1's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R1's medical record did not include current documentation that showed the pneumonia vaccination was offered or received.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 24, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated October 10, 2023. These medication orders stated the following: "Eliquis 5mg take 1 tablet by mouth 2 times per day" "Atorvastatin Calcium 80mg 1/2 tab po BID" "Wellbutrin 100mg take 1 tablet by mouth daily" "Lexapro 10mg take 1 tablet by mouth once daily" "Flonase 50mcg 1 spray intranasally daily" "Insulin Glargine 100unit/ml take 70u QHS" "Lisinopril 10mg take 1 tablet by mouth daily" "Trazodone HCL 150mg take 1 tablet by mouth daily at bedtime" 3. Review of R1's medical record revealed an October 2023 medication administration record (MAR). This MAR stated the following: "Eliquis 5mg 1 tab PO BID" however, did not include documentation the medication was administered at 8am October 14th - present and at 8pm October 13th - present. "Atorvastatin Ca 80mg 1/2 tab po BID" however, did not include documentation the medication was administered at 8am October 14th - present and at 8pm October 13th - present. "Wellbutrin 100mg 1 tab PO morning" however, did not include documentation the medication was administered at 8am October 14th - present. "Lexapro 10mg 1 tab PO QD" however, did not include documentation the medication was administered at 8am October 14th - present. "Flonase 50mcg 1 spray QD each nostril" however, did not include documentation the medication was administered at 8am October 14th - present. "Lantus 100unit/ml 70u QHS" however, did not include documentation the medication was administered at 8pm October 13th - present. "Lisinopril 10mg 1 tab PO QD" however, did not include documentation the medication was administered at 8am October 14th - present. "Trazodone HCL 150mg 1 tab PO QHS" however, did not include documentation the medication was administered at 8pm October 13th - present. 4. During an observation of R1's medications, the above listed medications were available. 5. Review of R2's medical record revealed a current written service plan dated September 8, 2023. This service plan indicated R2 received medication administration. 6. Review of R2's medical record revealed signed medication orders dated April 10, 2023. These medication orders stated the following: "Amlodipine Besylate 10mg 1 tablet 1 time a day" "Aspirin 81mg 1 tablet 1 time a day" "Cymbalta 60mg 2 capsules 1 time a day" "Hydralazine HCL 25mg 1 tablet 3 times a day" "Lorazepam 1mg 1 tablet 3 times a day" "Morphine Sulfate 20mg/ml 0.5ml 3 times a day" "Omeprazole 20mg 1 capsule 1 time a day" "Senna S 8.