Garden Enclave Assisted Living Homes

Based on the documentation review, record review, and interview the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9) for three of three residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of the medical records for R1's, R2's and R3's did not include a standardized form for each resident that included the information as required in A.R.S. 36-420.04(A)(1) through (9). 3. In an interview, E2 acknowledged that the documentation provided to the Compliance Officers was blank and not prefilled with the required information as prescribed in A.R.S. § 36-420.04(A).

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available. 2. In an interview, E2 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not available for review during the inspection.

Based on observation and interview, the manager failed to ensure that the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection could be found, was conspicuously posted. Findings include: 1. During the environmental tour, the Compliance Officers observed no posting indicating where the most recent inspection report could be located. 2. In an interview, E2 acknowledged that documentation of the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed was not posted.

Based on documentation review and interview, the manager failed to ensure the report required in subsection (2) was maintained for at least 12 months after the date the report was submitted to the governing authority. Findings include: 1. A review of the facility's quality management documentation revealed that no quality management reports were available for review. 2. In an interview, E2 acknowledged the report required in subsection (2) was not maintained for at least 12 months after the date the report was submitted to the governing authority.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for three of three residents sampled. The deficient practice posed a TB exposure risk to residents and the Department was unable to determine substantial compliance as the documentation was not provided during the inspection. 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 R1's, R2's, and R3's medical records revealed no documentation of evidence of freedom from infectious tuberculosis was available for review at the time of inspection. Based on R1's, R2's, and R3's date of acceptance, this documentation was required. 3. In an interview, E2 reported this documentation was completed, however could not be found at the time of inspection. E2 acknowledged R1's, R2's, and R3's medical records did not contain documentation of TB requirements at the time of the inspection.

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 reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's (accepted February 2025) medical record revealed documentation to include R1 did not require continuous medical services, continuous or intermittent nursing services, or restraints dated February 18, 2025. However, this documentation was not signed by a medical practitioner or a registered nurse. Based on R1's acceptance date, this document was required. 2. In an interview, E2 acknowledged that R1's medical record did not contain documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. This is a repeat deficiency from the complaint inspection conducted on November 19, 2024.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility for one of three sampled residents. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R2's medical record revealed that R2 was admitted in February 2025. 2. A review of R2's medical records revealed that no documentation of residency agreements was available for review at the time of inspection. 3. In an interview, E2 acknowledged that documentation of R2 residency agreements was not available for review at the time of inspection.

Based on observation, interview, and record review, for one of three residents sampled, the manager failed to ensure a resident had a written service plan that included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to residents if the service plan did not include documentation of the resident's condition and services to be provided for the resident. Findings include: 1. The Compliance Officers observed R2 trying to escape multiple times from the front door, and R2 was agitated, yelling and screaming at E3 using profanity. 2. In an interview, E3 reported that R2 has escaped multiple times to the neighbors and has some behaviors towards E3, but not towards any residents. E3 also reported R2 wanders out of the front door and needs constant redirection. 3. A review of R2's medical record revealed a service plan dated for February 19, 2025, for personal care services, which did not include exit-seeking behavior or other behaviors that was observed. 4. A review of R2's medical record revealed a document titled "caregiver notes." This document stated on May 05, 2025 "[R2] having a tantrum today, [R2] try to run away in the door for 3x, saying [R2] wants to go home. [R2] trying to hit [R2] head on the frame on the wall, and trying to hit [R2] forehead in the door frame. [R2] trying to ruin the leaves of the plant inside the house." 5. In an interview, E1 acknowledged that R2's service plan did not include documentation of the resident's medical or health problems, as required.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for one of three residents sampled. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. A review of R2's medical record revealed a written service plan for personal care services dated February 19, 2025. However, the service plan did not include a signature and date from the resident or representative. 2. In an interview, E2 acknowledged R2's service plan did not include a signature and date from the resident or representative.

Based on record review, and interview, the manager failed to ensure that a resident medical record contained a medication order from a medical practitioner for each medication that was administered, for two of three residents sampled. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed a current written service plan dated February 2025. This service plan indicated R1 received medication administration. 2. A review of R1's medical record revealed no documentation of signed medication orders or verbal medication orders for the following: - Carvedilol 12.5mg tab - Eliquis 2.5mg tab - Furosemide 40mg tab - Pantoprazole 40mg tab - Sucontral D 1mg cap - Omeprazole 20 mg 3. Review of R1's medical record revealed an April 2025 medication administration record (MAR). This MAR stated the following: -Carvedilol 12.5mg tab – 1 tab twice daily (for Hypertension); -Eliquis 2.5mg tab – 1 tab twice daily for 30 days, reassess (for Xa Inhibitor); -Furosemide 40mg tab – ½ tab once daily, may take additional ½ tab in evening if SOB worsens; -Potassium Chloride 10meq – 1 tab twice daily (for Minerals and Electrolytes); -Pantoprazole 40mg tab – 1 tab twice daily (for Proton Pump Inhibitors); -Omeprazole 20mg delayed release cap – 1 cap once daily. 4. A review of R2's medical record revealed a current written service plan dated February 2025. This service plan indicated R2 received medication administration. 5. A review of R2's medical record revealed no documentation of signed medication orders or verbal medication orders for the following: -Valproic Acid 250mg/mL -Aspirin 81mg tab -Trazodone 100mg tab -Haldol – 1 tablespoon twice daily -Sertraline tab – 1 tab 6. A review of R2's medical record revealed a May 2025 medication administration record (MAR). This MAR stated the following: -Valproic Acid 250mg/mL – 1 teaspoon (5mL) twice daily (for Behavior); -Aspirin 81mg tab – 1 tab daily (for Hypertension); -Trazodone 100mg tab – 1 tab at bedtime (for Sleep Aid); -Haldol – 1 tablespoon twice daily (for Behavior); -Sertraline tab – 1 tab daily (for Depression). 7. In an interview, E2 reported the medications were administered per the MAR, and E2 acknowledged R1's and R2’s medical records did not contain a medication order from a medical practitioner for each medication that was administered.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility for one of three sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R2's medical record revealed no documentation of the resident's orientation to exits from the assisted living facility was available for review at the time of inspection. 2. In an interview, E2 acknowledged R2's medical record did not contain documentation of R2's orientation to exits from the assisted living facility at the time of the inspection.

Based on record review, and interview, the manager failed to ensure a resident's medical record contained the resident's signed residency agreement, for one of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not provided during the inspection. Findings include: 1. A review of R3's medical record revealed a residency agreement with "Garden Enclave Assisted Living Home, LLC"; however, the signature page was missing and not available for review during the inspection. 2. In an interview, E1 acknowledged that R3's medical record did not contain the signature page of the residency agreement for review during the inspection.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of one residents sampled receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of R3's medical record revealed a service plan dated February 18, 2025, that indicated R3 required directed care services. The service plan did not include documentation of R3's weight or documentation from R3's medical practitioner stating that weighing R3 was contraindicated. 2. In an interview, E1 acknowledged R3's service plan did not include documentation of R3's weight or documentation from R3's medical practitioner stating that weighing R3 was contraindicated.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled 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. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officers observed two ambulatory residents. 3. During the environmental tour, the Compliance Officers observed the back sliding door leading to the back yard. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the door was not secured, and the door chime was not functioning. 4. In an interview, E2 acknowledged that a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility. This is a repeat deficiency from the complaint inspection conducted on November 19, 2024.

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. The deficient practice posed a risk to the physical health and safety of residents with access to unsecured medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the unlocked medication lockbox in the refrigerator containing medication. The medication lockbox had a bottle of “Lorazepam 2 Milligrams per milliliter” 2. In an interview, E2 and E3 acknowledged the medication in the medication in the refrigerator was unlocked and the aforementioned medications were accessible to residents at the facility.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk if employees were unable to implement the disaster plan in an emergency. Findings include: 1. A review of facility documentation revealed no documented review of the facility's disaster plan conducted at least once every 12 months. 2. In an interview, E2 acknowledged there was no documentation available for review at the time of the inspection to indicate the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months.

Based on documentation review, observation, record review, and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as E3 was not qualified to provide the required services unsupervised. Findings include: 1. Arizona Revised Statutes (A.R.S.) \'a7 36-401(A)(49) states "[s]upervision" means "directly overseeing and inspecting the act of accomplishing a function or activity." 2. During the environmental inspection of the facility, the Compliance Officers arrived at the facility at 9:45 AM on November 19, 2024, and observed E3 working alone and providing direct services to residents. After the Compliance Officer arrived, E3 called E4 and informed E4 that the Compliance Office was there for an inspection. E4 reported E4 would call E2 and inform E2 that the Compliance Office was there for an inspection. E2 arrived at the facility around 1:00 PM only after the Deputy Bureau Chief called E2 and informed E2 of the severity of the issue of no certified staff being on-site at the facility. 3. A review of facility personnel records revealed no personnel records for E3. 4. In an interview, E3 reported E4 dropped E3 and R3 off at the facility the night of November 18, 2024, around 7:00 PM. E3 reported E3 worked November 18, 2024, and November 19, 2024, until 1:00 PM alone. E3 also reported E3 had never completed a caregiver training program. E3 reported E4 made E3 a fake caregiver certificate and E3 had only been in Arizona for two years. 5. In an interview, E2 and E4 reported E3 had arrived and worked at the facility alone the night of November 18, 2024, around 7:00 PM and worked alone on November 18, 2024, and November 19, 2024, due to E2 working a different job the night of November 18, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked. The deficient practice posed a risk as there was no documentation to identify the staff present each day to ensure the health and safety of residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3 working at the facility at the time of the inspection. 2. The Compliance Officer requested documentation of the caregivers and assistant caregivers working each day, including the hours worked by each, however, it was not provided. 3. In an interview, E2 and E3 acknowledged documentation was not maintained of employees working each day, including the hours worked, for the months of February 2024 to November 2024.

Based on documentation review, record review, and interview, the manager failed to maintain a personnel record for each employee which included the items required by this rule, for two of four employees sampled. The deficient practice posed a risk as required information could not be verified for two employees. Finding include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3 working at the facility on November 19, 2024. The Compliance Officer requested a personnel record for E3 and no record was available for review. 2. A review of medication administration record (MAR) for R1 revealed initials of E4 from the date of November 9, 2024, through November 20, 2024. The Compliance officer requested a personnel record for E4 and no personnel record was available for review. 3. In an interview, E3 reported E4 had filled out the MAR documentation from November 9, 2024 to November 20, 2024. E3 also reported E3 had not completed a caregiver training programs and E3 reported E4 had provided E3 with a fake caregiver certificate. 4. In an interview, E2 acknowledged no personnel records were available for E3 and E4 before the end of the inspection.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for three of three sampled residents. The deficient practice posed a risk if staff were unable to meet the needs of residents. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed no documentation dated within 90 calendar days before R1, R2 and R3 were accepted by the assisted living facility to include whether R1, R2 and R3 required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E2 acknowledged R1, R2 and R3 medical records did not contain the required documentation.

Based on observation, interview, and record review, the manager failed to ensure a medical record was established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1 for one of three residents sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R3 at the facility at the time of inspection. 2. A review of resident medical records revealed no medical record for R3. 3. In a interview, E3 reported R3 was a resident of facility had just arrived at the facility the night of November 18, 2024 and no medical record was available for review. 4. In a telephonic interview E4 reported E4 had dropped off R3 at the facility around 7:00 PM on November 18, 2024. 5. In an interview, E2 acknowledged no medical record was available for R3.

Based on observation and interview, the manager failed to ensure a means of exiting the facility controlled 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. During the environmental inspection of the facility, the Compliance Officer observed the front door and a door leading from the common area to the backyard had a mechanism to alert employees of the egress of a resident from the facility, However, the mechanism to alert employees of the egress of a resident from the facility were not working. 2. In an interview, E3 acknowledged that the door mechanism were not working at the time of the inspection.

Based on observation, record review, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for three of three sampled residents who received medication administration. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R1, and R2 at the facility during the time of inspection. 2. A review of R1's and R2's medical records revealed R1 and R2 were receiving directed care services and medication adminsitration services. 3. A review of R1's medical record revealed a medication administration record (MAR). The MAR revealed the MAR had not been filled out from November 9, 2024, to Novemeber 19, 2024. 4. A review of R2's medical record revealed a medication administration record (MAR). The MAR revealed the MAR had not been filled out from November 9, 2024, to Novemeber 19, 2024. 5 In an interview, E2 acknowledge E1 one had not filled out the MAR since November 9, 2024, to Novemeber 19, 2024 for R1 and R2.