Mama's Garden LLC

Based on documentation review, record review, and interview, the governing authority failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Fall Prevention and Recovery Policy", which stated: "MAMA'S GARDEN LLC has developed and administers a training program for all caregiving staff regarding fall prevention and fall recovery. The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery. Policy Interpretation and Implementation 1. All new employees shall attend a Fall Prevention and Recovery training upon hire and certificates of participation filed in the respective personnel file." 2. A review of E1's and E2's personnel records revealed no fall prevention and fall recovery Training. 3. In an interview, E1 acknowledged that the Fall Prevention and Recovery policy was not implemented.

Based on Documentation review, record review, and interview, the manager failed to ensure the caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Employee Orientation Policy", which referred to a "Employee Qualification and Skills Verification Form". 2. A record review of E1's personnel record revealed no documentation of Skills and Knowledge. 3. In an interview, E1 reported that they had recently become a caregiver due to a staffing shortage. Most of the required documentation would not be available for review since it had not been completed.

Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for three of three personnel sampled. The deficient practice posed a potential 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 the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) test is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1 and E2 revealed no documentation of TB skin test or risk assessment, and signs and symptoms screening. 4. In an interview, E1 reported that they did have the documentation but were unable to locate it.

Based on documentation review, record review, and interview, the manager failed to ensure that, before providing assisted living services to a resident, a caregiver received orientation that is specific to the duties to be performed by the caregiver. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Personnel Policy", which stated: "Prior to the new employee providing services to the resident, the Facility Manager shall ensure that the employee completes an orientation training that is specific to the duties to be performed by the manager, caregiver, or assistant caregiver. An Orientation Training Checklist shall be used for verification." 2. A record review of E1's personnel record revealed no documentation of orientation. 3. In an interview, E1 reported that they had recently become a caregiver due to a staffing shortage. Most of the required documentation would not be available for review since it had not been completed.

Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "CPR-Cardiopulmonary Resuscitation Policy", which stated: "Personnel shall provide basic life support, including CPR, to a resident who requires such emergency care prior to arrival of emergency medical personnel (in which case 911): A) Subject to related physician orders B) Consistent with the resident's Advance Directive. C) CPR certified staff shall always be available on the Facility Premises. 4. All staff shall be CPR certified upon hire. 5. All staff shall maintain current CPR certification for healthcare providers in compliance with R9-10-803(C)(1)(e)(ii). 6. All staff shall renew their CPR documentation within the required time frames for their resident rescue abilities to be affirmed in line with 803(C)(1)(e)(iii). 7. Online-only certification shall not be acceptable....: 2. A review of E1 personnel record revealed no documentation of CPR and First Aid Training. 3. In an interview, E1 reported that they had recently become a caregiver due to a staffing shortage. Most of the required documentation would not be available for review since it had not been completed.

Based on record review and interview, the manager failed to ensure an individual residing in an assisted living home, who is not a resident, complied with fingerprinting requirements in A.R.S. 36-411 and evidence of freedom from infectious tuberculosis as specified in R9-10-113. Findings include: 1. A review of O1's record revealed no documentation of an infectious tuberculosis test or a fingerprint card. 2. In an interview, E1 reported that O1 is renting out a room and is not a resident and has only a resident agreement in their record.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner or registered nurse. Findings include: 1. A review of R1's medical record revealed there was no documentation dated within 90 days of their acceptance date, which included whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner or registered nurse. 2. In an exit interview, findings were discussed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident had a service plan that was completed no later than 14 calendar days after the resident's date of acceptance. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Service Plan Policy", which stated: ".....MAMA'S GARDEN LLC's management with the help of the resident, the residents primary care physician and the resident's representative will ensure that a resident's Service Plan that meets the client's expectations is designed within fourteen (14) days after acceptance of and commencement of residency services..." 2. A record review of R1's medical record revealed no documentation of a service plan. Based on the date of admission, this would be required. 3. In an interview, E1 reported that R1 had a service plan but was not able to provide one for review.

Based on record review and interview, the manager failed to ensure that a caregiver documented the services provided in the resident's medical record. Findings include: 1. A review of R1's medical record revealed a document titled "Activities of Daily Living" for November 2025, which listed various services, such as bathing, incontinence care, oral care, liquid intake, and room cleaning. Further review indicates that between November 12th and 19th, 2025, there was no documentation of services provided. 2. In an interview, E1 reported that another caregiver failed to document services. However, services were provided to the resident. 3. In an interview, R1 reported that the facility was providing services and that R1 was being taken care of.

Based on record review and interview, the manager failed to ensure that the medication administered to a resident was documented in the resident's medical record. Findings include: 1. A record review of R1's medical record revealed a medication order and medication administration record (MAR) for November 2025. The medication order revealed various: -Carb/Levo 4 times a day 25mg-100mg -Trazodone 2 times a day 25mg -Trazodone at bedtime 50mg -Senna 2 times at night 8.6mg Further review of R1's MAR revealed: Carb/Levo 4 times a day 25mg-100mg: November 11th: No documentation that medication was administered the 4th time that day. November 12th and 19th: No documentation that medication was administered.. Trazodone 2 times a day 25mg: November 7th-9th: No documentation that medication was administered the 2nd time each day November 11th-19th: No documentation that medication was administered. Trazodone at bedtime 50mg: November 11th-19th: No documentation that medication was administered. Senna 2 times at night 8.6mg: November 1st-6th: No documentation that medication was administered. November 11th-19th: No documentation that medication was administered. 2. In an interview, R1 reported that caregivers are providing medication. 3. In an interview, E1 acknowledged that medication administration was not documented, but medication was given.