Secret Garden Assisted Living II

Based on observation, record review, and interview, the facility exceeded the licensed type of services as specified by the license issued by the Department. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of Department documentation revealed the facility was licensed at a directed level of care and a total capacity of five. 2. The Compliance Officer arrived at the facility around 11:00 am, E3 reported the census of the facility was six residents. 3. During the environmental inspection of the facility, the Compliance Officer observed R1, R2, R3, R4, R5, and R6 at the facility receiving assisted living services. 4. A review of the resident medical records revealed medical records R1, R2, R3, R4, R5, and R6. In addition, the facility was providing medication services and help with activities of daily living for all six residents. 5. In an interview, E1 reported the facility had six residents since July 16, 2025, and acknowledged the facility was overcapacity. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, and interview, the health care institution failed to ensure that staff who are certified in cardiopulmonary resuscitation (CPR) were available at all times at the facility. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer arrived at the facility around 11:00 a.m. and observed that E3 and E4 were the only personnel present. E1 was not at the facility when the Compliance Officer arrived around 12:00 p.m. 2. A review of E3’s personnel record revealed there was no personnel file for E3. E3 reported being hired the day before the inspection and acknowledged not having a CPR certification. 3. A review of E4’s personnel records revealed there was no personnel file for E4. E4 reported being hired a week before the inspection and acknowledged not having a CPR certification. 4. In an interview, E1 reported that they went home around 9:30 pm the night before the inspection and had arrived around 6:00 am the day of the inspection. E1 then reported that they had left the facility around 10:00 am the day of the inspection and came back to the facility once they were notified that a Compliance Officer was at the facility. 5. During the inspection, the Compliance Officer observed that E3 and E4 did not have CPR certification, and the facility did not have staff who were certified in CPR available when E1 was away from the facility. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on 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 and E4 were not qualified to provide the required services unsupervised. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3 and E4, who identified themselves as caregivers. E3 and E4 were the only staff present at the facility with R1, R2, R3, R4, R5, and R6. E3 and E4 were providing assisted living services to residents. E1 was not at the facility when the Compliance Officer arrived. 2. A review of E3 personnel record revealed no personnel record for E3. E3 reported being hired the day before the inspection and acknowledged not being a certified caregiver. 3. A review of E4 personnel records revealed no personnel record for E4. E4 reported being hired a week before the inspection and acknowledged not being a certified caregiver. 4. Review of the https://azcg.tmutest.com website, revealed that neither E3 nor E4 had completed a caregiver's training program. 5. In an interview, E1 reported that E1 went home around 9:30 pm the night before the inspection and had arrived around 6:00 am the day of the inspection. E1 then reported that they had left the facility around 10:00 am the day of the inspection and came back to the facility once they were notified that a Compliance Officer was at the facility. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, and record review, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was incomplete documentation identifying the staff present each day to ensure the health and safety of residents and the Department was provided false and misleading information. Findings include: 1. A review of facility documentation revealed a series of work schedules dated between July, August, September, and October 2025. However, documentation was not maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. Also, for October 2025, it did not include E3 or E4 names on the work schedule. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, and interviews, the manager failed to ensure that a personnel record for each employee included current documentation of cardiopulmonary resuscitation (CPR) training for one of four reviewed employee records. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the personnel record for E1 revealed that the employee’s Cardiopulmonary resuscitation (CPR) and Automated external defibrillator (AED) certification was issued on November 28, 2023. However, no First Aid (FA) was available for review. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that a trained caregiver was present on the assisted living facility's premises when the manager was not present. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3 and E4, who identified themselves as caregivers. E3 identified themselves by E2’s name. E3 and E4 were at the facility alone with R1, R2, R3, R4, R5, and R6. E1 was not at the facility when the Compliance Officer arrived. 2. A review of E3 personnel record revealed no personnel record for E3. E3 reported being hired the day before the inspection and acknowledged not being a certified caregiver. 3. A review of E4 personnel records revealed no personnel record for E4. E4 reported being hired a week before the inspection and acknowledged not being a certified caregiver. 4. Review of the https://azcg.tmutest.com website, revealed that neither E3 nor E4 had completed a caregiver's training program. 5. In an interview, E1 referred to E3 by E3’s real name. After further review, the Compliance Officer asked E3 to confirm their identity, and E3 acknowledged E3 had given false information and used E2’s name because E3 was not a certified caregiver. E1 acknowledged that a manager or caregiver was not to be present at an assisted living when a resident was on the premises. E1 acknowledged that at least a manager or a caregiver was not present in the assisted living home when a resident was in the home. 6. In an interview, E1 reported that E1 went home around 9:30 pm the night before the inspection and had arrived around 6:00 am the next morning. E1 then reported they had left the facility around 10:00 am the day of the inspection and came back to the facility once they were notified that a Compliance Officer was at the facility and false and misleading information was provided to the Department. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure a personnel record was established and maintained for each employee as required for two of four employees sampled. The deficient practice posed a risk as the required information could not be verified, and the Department was provided false or misleading information. Findings include: 1. The Compliance Officer arrived at the facility around 11:00 am. During the environmental inspection of the facility, the Compliance Officer observed E3 and E4, who identified themselves as caregivers. E3 identified themselves by E2’s name. E3 and E4 were at the facility alone with R1, R2, R3, R4, R5, and R6. E1 was not at the facility when the Compliance Officer arrived. 2. In an interview, E1 referred to E3 by E3’s real name. After further review, the Compliance Officer asked E3 to confirm their identity, and E3 admitted they had given false information and used E2’s name because they were not a certified caregiver. 3. A review of E3 personnel record revealed no personnel record for E3. E3 reported being hired the day before the inspection and acknowledged not being a certified caregiver. In an interview, 4. A review of E4 personnel records revealed no personnel record for E4. E4 reported being hired a week before the inspection and acknowledged not being a certified caregiver 5. A review of facility personnel records revealed no personnel record for E3 and E4; no other documentation was available for review. 7. Upon further review of the https://azcg.tmutest.com website, it was revealed that neither E3 nor E4 had completed a caregiver's training program. 8. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area that monitored 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 documentation revealed the facility was licensed for a directed level of care. 2. The Compliance Officer observed multiple ambulatory residents. 3. The Compliance Officer observed an unlocked door leading to a garage, which was not monitored and did not alert an employee of the egress of a resident from the facility. Also, inside the garage, there was an unlocked door that led out to the front yard of the facility, which was also not monitored or alert an employee of the egress of a resident from the facility. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure medication stored by an assisted living facility 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 the medication. Findings include: 1. A review of Department documentation revealed the facility is licensed for directed care service. 2. During the environmental inspection of the facility with E3, the Compliance Officer observed ambulatory residents at the facility. 3. During the environmental inspection of the facility with E3, the Compliance Officer observed a medication cabinet in the hall area adjacent to the kitchen area. The medication cabinet was unlocked and accessible to residents at the facility. The medication cabinet contained medication for the six residents at the facility. 4. During the environmental inspection of the facility with E3, the Compliance Officer observed medication in a locked box in the refrigerator; the locked box was unlocked and accessible to residents. The medication in the kitchen refrigerator contained medication for the six residents at the facility. 5. During the environmental inspection of the facility with E3, the Compliance Officer observed medication in a desk in the common area of the facility, which the medication was accessible to residents. The mediation at the desk: 1- Bottle of “Signature Care Extra Strength Pain Relief Acetaminophen 500MG - 24 caplets” 1- Bottle of “Kroger Extra Strength Acetaminophen, Diphenhydramine HCI PM Sleep Aid- 100 caplets” 1- Bottle of “Fluticasone Propionate Nasal Spray 50 MCG” 1- Bottle of “Aspirin 81 MG 500 Tablets” 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat citation from an inspection conducted on June 22, 2023.

Based on observation and interview, the manager failed to ensure that oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During the environmental inspection of the facility with E3, the Compliance Officer observed, in R6’s room, an unsecured oxygen tank in the corner of the room. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet which contained the following toxic materials: 1- Bottle of “Purex Laundry Detergent” 1- Bottle of “Downy Fabric Softener” 1- Bottle of “Raid Ant and Roach Killer” 2- Bottle of “Fabuloso Multi-Purpose Cleaner” 1- Bottle of “Clorox Toilet Bowl Cleaner” 1- Bottle of “Clorox Disinfecting Wipes” 1- Bottle of “Lysol Toilet Bowl Cleaner” 1- Bottle of “Clorox Tilex Mold and Mildew Remover” 2- Bottle of “Febreze Air Mist” 2- Bottle of “Lysol Power Clean Multi-Surface Cleaner” 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided. Technical assistance was provided on this Rule on inspection on June 22, 2023

Based on documenation review, record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10), for one of two residents sampled. Findings include: 1. A review of Department documentation revealed the license for AL12543 was effective April 6, 2023. 2. A review of R2's medical record revealed a residency agreement dated August 25, 2022. However, the residency agreement was for AL11456 and a documented residency agreement for Secret Gardens Assisted Living II, AL12543, was not available for review. 3. In an interview, E1 reported E1 did not update the residency agreement for R2. E1 acknowledged a documented residency agreement with AL12543 for R2, was not available for review.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as the Department was provided false and misleading information. Findings include: 1. The Compliance Officer arrived at the facility at approximately 10:40 AM. 2. A review of R1's medical record revealed an Activities of Daily Living (ADL) Chart for June 2023. The chart revealed the following ADL's were documented as provided on June 22, 2023 at the following times: -"Partial bathing (PRN)" at 8:00 AM; -"Comb hair, wash face oral care (2x/day)" at 8:00 AM; -"Incontinence checks every 2 hours daytime twice at night...(includes skin care, and skin condition as need)" at 4:00 AM, 8:00 AM, and 10:00 AM; and -"Night checks" at 5:00 AM. However, the following ADL was documented on June 22, 2023 prior to the services being provided to R2: -"Comb hair, wash face oral care (2x/day)" at 8:00 PM. 3. In an interview, E1 reported E2 accidentally filled out the "Comb hair, wash face oral care (2x/day)" at 8:00 PM on R2's ADL. E1 acknowledged the service was documented as provided prior to the service being provided.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of one resident who received directed care services. Findings include: 1. A review of R2's medical record revealed a service plan dated in 2023 for directed care sevices. However, the service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 2. In an interview, E1 acknowledged R2's current service plan did not include R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated.

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 to the outside area allowing the resident to be at least 30 feet away from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of the facility's policies and procedures revealed a policy titled "Wandering Residents" dated April 20, 2023. The policy stated "...4. Caregivers will maintain security of locks on the front door, gates entering into the yard and hazardous areas at all times." 3. The Compliance Officer observed two ambulatory residents. 4. During the environmental inspection of the facility, the Compliance Officer observed one door which contained a locking device, leading to an outside area in the back yard, allowing residents to be a least 30 feet away from the facility. The Compliance Officer observed the door contained an alarm, however, the alarm did not control or alert employees of the egress of a resident from the facility. 5. In an interview, E1 reported the facility controls egress by locking the door leading out to the back yard. E1 acknowledged the door leading to the outside area did not control or alert employees of the egress of a resident from the facility.

Based on documentation review and interview, the manager failed to ensure medication was administered in compliance with a medication order, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a medication administration record (MAR) for June 2023. R1's June 2023 MAR indicated R1 was administered the following medications on the following dates and times: -"Trazadone 50 mg (milligrams) 1 tab @ bedtime" on June 1-21, 2023 at 8:00 PM; -"Fluoxetine cap 10 mg 1 tab daily" on June 1-21, 2023 at 8:00 AM; -"Gabapentin 100 mg takes 3 per day" on June 1-21, 2023 at 8:00 AM, 12:00 PM, and 8:00 PM; and -"Rosuvastatin 10 mg tab qd" on June 1-21, 2023 at 8:00 AM. 2. A review of R1's medical record revealed medication orders for the following medications: -"Sodium Chloride 1 mg tablet take 1 tablet by oral route 3 times every day" dated June 22, 2023; -"Gabapentin 100 mg capsule take 1 capsule by oral route 3 times every day" dated June 22, 2023; -"Prozac 10 mg capsule take 1 capsule every day" dated June 22, 2023; -"Melatonin 3 mg take 1 tablet at bedtime for sleep" dated June 22, 2023; and -"Rosuvastatin tab 10 mg take 1 tablet by mouth every day" dated May 1, 2023 through June 22, 2023. However, a medication order for "Trazadone 50 mg" was not available for review. 3. In an interview, E1 reported "Melatonin 3 mg take 1 tablet" and "Sodium Chloride 1 mg tablet" were being delievered by the pharmacy today. 4. In an interview, E1 reported E1 had an order for "Trazadone 50 mg" for R1 but could not find it. E1 reported "Trazadone 50 mg" was discontinued on June 21, 2023. E1 reported E1 did not have a discontinue order for 'Trazadone 50 mg". E1 acknowledged medications were not administered to R1 in compliance with R1's medication orders.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as the Department was provided false and misleading information. Findings include: 1. The Compliance Officer arrived at the facility at approximately 10:40 AM. 2. A review of R2's medical record revealed a medication administration record (MAR) dated June 2023. R2's June 2023 MAR revealed the following medications were documented as administered on June 22, 2023: -"Ramipril 2 mg (milligrams), 1 tab daily" at 8:00 AM; -"Sertraline HCL 100 mg 1 tab daily" at 8:00 AM; -"Solifenacin Succinate 10 mg, 1 tab daily" at 8:00 AM; -"Atorvastatin 20 mg, 1 tab daily" at 8:00 AM; -"Ferrous Sulfate 325 mg, 1 tab twice daily" at 8:00 AM; and -"Aspirin-Dipyridamole 25-200 mg 1 tab twice daily" at 8:00 AM. However, the following medication was documented as administered on June 22, 2023 at 8:00 PM, prior to the medication being administered to R1: -"Aspirin-Dipyridamole 25-200 mg 1 tab twice daily" at 8:00 PM. 3. In an interview, E2 reported E2 accidentally documented "Aspirin-Dipyridamole 25-200 mg 1 tab twice daily" as administered at 8:00 PM. 4. In an interview, E1 acknowledged R2's aforementioned PM medication was documented as administered prior to the medication being administered.