The Gardens at La Cholla

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, emergency, or injury and needed medical services, as required per R9-10-818.D.2. Findings include: 1. A review of facility documentation revealed an incident report, dated September 3, 2025, documenting an incident in which R1 required medical services. The report documented the event, including the description of the emergency, names of individuals who observed the incident, actions taken by the caregiver, individuals notified, and any actions taken to prevent the emergency in the future. However, the report did not include the time the emergency occurred. 2. In an 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 provide written notification to the Department of a resident’s self-injury, within two working days after a resident inflicts a self-injury requiring immediate intervention by an emergency services provider. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for the other residents residing in the assisted living facility. Findings include: 1. A review of R1’s medical record revealed an incident report dated July 20, 2025, which indicated R1 was sent to the hospital after suffering a head injury. The report reflected R1 “…smacked [R1’s] head purposely against the sharps container,” and R1 was left “…unresponsive and shaking.” 2. A review of Department documentation revealed evidence of the facility’s written notification to the Department of R1’s self-injury was unavailable for review. 3. In an interview, E1 acknowledged the facility had failed to notify the Department within two days of R1’s self-injury, which required immediate intervention by an emergency services provider.

Based on record review and interview, the manager failed to ensure the service plan for one of two sampled residents receiving directed care services included strategies to ensure a resident’s personal safety and documentation of the coordination of communications with the resident’s representative or family members. Findings include: 1. A review of R2’s medical record revealed a service plan, dated April 29, 2025, for directed care services. The service plan included documentation of R2’s weight and indicated R2 had lost 13.6 pounds between March 17, 2025, and April 29, 2025. The service plan included a section titled ‘Weight Loss/Gain,” which contained a note stating, “Care associate will weigh resident monthly or as ordered and will report significant weight loss of 5% or more in 30 days, 7.5% or more 90 days or 10% or more in 180 days to Provider.” However, the service plan did not include documentation of coordination of communications with R1’s representative or family members. 2. In an interview, E1 acknowledged R1’s service plan did not include documentation of coordination of communications with the resident’s representative or family members.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident’s date of occupancy. Findings include: 1. A review of R2’s medical record revealed evidence of documentation of a negative TB skin test. However, the test was not performed and entered into R2’s medical record until twelve days after R2’s date of occupancy at the facility. 2. In an interview, E1 acknowledged R2 had not provided evidence of freedom from infectious TB as specified in R9-10-113, within seven calendar days of their respective dates of occupancy.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which included the level of service the resident is expected to receive, or included the amount, type, and frequency of assisted living services being provided, for two of four residents sampled. Findings include: 1. A review of R1’s medical record revealed written and signed service plans. R1’s service plan included the service “Support Stockings,” which indicated caregivers were to “assist resident with applying/removing support stockings…” R1’s service plan also included the service “Denture(s),” which indicated caregivers “will provide assistance with oral care, resident has [their] own teeth.” However, the service plan did not indicate the amount of assistance the resident required or the frequency of either service. 2. A review of R2’s medical record revealed written and signed service plans. However, R2’s service plan did not include the level of service (directed care) R2 would receive. 3. In an interview, E1 agreed R1’s and R2’s service plans did not include either the amount and frequency or the level of service each resident was expected to receive.

Based on document review and interview, the manager failed to ensure an evacuation drill was conducted at least every six months. Findings include: 1. A review of facility documentation revealed evidence of documentation of an evacuation drill conducted on April 2, 2025. However, evidence of documentation an evacuation drill was conducted in the preceding six months was unavailable for review. 2. In an interview, E1 advised they were unable to locate documentation of an evacuation drill conducted in September 2024, October, 2024, or November 2024. E1 acknowledged the facility had not conducted an evacuation drill every six months as required.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed each resident had a current service plan which included the services needed by each resident. 2. A review of R1's and R2's medical record revealed documentation of services provided to each resident on each shift. However, the documentation included multiple omissions for each resident where provided services had not been documented, and where documentation of, "as needed," (PRN) tasks were erroneously indicated to have been provided. 3. In an interview, E1 acknowledged the services provided to each resident were not accurately documented in each resident's medical record.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include the amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication, for one of three residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan updated May 11, 2023 for directed care services. The service plan included assistance with dressing and grooming. However, the service plan did not include the frequency at which the dressing and grooming services would be provided to R2. In addition, the service plan indicated R2 would be "supported to take all medications...," however the service plan did not indicate if R2 received medication administration or assistance in self-administration of medication. 5. In an interview, E1 acknowledged R2's service plan did not include the frequency of assisted living services and did not indicate if R2 was being provided medication administration or assistance in the self-administration of medication.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of three directed care residents sampled. Findings include: 1. A review of R3's (admitted April 2022) medical record revealed a service plan for directed care services dated March 6, 2023. However, evidence of an updated service plan after March 6, 2023, was unavailable for review. 2. In an interview, E1 acknowledged R3's service plan was not updated at least once every three months.

Based on record review and interview, the manager failed to ensure that resident medical record contained documentation of assisted living services provided for two of three residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated May 11, 2023, which indicated R2 received directed care services for a variety of daily services to include the following: Eating: Staff will cue R2 for meals, offer and encourage hydration with all meals... Dressing: Staff will provide assistance with fastening clothing as needed 2. A review of R2's medical record revealed a document used for tracking activities of daily living, dated "July 2023." The document contained sections for documentation of meal services at "0900, 1300" and "1800" hours, and daily dressing services. However, documentation of these services having been provided was not available for review during the following dates and/or times indicated: Eating: at 1300 hours on July 3, July 6 and July 19, 2023, at 1800 hours on July 2, July 8 and July 9, 2023 Dressing: July 8, July 11, July 13, July 17 and July 18, 2023. 3. A review of R3's medical record revealed a service plan, dated March 6, 2023, which indicated R3 received directed care services for a variety of daily services to include the following: Eating: Staff will cue R3 for meals, R3 will be present at all meals... Dressing: Associates will supervise R3's clothing set-up. Assist R3 with dressing and undressing as needed. Grooming: Provide assistance with grooming needs Hearing: Assist R3 with R3's hearing aides and observe for support needs 4. A review of R3's medical record revealed a document used for tracking activities of daily living, dated "July 2023." The document contained sections for documentation of meal services at "0900, 1300" and "1800" hours, daily dressing services, grooming and hearing. However, documentation of these services having been provided was not available for review during the following dates and/or times indicated: Eating: at 0900 and 1300 hours on July 2-6, July 8, July 10-15, and July 17-19, 2023, at 1800 hours on July 4, July 11 and July 16 2023 Dressing: July 4 and July 11, 2023 Grooming: July 4 and July 11, 2023 Hearing: July 4 and July 11, 2023 5. In an interview E1 acknowledged there was no documentation of aforementioned services provided to R2 or R3 during the dates and times noted above.

Based on document review, observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom or residential unit being used by a resident receiving directed care services. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During a facility tour, the Compliance Officer observed three residential units which did not did not have a bell, intercom, or other mechanical means to alert employees to a resident's needs. 3. In an interview, E1 confirmed all residents at the facility received directed care. E1 acknowledged the residential units were occupied, however did not include a bell, intercom or other mechanical means to alert employees to a resident's needs.