Tucson Gardens Memory Care

Based on documentation review and interview, the assisted living center failed to provide an emergency responder a written document which included the reason the emergency responder was requested on behalf of the resident, whether a resident received medication services, basic information about the resident's physical and mental conditions and basic medical history, or a copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. Findings include: A review of facility incident reports revealed an incident report, dated February 4, 2026, at 15:49, which indicated emergency responders had been contacted on R3's behalf on February 1, 2026, at 21:00. During the on-site inspection, the Compliance Officer requested to review a copy of the documentation provided to emergency responders on February 1, 2026; however, a copy was not available. Instead, E2 provided a packet of the information which would have been provided for R3. A review of R3's emergency responder packet revealed a face sheet, orange DNR, and a list of medications; however, the reason the emergency responder was requested on behalf of the resident, whether a resident received medication services, basic information about the resident's physical and mental conditions and basic medical history, or a copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge, were not included in the packet. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the assisted living center failed to maintain a copy of the document provided to an emergency responder and documentation of the actions required by subsection B of this section for a period of two years after the date of an emergency. Findings include: A review of facility incident reports revealed an incident report dated February 4, 2026, at 15:49, which indicated emergency responders had been contacted on R3's behalf on February 1, 2026, at 21:00. During the on-site inspection, the Compliance Officer requested to review a copy of the documentation provided to emergency responders on February 1, 2026; however, a copy was not available. Instead, E2 provided a packet of the information which would have been provided for R3. In an interview, E2 reported a copy of the packet was not retained. E2 reported E2 usually puts together the information and sends it directly to the hospital electronically after the emergency responders pick up the resident, and reported emergency responders do not always want the packet. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a report of suspected abuse, neglect, or exploitation was made immediately per A.R.S. § 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: A review of facility incident reports revealed an incident report for R1, dated February 24, 2026, at 11:30. The incident report was very minimal, and stated, "Incident Description: Nursing Description: Resident pushed another resident to the floor. Resident Description: Resident would not answer questions or respond in any way. Injury Type: No injuries observed at time of incident. Other info: [R1] did not want the other resident to sit next to [R1]." A review of facility internal investigations revealed an internal investigation report dated February 27, 2026. The report stated: "Date of Incident: 02/24/2026....Facility care staff members were assigned to spend their shift providing 1:1 oversight of [R1]. The incident was reported to AZDHS & APS on 02/25/2026. [R1's] medical provider adjusted [R1's] medication, specifically Depakote. On 02/25/2026, [R1's] fiduciary began providing outside contracted caregivers to provide 1:1 oversight of [R1]. On 02/26/2026, [R1] was relocated from Cottage #3 to Cottage #4." In an interview, E1 reported E1 thought they had 24 hours to report the incident to APS. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site complaint inspection conducted on November 21, 2025.

Based on documentation review and interview, when a resident had an emergency resulting in the resident needing medical services, the manager failed to ensure a caregiver immediately notified the resident's emergency contact and primary care provider. Findings include: A review of facility incident reports revealed an incident report for R3, dated February 4, 2026, at 15:49. The incident report stated, "Incident Description: Nursing Description: Resident had difficulty breathing. 911 was called. Resident was DNR. Resident passed before they arrived.." Immediate Action taken: 911 was called. ED, RCD, RCC, MD, staff nurse, and police were notified. [R3's representative] was notified and arrived to sit with the resident." The incident report included a list of people notified and the time they were notified, which included the following: [E2] was notified on February 1, 2026, at 23:00; [R3's representative] was notified on February 1, 2026, at 21:00; [R3's primary care provider] was notified on February 1, 2026, at 23:00, two hours after the emergency contact was notified; and Tucson police department was notified on February 1, 2026, at 21:00. In an interview, E2 reported the incident occurred on February 1, 2026. E2 reported E2 had filled out the incident report, which is why the times were not exact. E2 reported, based on what the caregiver had told E2, R3 had struggled to take a few breaths and then stopped breathing. However, the narrative suggested R3 continued to breathe after 911 was called, but stopped before emergency responders arrived. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, when a resident had an emergency resulting in the resident needing medical services, the manager failed to ensure a caregiver documented the date and time of the emergency, the names of individuals who observed the emergency, or the actions taken by the caregiver. Findings include: A review of facility incident reports revealed an incident report for R3, dated February 4, 2026 at 15:49. The incident report stated, "Incident Description: Nursing Description: Resident had difficulty breathing. 911 was called. Resident was DNR. Resident passed before they arrived.." Immediate Action taken: 911 was called. ED, RCD, RCC, MD, staff nurse and police were notified. [R3's representative] was notified and arrived to sit with the resident." The incident report included a list of people notified and the time they were notified. However, the incident report did not include the date and time of the emergency, the names of individuals who observed the emergency to include the caregiver who responded to the resident, or the actions taken by the caregiver to provide first aid or other services to the resident except for calling 911. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, after having a reasonable basis to believe abuse, neglect, or exploitation of a resident had occurred, the manager failed to immediately report the incident according to A.R.S. § 46-454. The deficient practice posed a potential safety risk for residents and a potential rights violation due to a delay in reporting alleged abuse, neglect, or exploitation. Findings include: 1. A review of facility documentation revealed an incident report, dated September 28, 2025 at 13:28 which documented an allegation of physical abuse involving R4 and R5. The report stated, "Nursing Description: this resident took another residents phone. Staff returned it to the owner. Then this resident took it back from the other resident and would not let it go. So the other resident (owner of phone) got up and punched resident in the face. Immediate Action Taken: Contacted POA, and Nurse and ED. Phone was returned. Injuries observed at time of incident: No apparent injury." However, the incident report did not indicate law enforcement or adult protective services were immediately contacted or an investigation was initiated and documented within five working days. 2. In an 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 resident's service plan, when initially developed or when updated, was signed and dated by the resident or resident's representative, the manager, or the nurse who reviewed the service plan, for one of four sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan, updated October 23, 2025, for directed care services including medication administration. However, the service plan did not include any signatures. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.