GARDEN ENCLAVE ASSISTED LIVING HOMES

INSP-0131122

POC

Date: 5/9/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-06-11

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00129767 conducted on May 09, 2025:

Deficiencies Found: 16

Deficiency #1

Rule/Regulation Violated:

A.R.S. § 36-420.04.C. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document C. Each assisted living center and assisted living home must maintain a standardized form for each resident that includes the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. Each assisted living center and assisted living home shall periodically update this form for each resident as necessary.

Evidence/Findings:

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).

Temporary Solution:

The manager has created a standardized form for each resident. The Manager has completely filled up the information required on the form

Permanent Solution:

The manager will review the medical records to see if the standardized form for first responders are completed and updated.

Person Responsible:

Alma Pagay- Licensee

Deficiency #2

Rule/Regulation Violated:

R9-10-113.A.1-2. Tuberculosis Screening A. 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: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 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); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

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.

Temporary Solution:

The manager has requested a registered nurse to conduct an assessment of the health care institution's risk of exposure to infectious TB.

Permanent Solution:

The manager will conduct an assessment of the health care institution's risk of exposure to infectious TB. It will have its own folder for filing.

Person Responsible:

Alma Pagay

Deficiency #3

Rule/Regulation Violated:

R9-10-803.D.1-4. Administration D. A manager shall ensure that the following are conspicuously posted: 1. A list of resident rights; 2. The assisted living facility ' s license; 3. Current phone numbers of: a. The unit in the Department responsible for licensing and monitoring the assisted living facility, b. Adult Protective Services in the Department of Economic Security, c. The State Long-Term Care Ombudsman, and d. The Arizona Center for Disability Law; and 4. 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.

Evidence/Findings:

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.

Temporary Solution:

The manager has conspicuously posted a sign where the most recent inspection report could be located.

Permanent Solution:

The manager will conduct rounds in the facility to check if the sign is posted where the most recent inspection report could be located.

Person Responsible:

Alma Pagay

Deficiency #4

Rule/Regulation Violated:

R9-10-804.3. Quality Management A manager shall ensure that: 3. The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority.

Evidence/Findings:

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.

Temporary Solution:

The manager has completed the quality management report and submitted it to the governing authority.

Permanent Solution:

The manager will check the quality management documentation and see if the quality management report has been completed. The quality management documentation will have its own folder.

Person Responsible:

Alma Pagay

Deficiency #5

Rule/Regulation Violated:

R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident's date of occupancy, and 2. As specified in R9-10-113.

Evidence/Findings:

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.

Temporary Solution:

The manager has requested a registered nurse to complete the assessment for R1, R2, and R3's documentation of evidence of freedom from infectious tuberculosis.

Permanent Solution:

The manager will review each resident's medical records to see if the documentation of evidence of freedom from infectious tuberculosis is available.

Person Responsible:

Alma Pagay

Deficiency #6

Rule/Regulation Violated:

R9-10-807.B.1.a-b. Residency and Residency Agreements B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and

Evidence/Findings:

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.

Temporary Solution:

The manager has requested a medical professional to complete the Pre-determination form that stated whether the R1 required continuous medical services, continuous or intermittent nursing services, or restraints.

Permanent Solution:

The manager will include the Pre-determination form in the admission packet. The manager will request a medical practitioner or registered nurse to complete the form before or at the time of admission.

Person Responsible:

Alma Pagay

Deficiency #7

Rule/Regulation Violated:

R9-10-807.D.1-10. Residency and Residency Agreements D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 1. The individual's name; 2. Terms of occupancy, including: a. Date of occupancy or expected date of occupancy, b. Resident responsibilities, and c. Responsibilities of the assisted living facility; 3. A list of the services to be provided by the assisted living facility to the resident; 4. A list of the services available from the assisted living facility at an additional fee or charge; 5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours; 6. The policy for refunding fees, charges, or deposits; 7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident's service plan; 8. The policy and procedure for an assisted living facility to terminate residency; 9. The complaint process; and 10. The manager's signature and date signed.

Evidence/Findings:

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.

Temporary Solution:

The manager has completed the residency agreement for R2. The resident or resident representative has signed it and was given a copy.

Permanent Solution:

The manager will review each resident's medical records to see if the residency agreement has been completed and signed and is available for review.

Person Responsible:

Alma Pagay

Deficiency #8

Rule/Regulation Violated:

R9-10-808.A.3.a. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: a. A description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments;

Evidence/Findings:

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.

Temporary Solution:

The manager has requested a registered nurse to review and revise R2's service plan. It will include the medical or health problems of R2.

Permanent Solution:

The manager will review each resident's medical records to see if the service plan includes the medical or health problems of the residents.

Person Responsible:

Alma Pagay

Deficiency #9

Rule/Regulation Violated:

R9-10-808.A.5.a. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative;

Evidence/Findings:

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.

Temporary Solution:

The manager has requested R2's representative to sign and date the service plan.

Permanent Solution:

The manager will review each resident's medical records to see if the service plan includes the acknowledgement of the resident or resident's representative by signing and putting the date on it.

Person Responsible:

Alma Pagay

Deficiency #10

Rule/Regulation Violated:

R9-10-811.C.12. Medical Records C. A manager shall ensure that a resident's medical record contains: 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;

Evidence/Findings:

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.

Temporary Solution:

The manager has requested R1 and R2's medical practitioner to sign the doctor's orders for their medications.

Permanent Solution:

The manager will review each resident's medical records to see if doctor's orders for all the medications of the residents are signed. Upon admission, the manager will also request the resident's medical practitioner to give the facility the doctor's orders.

Person Responsible:

Alma Pagay

Deficiency #11

Rule/Regulation Violated:

R9-10-811.C.18. Medical Records C. A manager shall ensure that a resident's medical record contains: 18. Documentation of the resident's orientation to exits from the assisted living facility required in R9-10-818(B);

Evidence/Findings:

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.

Temporary Solution:

The manager has requested R2's representative to sign a documentation of the resident's orientation to exits from the assisted living facility.

Permanent Solution:

The manager will review each resident's medical records to see if there is documentation of the resident's orientation to exits from the assisted living facility. Upon admission, the manager will request the resident or resident's representative to sign the documentation.

Person Responsible:

Alma Pagay

Deficiency #12

Rule/Regulation Violated:

R9-10-811.C.9. Medical Records C. A manager shall ensure that a resident's medical record contains: 9. The resident's signed residency agreement and any amendments;

Evidence/Findings:

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.

Temporary Solution:

The manager has requested R3's representative to sign and date the residency agreement.

Permanent Solution:

The manager will review each resident's medical records to see if the residency agreement includes the acknowledgement of the resident of resident's representative by signing and putting the date on it.

Person Responsible:

Alma Pagay

Deficiency #13

Rule/Regulation Violated:

R9-10-815.C.6.a-b. Directed Care Services C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 6. Documentation: a. Of the resident's weight, or b. From a medical practitioner stating that weighing the resident is contraindicated; and

Evidence/Findings:

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.

Temporary Solution:

The manager has requested the caregivers weigh R3. If it is contraindicated, the manager will request a documentation from R3's medical practitioner stating that weighing R3 is contraindicated.

Permanent Solution:

The manager will review each resident's service plans to see if there is documentation of the resident's weight. If contraindicated, the manager will request the resident's medical practitioner for a documentation that weighing the resident is contraindicated.

Person Responsible:

Alma Pagay

Deficiency #14

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a 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 that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

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.

Temporary Solution:

The manager has requested a handyman to fix the alarm on the sliding door. When opened, the alarm will alert employees of the egress of a resident.

Permanent Solution:

The manager will instruct the employees to check the doors to see if the alarms or chimes are working.

Person Responsible:

Alma Pagay

Deficiency #15

Rule/Regulation Violated:

R9-10-816.F.1. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Evidence/Findings:

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.

Temporary Solution:

The manager has requested the caregivers to always lock the container for medications in the refrigerator.

Permanent Solution:

The manager and caregivers will check the medication cabinet and the medication container in the refrigerator to see if they are locked.

Person Responsible:

Alma Pagay

Deficiency #16

Rule/Regulation Violated:

R9-10-818.A.2. Emergency and Safety Standards A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

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.

Temporary Solution:

The manager has reviewed and approved the disaster plan

Permanent Solution:

The manager will review and make amendments to the disaster plan

Person Responsible:

Alma Pagay- Licensee

GARDEN ENCLAVE ASSISTED LIVING HOMES

Facility Information

Inspection History

INSP-0131122

Summary:

Deficiencies Found: 16

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #10

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #11

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #12

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #13

Rule/Regulation Violated: