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”