Inspection Reports for
The Bluffs of Flagstaff Senior Living

R9-10-807 — The manager failed to ensure that seven sampled residents provided evidence of freedom from infectious tuberculosis before or within seven calendar days after occupancy, including missing TB Screening and Risk Assessment documentation. This posed a potential TB exposure risk to residents.

R9-10-808 — The manager failed to ensure that two residents had current service plans available for review due to a system glitch that resulted in shredding originals before confirming electronic uploads. The facility confirmed residents were receiving necessary services and was creating new service plans.

R9-10-810 — The manager failed to ensure a resident was not subjected to misappropriation of personal and private property by facility staff. Evidence showed an employee admitted to removing food from residents’ apartments and the facility without consent and was terminated.

R9-10-808 — The manager failed to ensure written service plans included the level of service the resident received for four residents, posing a risk due to lack of clarity on services provided.

R9-10-808 — The manager failed to ensure written service plans included the level of medication assistance for four residents, risking unclear documentation of services to be provided.

R9-10-808 — The manager failed to ensure the service plan for a resident who stored medication in their unit included how medication was stored and controlled.

R9-10-815 — The manager failed to ensure a service plan included cognitive stimulation and activities to maximize functioning for a resident receiving directed care services.

R9-10-815 — The manager failed to ensure a service plan included documentation of the resident's weight or a medical practitioner's statement that weighing was contraindicated for a resident receiving directed care services.

R9-10-806 — The manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before providing physical health services, posing a risk to resident health and safety.

R9-10-810 — The manager failed to ensure a resident was treated with dignity, respect, and consideration, including belittling and harsh treatment observed in video evidence. This deficiency was a repeat from a prior inspection.

R9-10-816 — The manager failed to ensure medication was administered in compliance with a physician's order, as a resident did not receive Sodium Chloride tablets from June 10-16, 2024 due to pharmacy non-delivery.

R9-10-818 — The manager failed to ensure documentation of resident orientation to evacuation routes within 24 hours of acceptance, as records for nine residents lacked this documentation despite orientation being conducted.

36-420.01 — The facility failed to develop and administer a fall prevention and fall recovery training program for all staff, with missing documentation for employee E4 and acknowledgment from E1 that training was not administered to all staff.

The manager failed to designate in writing a caregiver present on the premises and accountable when the manager was absent, with documentation showing E7 and E8 were not caregivers and no proper designation was made.

The manager failed to ensure that policies and procedures were reviewed at least once every three years, with no documentation indicating such review and acknowledgment from E1.

R9-10-804.1.a.-e — The manager failed to ensure a quality management plan was established, documented, and implemented, lacking required documentation despite partial reflection of rule subsections.

The manager failed to ensure documentation of current first aid and CPR training certification for two of four records, including expired certification for E1 and missing documentation for E4.

R9-10-808 — The manager failed to ensure two of three resident records contained evidence of freedom from infectious tuberculosis as required, with missing documentation for residents R2 and R3.

The manager failed to ensure that a resident's service plan was reviewed and updated at least once every three months, with the record for R5 last updated on May 2, 2023.

The manager failed to ensure a resident was treated with dignity, respect, and consideration, with an incident report showing staff E4 struck resident R1 and acknowledgment from E1.

R9-10-814 — The manager failed to obtain documentation that a non-ambulatory resident requested to remain in the facility and a medical practitioner's statement that the resident's needs were met as per the scope of services.

The manager failed to ensure medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist, with no evidence of such review.

The manager failed to ensure the disaster plan was reviewed at least once every 12 months, with no documentation available and acknowledgment from E1.

The manager failed to ensure disaster drills for employees were conducted on each shift at least once every three months and documented, with no documentation available and acknowledgment from E1.

The manager failed to ensure evacuation drills for residents were conducted at least once every six months, with documentation only for employee drills and acknowledgment from E1.

The manager failed to ensure documentation of each evacuation drill included the amount of time taken for employees to evacuate, with missing timing data for multiple 2023 drill dates and acknowledgment from E1.

The manager failed to ensure a fire inspection was conducted by the local fire department or State Fire Marshal according to the required annual timeframe, with last inspection dated April 27, 2022.