Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 38
Deficiencies: 14
Oct 23, 2024
Visit Reason
State-compiled facility profile showing 5 inspections from 2023-08 to 2024-10 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility had 14 deficiencies including failure to complete accurate resident assessments, inadequate emergency preparedness communication plans, missing fire safety equipment markings, failure to notify residents and ombudsman properly about transfers, and improper infection control practices. Some inspections found no deficiencies.
Complaint Details
Complaint investigations were conducted for intake #AZ00198605 on 2023-08-09 with no deficiencies cited, and for complaint #AZ 00203951 and #AZ 00203950 in October 2024 with deficiencies cited.
Deficiencies (14)
| Description |
|---|
| R9-10-403.C. An administrator shall ensure that: R9-10-403.C.1.g. Include a method to identify a resident to ensure the resident receives physical health services and behavioral health services as ordered; - Facility failed to properly complete a Discharge Minimum Data Set (MDS) assessment for Resident #31. |
| Emergency preparedness communication plan - Facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws including contact information for staff, physicians, volunteers, next of kin, and entities providing services. |
| Testing of emergency plan - Facility failed to participate in required drills and exercises to test the emergency plan at least annually. |
| Fire Alarm System - Installation - Facility failed to ensure the electrical breaker for the fire alarm system has visual markings to distinguish it from other breakers. |
| Portable Fire Extinguishers - Facility failed to provide a fire extinguisher near the generator as required by NFPA 10. |
| R9-10-403.C.2.a. Policies and procedures for physical health services and behavioral health services - Facility failed to ensure two residents (#86, #26) were notified of the bed-hold policy upon transfer to the hospital. |
| §483.15(c) Transfer and discharge - Facility failed to ensure one resident (#86) was permitted to return to the facility after hospitalization. |
| §483.15(c)(3) Notice before transfer - Facility failed to ensure two residents (#86, #26) were notified in writing regarding the reason for transfer and a copy was sent to the ombudsman. |
| §483.15(d) Notice of bed-hold policy and return - Facility failed to ensure two residents (#86, #26) were made aware of the bed-hold policy upon transfer to the hospital. |
| R9-10-406.F.3.c. Documentation of compliance with fingerprint clearance - Facility failed to ensure documentation of fingerprint clearance for two staff (#72 and #88). |
| R9-10-408.A.1.a. Resident transfer/discharge - Facility failed to ensure one resident (#86) was permitted to return to the facility after hospitalization. |
| R9-10-408.A.2.b. Documentation of reason for transfer or discharge - Facility failed to ensure two residents (#86, #26) were notified in writing regarding the reason for transfer and a copy was sent to the ombudsman. |
| §483.80 Infection Control - Facility failed to use appropriate hand hygiene practices and PPE when providing wound care for one resident (#18). |
| R9-10-422.3.c. Use of personal protective equipment - Facility failed to use appropriate hand hygiene practices and PPE when providing wound care for one resident (#18). |
Report Facts
Inspections on page: 5
Total deficiencies: 14
Complaint Inspections: 3
Total Capacity: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LISA M HARRISON | Administrator | Named in interviews related to bed-hold policy and fingerprint clearance deficiencies |
| Director of Nursing | Director of Nursing | Named in interviews related to bed-hold policy, transfer notifications, and fingerprint clearance deficiencies |
| RN/MDS Coordinator (Staff #9) | Registered Nurse & Minimum Data Set Coordinator | Interviewed regarding inaccurate MDS assessment for Resident #31 |
| Registered Nurse/Clinical Nurse Manager (RN/staff #1) | Registered Nurse/Clinical Nurse Manager | Observed and interviewed regarding improper hand hygiene and PPE use during wound care |
| Registered Nurse/Critical Nurse Manager (RN/staff #25) | Registered Nurse/Critical Nurse Manager | Interviewed regarding discharge planning and family concerns |
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