10 Reports
Inspection Report — Sep 5, 2025
Annual Inspection
Date: Sep 5, 2025
Visit Reason
On-site complaint investigation of complaint #2609854 combined with an annual recertification survey at a Nursing Care Institution, conducted 2 through 5 September 2025.
Complaint Details
The recertification survey was conducted in conjunction with the investigation of complaint #2609854.
Findings
The inspection found six deficiencies related to failure to provide required written notices, timely reporting and documentation of abuse allegations, and adherence to abuse policies and procedures.
Deficiencies (6)
R9-10-403 — The facility failed to provide written notice to the resident or resident representative specifying the duration of the state bed-hold policy for one resident (#48).
R9-10-403 — The facility failed to ensure that an allegation of abuse for one resident (Resident #20) was reported to the State Agency in a timely manner.
R9-10-403 — The facility failed to ensure that written abuse policy and procedures were followed regarding the alleged abuse of one resident (Resident #20).
The facility failed to ensure that written abuse policy and procedures were followed and adhered to regulations regarding the alleged abuse of one resident (Resident #20).
The facility failed to ensure that an allegation of abuse for one resident (Resident #20) was reported to the State Agency in a timely manner.
The facility failed to provide written notice to the resident or resident representative specifying the duration of the state bed-hold policy for one resident (#48). This could result in residents not being able to exercise their right to return to the facility of choice.
Report Facts
Deficiencies cited: 6
Complaints investigated: 1
Inspection Report — Oct 23, 2024
Date: Oct 23, 2024
Visit Reason
On-site inspection of type Other at a Nursing Care Institution, conducted 23 October 2024.
Findings
The inspection found four deficiencies related to emergency preparedness communication, participation in drills, fire alarm system identification, and fire extinguisher placement. Plans of correction were provided for all deficiencies.
Deficiencies (4)
The facility failed to develop and maintain an emergency preparedness communication plan that includes contact information for staff, physicians, volunteers, next of kin, and entities providing services under arrangement. Management confirmed the absence of this information in the Emergency Plan during the exit conference.
The facility failed to participate in required drills, lacking documentation of participation in a full-scale community-based exercise or tabletop drills within the last year. Management confirmed no proof of participation during the exit conference.
NFPA 101 - 2012 Edition, Section 18.3.4.5.1 — The facility failed to ensure the electrical breaker for the fire alarm system had visual markings to distinguish it from other breakers. Management confirmed this deficiency during the facility tour and exit conference.
NFPA 10 — The facility failed to provide a fire extinguisher within 50 feet of the generator. Management confirmed the absence of a fire extinguisher near the generator during the facility tour and exit conference.
Report Facts
Deficiencies cited: 4
Inspection Report — Oct 18, 2024
Annual Inspection
Date: Oct 18, 2024
Visit Reason
On-site complaint investigation of complaint AZ 00203951 and annual compliance survey at a Nursing Care Institution, conducted 15 to 18 October 2024.
Complaint Details
The State compliance survey was conducted October 15, 2024 through October 18, 2024, in conjunction with the investigation of Complaint # AZ 00203951. The Recertification survey was conducted October 15, 2024 through October 18, 2024, in conjunction with the investigation of Complaint # AZ 00203950.
Findings
One deficiency was cited related to inaccurate completion of the Discharge Minimum Data Set (MDS) assessment for Resident #31, which could delay identification of potential risks and care needs.
Deficiencies (1)
R9-10-403 — The facility failed to properly complete a Discharge Minimum Data Set (MDS) assessment for Resident #31, resulting in discrepancies between progress notes and MDS regarding the resident's discharge destination.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #9 | RN/MDS Coordinator | Interviewed regarding discrepancies in Resident #31's MDS and progress notes. |
Inspection Report — Oct 18, 2024
Date: Oct 18, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with proper completion of the Resident Assessment Instrument (RAI), specifically focusing on the accuracy of the Discharge Minimum Data Set (MDS) assessment for Resident #31.
Findings
The facility failed to properly complete the Discharge MDS assessment for Resident #31, resulting in discrepancies between progress notes and the MDS regarding the resident's discharge destination. The RN/MDS Coordinator inaccurately recorded the discharge to a short-term hospital instead of home health, contrary to facility expectations and Medicare guidelines.
Deficiencies (1)
Failure to properly complete a Discharge Minimum Data Set (MDS) assessment for Resident #31, causing inaccurate resident discharge information.
Report Facts
Resident ID: 31
Discharge date: Jul 5, 2024
Discharge summary date: Jul 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/MDS Coordinator | Interviewed regarding the inaccurate MDS assessment for Resident #31 | |
| Director of Nursing | Interviewed regarding facility expectations for MDS completion |
Inspection Report — Nov 10, 2023
Date: Nov 10, 2023
Visit Reason
On-site other inspection of a Nursing Care Institution at Advanced Healthcare of Mesa, conducted 6 to 10 November 2023.
Findings
No deficiencies were found during this inspection. The facility met all applicable federal, state, and local standards.
Inspection Report — Nov 9, 2023
Annual Inspection
Date: Nov 9, 2023
Visit Reason
On-site complaint investigation and annual compliance survey conducted November 6 through November 9, 2023, including investigation of complaint AZ00178129 and federal investigation AZ00178127 at a Nursing Care Institution.
Complaint Details
The State compliance survey was conducted November 6, 2023 through November 9, 2023, in conjunction with the investigation of complaint AZ00178129. The federal recertification survey was conducted concurrently with investigation of complaint AZ00178127.
Findings
The inspection found nine deficiencies related to failure to notify residents of bed-hold policies upon hospital transfer, failure to permit a resident to return after hospitalization due to COVID-19 status, failure to provide written transfer notices to residents and ombudsman, incomplete personnel fingerprint clearance documentation, and improper hand hygiene and PPE use during wound care. Plans of correction were provided for all deficiencies.
Deficiencies (9)
R9-10-403 — The facility failed to ensure two residents (#86, #26) were notified of the bed-hold policy upon transfer to the hospital, and no signed bed-hold policy was found in their records.
§483.15(c) — The facility failed to ensure one resident (#86) was permitted to return after hospitalization due to COVID-19 positive status and lack of implemented COVID-19 care plan.
§483.15(c)(3) — The facility failed to provide two residents (#86, #26) with written notification of the reason for transfer and failed to send a copy to the ombudsman.
§483.15(d) — The facility failed to ensure two residents (#86, #26) were made aware of the bed-hold policy in writing upon transfer to the hospital.
R9-10-406 — The facility failed to maintain documentation of fingerprint clearance for two staff members (#72 and #88).
R9-10-408 — The facility failed to permit resident #86 to return after hospitalization due to COVID-19 positive status and lack of staffing to care for COVID-19 positive residents.
R9-10-408 — The facility failed to document in writing the reason for transfer for two residents (#86, #26) and failed to send this documentation to the ombudsman.
§483.80 — The facility failed to use appropriate hand hygiene and PPE when providing wound care for resident #18, including failure to sanitize hands before donning new gloves and improper glove storage.
R9-10-422 — The facility failed to ensure proper use of hand hygiene and personal protective equipment during wound care for resident #18, increasing risk of infection.
Report Facts
Deficiencies cited: 9
Complaints investigated: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #81 | Director of Nursing | Interviewed regarding bed-hold policy, transfer procedures, and COVID-19 care plan implementation. |
| Staff #90 | Administrator | Interviewed regarding bed-hold policy, transfer procedures, fingerprint clearance, and COVID-19 care plan. |
| Staff #72 | Staff member | Personnel record reviewed for fingerprint clearance documentation. |
| Staff #88 | Staff member | Personnel record reviewed for fingerprint clearance documentation. |
| Staff #25 | Registered Nurse/Critical Nurse Manager | Interviewed regarding discharge planning and COVID-19 transfer procedures. |
| Staff #1 | Registered Nurse/Clinical Nurse Manager | Observed and interviewed regarding wound care hand hygiene and PPE practices. |
Inspection Report — Nov 9, 2023
Complaint Investigation
Date: Nov 9, 2023
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to properly transfer and discharge residents, provide timely notification to residents and ombudsman, notify residents of bed-hold policies, and implement infection prevention and control practices.
Complaint Details
The investigation was complaint-driven, focusing on issues related to resident transfers, notifications, bed-hold policies, and infection control. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure proper readmission of a Covid-19 positive resident, timely written notification of transfer reasons to residents and ombudsman, notification of bed-hold policies, and appropriate infection control practices during wound care. Interviews and documentation review revealed multiple deficiencies related to communication, policy implementation, and infection prevention.
Deficiencies (4)
Failed to permit one resident (#86) to return to the facility after hospitalization due to positive Covid-19 status without a signed bed-hold policy.
Failed to provide timely written notification to residents (#86, #26) and ombudsman regarding reasons for transfer and discharge.
Failed to notify residents (#86, #26) in writing about the bed-hold policy upon transfer to hospital.
Failed to use appropriate hand hygiene and PPE practices during wound care for resident (#18), increasing risk of infection.
Report Facts
Date of Covid-19 positive test: Nov 14, 2023
Mental status score: 13
Mental status score: 12
Pressure ulcer size: 3
Pressure ulcer size: 0.8
Vital signs: 112
Vital signs: 121
Vital signs: 72
Vital signs: 102.7
Vital signs: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding resident transfers, Covid-19 policies, and bed-hold policy implementation. |
| Administrator | Administrator | Interviewed regarding facility policies on Covid-19 positive residents and notification procedures. |
| Registered Nurse/Clinical Nurse Manager | Registered Nurse/Clinical Nurse Manager | Observed and interviewed regarding wound care practices and infection control. |
Inspection Report — Aug 9, 2023
Complaint Investigation
Date: Aug 9, 2023
Visit Reason
On-site complaint investigation of intake #AZ00198605 and #AZ00198604 at a Nursing Care Institution, conducted 9 August 2023.
Complaint Details
A complaint survey was conducted on August 9, 2023 for the investigation of intake #AZ00198605 and intake #AZ00198604. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 29, 2022
Annual Inspection
Date: Sep 29, 2022
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements, focusing on treatment and monitoring of a skin injury for resident #86.
Findings
The facility failed to ensure a physician's order was obtained for treatment and monitoring of a skin tear sustained by resident #86 after a fall. The wound care was inconsistently managed, with staff unaware or not responsible for dressing changes, and the Director of Nursing acknowledged the wound should have been monitored with a physician's order.
Deficiencies (1)
Failure to obtain a physician's order to treat and monitor a skin injury for resident #86.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)/Staff #29 | Stated awareness of resident #86's fall and skin tear but did not change dressing as it was the wound nurse's responsibility. | |
| Licensed Practical Nurse (LPN)/Staff #25 | Observed providing wound care; stated unawareness of wound and that an order should have been present to change dressing and monitor infection. | |
| Director of Nursing (DON)/Staff #47 | Acknowledged wound should have been monitored with a physician's order and that she would have followed up if aware of the skin tear. |
Inspection Report — Sep 29, 2022
Recertification
Date: Sep 29, 2022
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with care standards, specifically focusing on treatment and monitoring of a resident's skin injury.
Findings
The facility failed to ensure a physician's order was obtained to treat and monitor a skin injury for resident #86, resulting in inadequate wound care and oversight. Observations and interviews confirmed the wound was not properly monitored or treated according to policy.
Deficiencies (1)
Failure to obtain a physician's order to treat and monitor a skin injury for resident #86.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (Staff #29) | Interviewed regarding wound care and dressing changes for resident #86 | |
| Licensed Practical Nurse (Staff #25) | Observed providing wound care and interviewed about wound dressing for resident #86 | |
| Director of Nursing (Staff #47) | Interviewed about wound monitoring and physician's order requirements |
4 CMS Surveys
CMS Survey — Nov 9, 2023
Nov 9, 2023
CMS Survey — Sep 29, 2022
Sep 29, 2022
CMS Survey — Nov 9, 2023
Nov 9, 2023
CMS Survey — Oct 18, 2024
Oct 18, 2024
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