Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 14
Oct 7, 2025
Visit Reason
State-compiled facility profile showing 12 inspections from 2024-03 to 2025-10 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility was found to have 14 deficiencies primarily related to management of resident care, medication storage, emergency preparedness, and documentation. Several complaint investigations found no deficiencies, while others cited issues such as failure to ensure tuberculosis screening, inadequate transport documentation, and lack of proper opioid administration policies.
Complaint Details
Multiple complaint investigations were conducted, including complaints 00146658, 00146672, 00143076, 00134350, 00132920, 00128903, 00125973, AZ00222531, AZ00222878, AZ00220329, AZ00218076, AZ00215564, AZ00215608, AZ00214433, AZ00214450, AZ00210125, AZ00213696. Some complaint investigations found no deficiencies, while others resulted in cited deficiencies.
Deficiencies (14)
| Description |
|---|
| A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113; - Failed to ensure personnel records included documentation of freedom from infectious tuberculosis for two of ten personnel sampled. |
| A. Except as provided in subsection (B), a manager shall ensure that: 1. A caregiver or employee coordinates the transport and the services provided to the resident; 2. According to policies and procedures: a. An evaluation of the resident is conducted before and after the transport, and b. Information from the resident's medical record is provided to a receiving health care institution; and 3. Documentation includes: a. If applicable, any communication with an individual at a receiving health care institution; b. The date and time of the transport; and c. If applicable, the name of the caregiver accompanying the resident during a transport. - Failed to ensure proper evaluation and documentation for resident transport to dialysis clinic. |
| B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration; - Failed to ensure a resident was treated with dignity and respect, including improper transfer techniques and lack of use of transfer belts. |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2): 1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or - Failed to ensure required written determinations from medical providers for residents confined to bed or chair were obtained and updated every six months. |
| E. A manager shall ensure that: 1. A bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies is available in a bedroom being used by a resident receiving directed care services; or 2. An assisted living facility has implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies. - Failed to ensure working emergency alert systems in resident bedrooms on memory care unit. |
| 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; - Failed to ensure medications were stored in a locked manner; medications were found in resident bedrooms. |
| A. A manager shall ensure that 5. An evacuation drill for employees and residents: b. Includes all individuals on the premises except for: i. A resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident, and ii. Sufficient caregivers to ensure the health and safety of residents not evacuated according to subsection (A)(5)(b)(i); - Failed to ensure evacuation drills included all individuals on premises. |
| A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents; - Failed to ensure toxic materials were stored locked and inaccessible; housekeeping cart with cleaning supplies was unlocked in hallway. |
| A. A manager shall ensure that: 13. Equipment used at the assisted living facility is: a. Maintained in working order; - Failed to ensure nurse call system was maintained in working order; call system not working in several rooms on memory care unit. |
| R9-10-120. Opioid Prescribing and Treatment F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall: 1. Establish, document, and implement policies and procedures for administering an opioid as part of treatment or providing assistance in the self-administration of medication for a prescribed opioid, to protect the health and safety of a patient, that: a. Cover which personnel members may administer an opioid in treating a patient and the required knowledge and qualifications of these personnel members; b. Cover which personnel members may provide assistance in the self administration of medication for a prescribed opioid and the required knowledge and qualifications of these personnel members; c. Include how, when, and by whom a patient's need for opioid administration is assessed; d. Include how, when, and by whom a patient receiving an opioid is monitored; and e. Cover how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented; - Failed to establish and document policies and procedures for opioid administration including assessment and monitoring. |
| R9-10-120. Opioid Prescribing and Treatment F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall: 4. Except as provided in subsection (H), ensure that an individual authorized by policies and procedures to administer an opioid in treating a patient or to provide assistance in the self-administration of medication for a prescribed opioid: a. Before administering an opioid or providing assistance in the self-administration of medication for a prescribed opioid in compliance with an order as part of the treatment for a patient, identifies the patient's need for the opioid; b. Monitors the patient's response to the opioid; and c. Documents in the patient's medical record: i. An identification of the patient ' s need for the opioid before the opioid was administered or assistance in the self-administration of medication for a prescribed opioid was provided, and ii. The effect of the opioid administered or for which assistance in the self-administration of medication for a prescribed opioid was provided. - Failed to document identification of need and monitoring of opioid administration for one resident. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program. - Failed to administer a training program for all staff regarding fall prevention and fall recovery. |
| C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: g. Cover how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual; - Failed to ensure policies and procedures were established and implemented to respond to resident's sudden or intense behavior; no reassessment after incident. |
| 36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document 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 release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. - Failed to provide required written documentation to emergency responder for one resident. |
Report Facts
Inspections on page: 12
Total deficiencies: 14
Complaint inspections: 10
Total capacity: 112
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