Inspection Report
Modification
Capacity: 72
Deficiencies: 6
Oct 9, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-06-15 to 2025-10-09 with deficiency history and complaint investigations.
Findings
Across four inspections, deficiencies were found related to documentation of services, medication administration compliance, medication storage, premises safety, and timely submission of required medical documentation. Two complaint investigations were conducted, one with deficiencies and one without.
Complaint Details
Complaint investigations AZ00200459, AZ00200826, AZ00201167, and AZ00215609 were conducted on September 11, 2024 with deficiencies found; complaint AZ00210306 was investigated on May 15, 2024 with no deficiencies cited.
Deficiencies (6)
| Description |
|---|
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and - Failed to ensure accurate documentation of services provided to residents R1 and R3. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and - Failed to ensure medication was administered in compliance with orders for resident R3. |
| 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 medication was stored in a separate locked area. |
| A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury; - Failed to ensure premises were free from hazards such as unlocked cabinets containing cleaning supplies. |
| B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and 2. If an individual is requesting or is expected to receive behavioral health services, other than behavioral care, in addition to supervisory care services, personal care services, or directed care services from an assisted living facility: a. Includes whether the individual requires continuous behavioral health services, and b. Is signed and dated by a behavioral health professional. - Failed to ensure required documentation was submitted within 90 days before acceptance for two residents. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: iii. At least once every three months for a resident receiving directed care services; and - Failed to ensure service plan was reviewed and updated at least every three months for one resident. |
Report Facts
Inspections on page: 4
Total deficiencies: 6
Complaint inspections: 2
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