Inspection Report
Complaint Investigation
Capacity: 42
Deficiencies: 6
Sep 11, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2023-08-01 to 2025-09-11 with deficiency and complaint investigation history.
Findings
Across five inspections, including complaint and annual compliance investigations, a total of six deficiencies were found primarily related to documentation of training, service plan signatures, evacuation drills, and disaster plan reviews. Several complaint investigations found no deficiencies.
Complaint Details
Complaint investigations were conducted on 2025-09-11, 2025-07-15, and 2024-10-18 with no deficiencies found. Complaints investigated include 00144397, 00144393, 00137796, 00137769, 00136353, 00136338, AZ00217490, and AZ00217603.
Deficiencies (6)
| Description |
|---|
| A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. Based on documentation review, and interview, the manager failed to ensure before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults for one of four caregivers sampled. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative; Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, for one of four sampled residents. |
| F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or Based on record review, documentation review, observation, and interview, the manager of a facility providing directed care services failed to ensure a means of exiting the facility providing access to an outside area alerted employee of the egress of a resident from the facility. |
| A. A manager shall ensure that 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and 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); Based on documentation review, and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months and includes all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative; b. The manager; c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan. Based on record review, documentation review, and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative and the manager, when initially developed and when updated, for two of four residents sampled. |
| A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months; Based on documentation review, and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. |
Report Facts
Inspections on page: 5
Total deficiencies: 6
Complaint inspections: 4
Total capacity: 42
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