The most recent inspection on July 23, 2024, resulted in enforcement action due to regulatory non-compliance, with a fine that has been fully paid. Earlier inspections showed repeated deficiencies involving caregiver presence, personnel records, documentation of services, medication storage, and hot water temperature maintenance. Prior reports included substantiated complaints related to medication administration and documentation, as well as enforcement actions with fines totaling several thousand dollars. Complaint investigations were mostly substantiated when they occurred, focusing on medication and documentation issues. The facility’s inspection history shows ongoing challenges with compliance in key areas, with enforcement actions continuing through the most recent report.
Deficiencies (last 2 years)
Deficiencies (over 2 years)10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Multiple deficiencies found related to documentation, caregiver presence, medication storage, personnel records, and facility safety.
Findings
Multiple deficiencies found related to documentation, caregiver presence, medication storage, personnel records, and facility safety.
Deficiencies (13)
Description
A. A manager shall ensure that: 7. Documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and a...
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 mo...
B. A manager of an assisted living home shall ensure that: 4. At least the manager or a caregiver is present at an assisted living home when a residen...
C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: b. The individual's starting date of employment or volu...
C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual's name, date of birth, and contact te...
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
C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccinat...
C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services in...
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, c...
C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. F...
A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;
A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by re...
A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a lock...
The facility was found to have failed to ensure proper caregiver certification and personnel record maintenance, resulting in civil fines totaling $1000.
Fines & Penalties (2)
Amount
Reason
Status
$500.00
The manager failed to ensure an employee working as a caregiver provided documentation of completion of an approved caregiver training program.
—
$500.00
The manager failed to ensure a personnel record was established and maintained for one employee.
Three substantiated allegations with deficiencies related to documentation of services, medication administration, and compliance with medication orders.
Findings
Three substantiated allegations with deficiencies related to documentation of services, medication administration, and compliance with medication orders.
Complaint Details
Complaint AZ00188442 substantiated with three deficiencies cited.
Deficiencies (3)
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
C. A manager shall ensure that a resident's medical record contains: 13. Documentation of medication administered to the resident or for which the res...
B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is a...
Deficiencies found related to staff training on fall prevention, personnel records, medication storage, and hot water temperature maintenance.
Findings
Deficiencies found related to staff training on fall prevention, personnel records, medication storage, and hot water temperature maintenance.
Deficiencies (5)
Description
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop an...
A. A manager shall ensure that: 1. A caregiver: b. Provides documentation of: i. Completion of a caregiver training program approved by the Department...
C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual's name, date of birth, and contact te...
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, c...
A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by re...
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