Inspection Reports for Canyon Assisted Living LLC
750 E Grand Canyon Dr, Chandler, AZ 85249, AZ, 85249
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Inspection Report
Annual Inspection
Census: 3
Capacity: 5
Deficiencies: 21
Jul 10, 2024
Visit Reason
State-compiled facility profile showing 3 inspections from 2022-2024 with deficiency history
Findings
Across three inspections from December 2022 to July 2024, multiple deficiencies were found including failures in documentation, personnel records, medication storage and administration, caregiver training, and environmental safety measures. Several deficiencies were repeated from prior inspections, indicating ongoing compliance issues.
Complaint Details
An on-site investigation of complaint AZ00188442 was conducted on December 19, 2022. Three of three allegations were substantiated and deficiencies were cited related to documentation of care, medication administration, and compliance with medication orders.
Deficiencies (21)
| 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 assistant caregivers working each day, including the hours worked by each; - Failed to maintain documentation of caregivers and assistant caregivers working each day including hours worked. |
| 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 as specified in R9-10-113; - Failed to ensure employee provided documentation of freedom from infectious tuberculosis on or before the date services began. |
| 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 resident is present and awake except nighttime hours; - Failed to ensure a trained caregiver was present when the manager was not present. |
| 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 volunteer service and, if applicable, the ending date; - Failed to include starting date of employment in personnel record for one employee. |
| 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 telephone number; b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of qualifications, education, orientation, license, tuberculosis freedom, CPR, first aid, and compliance with A.R.S. § 36-411(A) and (C); - Failed to ensure personnel record was available for one employee. |
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; - Failed to ensure caregiver documented services provided in resident's medical record. |
| C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d); - Failed to document notification of vaccination availability in resident medical record. |
| 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 includes: 6. Documentation: a. Of the resident's weight, or b. From a medical practitioner stating that weighing the resident is contraindicated; - Failed to include documentation of resident's weight or contraindication in service plan. |
| 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 locked area. |
| C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; - Failed to maintain refrigerated foods at required temperature. |
| A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months; - Failed to review disaster plan within last 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 residents; - Failed to maintain hot water temperature within required range. |
| 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 store poisonous or toxic materials in locked area inaccessible to residents. |
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; - Failed to ensure caregiver documented services provided to resident in medical record. |
| C. A manager shall ensure that a resident's medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: c. The name and signature of the individual administering or providing assistance in the self-administration of medication; - Failed to ensure medication documentation included name of individual administering medication. |
| 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; - Failed to ensure medication was administered in compliance with medication order. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition - Failed to administer a training program for all staff regarding fall prevention and fall recovery. |
| A. A manager shall ensure that: 1. A caregiver: b. Provides documentation of: i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers; - Failed to provide documentation of completion of approved caregiver training program. |
| 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 telephone number; b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of qualifications, education, orientation, license, tuberculosis freedom, CPR, first aid, and compliance with A.R.S. § 36-411(A) and (C); - Failed to ensure one employee had a personnel record. |
| 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 locked location. |
| 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 residents; - Failed to maintain hot water temperature within required range. |
Report Facts
Inspections on page: 3
Total deficiencies: 21
Complaint inspections: 1
Facility capacity: 5
Resident census: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Named in multiple findings related to documentation and interviews | |
| E3 | Named in findings related to personnel records, caregiver training, and medication administration | |
| E4 | Named in findings related to personnel records and medication storage | |
| E2 | Participated telephonically in exit interviews related to complaint inspection |
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