Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 13
May 6, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-05 to 2025-05 with deficiency history and complaint investigations.
Findings
Across three inspections, multiple deficiencies were identified including failure to conspicuously post the facility license, incomplete resident documentation, inadequate medication storage, lack of staff training, and missing documentation of fire inspections and evacuation drills. Two inspections were complaint investigations and one was an annual compliance inspection.
Complaint Details
Two complaint investigations were conducted: complaint 00129363 on May 6, 2025 with deficiencies found, and complaint AZ00200696 on November 8, 2023 with no deficiencies found.
Deficiencies (13)
| Description |
|---|
| R9-10-803.D.1-4. Administration: Failed to conspicuously post the assisted living facility's license. |
| R9-10-807.B.1.a-b. Residency and Residency Agreements: Failed to ensure required documentation dated within 90 days before acceptance was submitted. |
| R9-10-808.C.1.g. Service Plans: Failed to document services provided in residents' medical records. |
| R9-10-816.F.1. Medication Services: Failed to store medication in a separate locked area. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to develop and administer fall prevention and recovery training for all staff. |
| Policies and procedures: Failed to ensure policies and procedures were reviewed at least once every three years. |
| Manager reporting: Failed to submit documented reports to governing authority as required. |
| Service plans: Failed to ensure service plans were signed and dated by nurse or medical practitioner when updated. |
| Documentation of vaccination notification: Failed to document notification of influenza and pneumonia vaccination availability. |
| Food menu: Failed to include foods to be served each day on the menu. |
| Disaster plan: Failed to review disaster plan at least once every 12 months. |
| Evacuation drill: Failed to conduct evacuation drills for employees and residents at least once every six months. |
| Fire inspection: Failed to maintain documentation of current fire inspection. |
Report Facts
Inspections on page: 3
Total deficiencies: 13
Complaint inspections: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monique Joy | Director | Named as person responsible in multiple deficiency findings |
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