Inspection Reports for Fairbrook Grove Assisted Living Home Mesa AZ
3916 E Fairbrook Cir, Mesa, AZ 85205, United States, AZ, 85205
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 8, 2025, found no deficiencies during the on-site modification to the floor plan. Prior inspections showed a pattern of deficiencies related mainly to management practices, including policy review, abuse reporting, documentation, resident dignity, and ensuring safe means of exiting the facility. Enforcement actions occurred in August and October 2024, resulting in fines that were paid in full, with one October enforcement citing repeat deficiencies involving health and safety risks. Complaint investigations in September 2024 substantiated multiple deficiencies, while most complaints were unsubstantiated. The record shows some improvement with the latest inspection free of deficiencies after a period of cited issues and enforcement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Capacity: 10
Deficiencies: 0
Jan 8, 2025
Visit Reason
No deficiencies were found during the on-site modification to modify the floor plan.
Findings
No deficiencies were found during the on-site modification to modify the floor plan.
Enforcement Action
Enforcement
Fines: 1
Total: $1,250.00
Oct 15, 2024
Summary
The enforcement resulted in a fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,250.00 | Fine associated with enforcement action #00110386 | Paid |
Enforcement Action
Enforcement
Fines: 2
Total: $1,250.00
Oct 15, 2024
Summary
The enforcement resulted in civil fines for deficiencies in management practices that posed health and safety risks to residents, including a repeat deficiency from a prior inspection.
Fines & Penalties (2)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Manager failed to ensure a reasonable basis to believe abuse had occurred on the premises. | — |
| $750.00 | Manager failed to ensure safe means of exiting the facility for a resident without a key or special knowledge; repeat deficiency. | — |
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 13
Sep 16, 2024
Visit Reason
Multiple deficiencies found during complaint and compliance annual inspection including failures in policy review, abuse reporting, documentation, resident dignity, facility modifications, and safety.
Findings
Multiple deficiencies found during complaint and compliance annual inspection including failures in policy review, abuse reporting, documentation, resident dignity, facility modifications, and safety.
Complaint Details
Complaints AZ00215638 and AZ00215591 were investigated during this inspection.
Deficiencies (13)
| Description |
|---|
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411. |
| C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed. |
| J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation has occurred on the premises or while providing services, the manager shall ensure proper reporting. |
| 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 incidental contact with residents provides documentation of freedom from infectious tuberculosis (TB). |
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record. |
| B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration. |
| 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 residents without keys or special knowledge. |
| D. A manager shall ensure that: 2. A current toxicology reference guide is available for use by personnel members. |
| B. If the assisted living facility offers therapeutic diets, a manager shall ensure that: 1. A current therapeutic diet manual is available for use by employees. |
| A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas used by residents. |
| R9-10-110. Modification of a Health Care Institution: A licensee shall submit a request for approval of a modification of a health care institution. |
| D. A manager shall ensure that: 4. A resident's sleeping area: b. Is not used as a passageway to a common area, another sleeping area, or common bathroom. |
| D. A manager shall ensure that: 5. If a resident's sleeping area is in a bedroom, the bedroom has: a. For a private bedroom, at least 80 square feet of floor space. |
Enforcement Action
Enforcement
Fines: 1
Total: $1,500.00
Aug 15, 2023
Summary
The enforcement resulted in a fine of $1,500.00 which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,500.00 | Fine associated with enforcement action #00112734 | Paid |
Inspection Report
Annual Inspection
Capacity: 10
Deficiencies: 4
May 26, 2023
Visit Reason
Four deficiencies found during the on-site compliance annual inspection including failures in policy implementation, caregiver training documentation, facility exit means, and medication documentation.
Findings
Four deficiencies found during the on-site compliance annual inspection including failures in policy implementation, caregiver training documentation, facility exit means, and medication documentation.
Deficiencies (4)
| Description |
|---|
| C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident. |
| A. A manager shall ensure that: 1. A caregiver: b. Provides documentation of: i. Completion of a caregiver training program approved by the Department. |
| 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 residents without keys or special knowledge. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident's medical record. |
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