Inspection Reports for Fairbrook Grove Assisted Living Home Mesa AZ
3916 E Fairbrook Cir, Mesa, AZ 85205, United States, AZ, 85205
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Inspection Report
Change Of Service
Capacity: 10
Deficiencies: 17
Jan 8, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-05-26 to 2025-01-08 with deficiency history and complaint investigation details.
Findings
Across three inspections, multiple deficiencies were identified including failures in personnel record compliance, policy reviews, abuse reporting, tuberculosis documentation, resident care documentation, facility modifications, and safety measures. One inspection found no deficiencies during a floor plan modification.
Complaint Details
The September 16, 2024 inspection included investigation of complaints AZ00215638 and AZ00215591.
Deficiencies (17)
| Description |
|---|
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411. - Failed to ensure documented good faith efforts to contact previous employers for personnel records. |
| C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed. - Failed to ensure policies and procedures were reviewed and updated as required. |
| J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation has occurred, the manager shall comply with reporting and documentation requirements. - Failed to ensure compliance with abuse reporting and investigation requirements. |
| A. A manager shall ensure that: 8. A manager, caregiver, or assistant caregiver provides evidence of freedom from infectious tuberculosis as specified in R9-10-113. - Failed to ensure documentation of freedom from infectious tuberculosis for one employee. |
| C. A manager shall ensure that: 1.g. Documents the services provided in the resident's medical record. - Failed to ensure documentation of services provided in residents' medical records. |
| B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration. - Failed to ensure resident's bedroom met minimum size and window requirements. |
| F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2.a.ii. Controls or alerts employees of the egress of a resident from the facility. - Failed to ensure means of exiting facility alerted employees of resident egress; device was switched off. |
| D. A manager shall ensure that: 2. A current toxicology reference guide is available for use by personnel members. - Failed to ensure a current toxicology reference guide was available. |
| 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. - Failed to ensure a current therapeutic diet manual was available. |
| A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas used by residents. - Failed to maintain hot water temperatures within required range; observed 142º F. |
| R9-10-110. Modification of a Health Care Institution: A licensee shall submit a request for approval of a modification affecting compliance. - Failed to submit request for approval of facility modifications. |
| D. A manager shall ensure that: 4.b. Resident's sleeping area is not used as a passageway unless conditions met. - Failed to ensure resident bedroom was not used as passageway to common area. |
| D. A manager shall ensure that: 5.a. Resident's bedroom has at least 80 square feet of floor space. - Failed to ensure resident bedroom met minimum floor space requirement. |
| C. A manager shall ensure that policies and procedures are: 1.e. Cover cardiopulmonary resuscitation training including hands-on demonstration. - Failed to ensure CPR training included hands-on demonstration for two personnel. |
| A. A manager shall ensure that: 1.b.i. Provides documentation of completion of a caregiver training program approved by the Department or NCIA Board. - Failed to ensure caregiver had approved training documentation. |
| F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2.a. Provides access to outside area and alerts employees of resident egress. - Failed to ensure exit alert systems functioned properly; some alarms did not sound. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 3.c. Medication administered is documented in resident's medical record. - Failed to ensure medication administration was properly documented. |
Report Facts
Inspections on page: 3
Total deficiencies: 17
Complaint inspections: 1
Total capacity: 10
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