45 Reports
Inspection Report — May 8, 2026
Complaint Investigation
Date: May 8, 2026
Visit Reason
On-site complaint investigation of intakes 2990039 and 2991856 at a Nursing Care Institution, conducted 7-8 May 2026.
Complaint Details
An onsite complaint survey was conducted on May 7, 2026 through May 8, 2026 for the investigation of the intakes# 2990039 & 2991856 under the Event ID# 230C5C -H1. No deficiencies cited. Life Care Center of Paradise Valley is in compliance with 9 A.A.C. 10, Article 4, Requirements for Nursing Care Institutions. An onsite complaint survey was conducted on May 7, 2026 through May 8, 2026 for the investigation of the intakes# 2990039 & 2991856 under the Event ID# 230C5C -H1. No deficiencies cited. Life Care Center of Paradise Valley is in compliance with 42CFR Part 483, Requirements for Long Term Care Facilities.
Findings
No deficiencies were cited during this complaint investigation. The facility was found in compliance with applicable state and federal requirements.
Inspection Report — Apr 14, 2026
Complaint Investigation
Date: Apr 14, 2026
Visit Reason
On-site complaint investigation of intakes 00163099, 00163099, 00163298, 00161394, and 00161395 at a Nursing Care Institution, conducted 14 April 2026.
Complaint Details
The complaint survey was conducted April 14, 2026, with investigation of intakes: 00163099, 00163099, 00163298, 00161394, and 00161395. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 5
Inspection Report — Mar 12, 2026
Date: Mar 12, 2026
Visit Reason
On-site inspection of type Other at a Nursing Care Institution, Life Care Center of Paradise Valley, conducted 12 March 2026.
Findings
The inspection identified seven deficiencies related to emergency preparedness drills, emergency power system documentation, exit door locking mechanisms, fire alarm system identification, sprinkler system maintenance, corridor door compliance, and smoke barrier penetrations.
Deficiencies (7)
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2) — The facility failed to participate in required emergency drills, which may lead to untrained staff and potential harm to residents during an emergency.
§482.15(e) — The facility failed to ensure that their Emergency Preparedness plan included documentation of emergency and standby power systems, risking harm during an emergency.
Egress Doors — The facility failed to maintain a special locking exit door on the 2nd floor, lacking manual release which could cause harm in an emergency.
Fire Alarm System - Installation — The facility failed to ensure the electrical breaker for the fire alarm system was visually marked to distinguish it from other breakers, risking harm in an emergency.
Sprinkler System - Maintenance and Testing — The facility failed to maintain sprinkler heads and ensure all parts met UL Listing, including damaged or missing escutcheon plates, risking harm to patients.
Corridor - Doors — The facility failed to provide corridor doors in accordance with NFPA 101 requirements, potentially affecting approximately 14 residents.
Subdivision of Building Spaces - Smoke Barrier Construction — The facility failed to fill penetrations in multiple smoke barriers, allowing smoke and heat to penetrate other areas, risking harm to all residents and staff in a fire.
Report Facts
Deficiencies cited: 7
Complaints investigated: 0
Inspection Report — Mar 6, 2026
Complaint Investigation
Date: Mar 6, 2026
Visit Reason
On-site complaint investigation of intakes 2794003, 00160964, 2796504, and 00161222 at a Nursing Care Institution, conducted 6 March 2026.
Complaint Details
A complaint survey was conducted on March 6, 2026 for the investigation of intake(s) #: 2794003, 00160964, 2796504, 00161222. There were no findings cited.
Findings
This inspection resulted in no citations or deficiency findings.
Report Facts
Complaints investigated: 4
Inspection Report — Feb 20, 2026
Annual Inspection
Date: Feb 20, 2026
Visit Reason
On-site complaint and annual recertification survey conducted from February 17 to 20, 2026, including investigation of complaints 00159245, 00155145, 2745157, and 2707640 at a Nursing Care Institution.
Complaint Details
The recertification and complaint survey was conducted from February 17 through February 20, 2026, with investigation of complaints 00159245, 00155145, 2745157, and 2707640.
Findings
The inspection found four deficiencies related to infection control and medication storage practices. The facility failed to implement appropriate infection control for a sampled resident and did not ensure secure medication storage for some residents.
Deficiencies (4)
R9-10-403 — The facility failed to ensure appropriate infection control practices were implemented for 1 of 5 sampled residents (#136) regarding following contact precautions.
§483.45(g) and §483.45(h) — The facility failed to ensure medications were stored securely and were left unattended at residents' bedsides for two sampled residents (#53 and #40) and on top of the medication cart, risking unauthorized access and harm.
§483.80 — The facility failed to ensure appropriate infection control practices were implemented for 1 of 5 sampled residents (#136) regarding following contact precautions, risking spread of preventable illness.
R9-10-421 — The facility failed to ensure medications were stored securely and were left unattended at residents' bedsides for two sampled residents (#53 and #40) or on top of the medication cart.
Report Facts
Deficiencies cited: 4
Complaints investigated: 4
Inspection Report — Dec 26, 2025
Complaint Investigation
Date: Dec 26, 2025
Visit Reason
On-site complaint investigation of complaints 00152373, 00151700, 00148768, and 00135263 at a Nursing Care Institution, conducted 26 December 2025.
Complaint Details
The onsite complaint survey was conducted on December 26, 2025, and investigated complaints # 00152373, 00151700, 00148768, and 00135263. The federal comments also note investigation of complaints #2684193, 2678919, 2651975, and 2678761. There were no deficiencies noted.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 4
Complaints investigated: 4
Inspection Report — Oct 1, 2025
Complaint Investigation
Date: Oct 1, 2025
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On-site complaint investigation of complaints 00146378, 00146575, 2631095, and 2632161 at a Nursing Care Institution, conducted 1 October 2025.
Complaint Details
The state complaint survey was conducted on October 1, 2025, of the following complaint numbers 00146378 and 00146575. The complaint survey was conducted on October 1, 2025, of the following complaint numbers 2631095 and 2632161. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 4
Inspection Report — Sep 26, 2025
Complaint Investigation
Date: Sep 26, 2025
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On-site complaint investigation of intakes 00146040, 00144536, 00144553, and 00144338 at a Nursing Care Institution, conducted 26 September 2025.
Complaint Details
An onsite complaint survey was conducted on September 26, 2025 for the investigation of intake #00146040, 00144536, 00144553, 00144338. Federal comments also note investigation of intake #2627284, 2613452, 2613580, 2612285. There were no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Report Facts
Complaints investigated: 4
Inspection Report — Sep 19, 2025
Complaint Investigation
Date: Sep 19, 2025
Visit Reason
On-site complaint investigation of complaints 00145202, 2620170, and 2619807 at a Nursing Care Institution, conducted 19 September 2025.
Complaint Details
The onsite complaint survey was conducted on September 19, 2025 and investigated complaints #00145202, 2620170, and 2619807. There were no deficiencies noted.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 3
Inspection Report — Aug 14, 2025
Complaint Investigation
Date: Aug 14, 2025
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On-site complaint investigation of complaints 00140781, 00137240, 00138792, 00136314, 2586237, 2562451, 2581102, and 2272085 at a Nursing Care Institution, conducted 14 August 2025.
Complaint Details
The investigation of complaints 00140781, 00137240, 00138792, and 00136314 was conducted on August 14, 2025. The investigation of complaints 2586237, 2562451, 2581102, and 2272085 was conducted on August 14, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 8
Inspection Report — Jun 19, 2025
Complaint Investigation
Date: Jun 19, 2025
Visit Reason
On-site complaint investigation of complaints 00133411, 00132731, 00132780, AZ00224863, AZ00224817, and AZ00224789 at a Nursing Care Institution, conducted 19 June 2025.
Complaint Details
The investigation of Complaints 00133411, 00132731, 00132780, AZ00224863, AZ00224817, and AZ00224789 was conducted on June 19, 2025.
Findings
The inspection found two deficiencies related to failure to properly clean and disinfect mechanical lifts used for resident transfers, which could result in the spread of infection and resident illness.
Deficiencies (2)
§483.80 — The facility failed to ensure that a mechanical lift for resident transfer was cleaned and disinfected according to professional standards after resident use, increasing risk of infection spread.
R9-10-422 — The facility failed to ensure policies and procedures for sterilization, disinfection, and storage of medical equipment were properly implemented for mechanical lifts used in resident transfers.
Report Facts
Deficiencies cited: 2
Complaints investigated: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #20 | Certified Nursing Assistant | Observed rolling mechanical lift without cleaning or disinfecting after resident use. |
| Staff #7 | Certified Nursing Assistant | Observed rolling mechanical lift without cleaning or disinfecting after resident use and confirmed lift was not wiped down after use. |
| Staff #54 | Unit Manager | Interviewed regarding cleaning and disinfecting procedures for mechanical lifts. |
| Staff #1 | Director of Nursing | Interviewed regarding facility expectations for cleaning and disinfecting resident equipment. |
Inspection Report — Jun 19, 2025
Routine
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards, specifically regarding the cleaning and disinfection of mechanical lifts used for resident transfers.
Findings
The facility failed to ensure that mechanical lifts were cleaned and disinfected according to professional standards after resident use, which could result in the spread of infection and resident illness. Observations and interviews confirmed that staff did not clean the lifts or slings after use, contrary to facility policy and manufacturer instructions.
Deficiencies (1)
Failure to clean and disinfect mechanical lifts after resident use as per professional standards and facility policy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/Staff #20) | Observed not cleaning or disinfecting mechanical lift after use. | |
| Certified Nursing Assistant (CNA/Staff #7) | Observed not cleaning or disinfecting mechanical lift after use and confirmed in interview. | |
| Unit Manager (Staff #54) | Interviewed regarding cleaning and disinfecting expectations for mechanical lifts. | |
| Director of Nursing (DON/Staff #1) | Interviewed regarding facility expectations for cleaning and disinfecting resident equipment. |
Inspection Report — Jun 19, 2025
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards, specifically regarding the cleaning and disinfection of mechanical lifts used for resident transfers.
Findings
The facility failed to ensure that mechanical lifts were cleaned and disinfected according to professional standards after resident use, which could result in the spread of infection and resident illness. Observations and interviews confirmed that staff did not clean the lifts or slings after use, contrary to facility policy and manufacturer instructions.
Deficiencies (1)
Failure to clean and disinfect mechanical lifts after resident use as required by facility policy and manufacturer instructions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Staff 20 | Certified Nursing Assistant | Observed not cleaning mechanical lift after use and picking up unwiped sling with bare hands. |
| CNA Staff 7 | Certified Nursing Assistant | Observed not cleaning mechanical lift after use. |
| Unit Manager Staff 54 | Unit Manager | Interviewed regarding cleaning procedures for mechanical lifts. |
| Director of Nursing Staff 1 | Director of Nursing | Interviewed regarding facility expectations for cleaning and disinfecting resident equipment. |
Inspection Report — Jun 3, 2025
Complaint Investigation
Date: Jun 3, 2025
Visit Reason
On-site complaint investigation of intakes AZ00224603 and 00131574 at a Nursing Care Institution, conducted 3 June 2025.
Complaint Details
Investigation of intakes #AZ00224603 and 00131574 was conducted on June 3, 2025. No deficiencies were cited. Investigation of intakes #AZ00224603 and AZ00224639 was conducted on June 3, 2025. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — May 20, 2025
Complaint Investigation
Date: May 20, 2025
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On-site complaint investigation of intake numbers 00130487, AZ00221961, AZ00224498, and AZ00221959 at a Nursing Care Institution, conducted 20 May 2025.
Complaint Details
The complaint survey was conducted on May 20, 2025, investigating intake numbers 00130487, AZ00221961, AZ00224498, and AZ00221959. No deficiencies were cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Report Facts
Complaints investigated: 4
Inspection Report — Mar 14, 2025
Complaint Investigation
Date: Mar 14, 2025
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On-site complaint investigation of complaints 00122141 and AZ00223768 at a Nursing Care Institution, conducted 13-14 March 2025.
Complaint Details
The investigation of complaint 00122141 was conducted on March 13, 2025- March 14, 2025. The investigation of complaint AZ00223768 was conducted on March 13, 2025- March 14, 2025. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Dec 26, 2024
Complaint Investigation
Date: Dec 26, 2024
Visit Reason
On-site complaint investigation of multiple complaints including AZ00203867, AZ00218238, AZ00214215, AZ00213629, AZ00213610, AZ00213421, AZ00213257, AZ00214259, AZ00213227, AZ00220929, AZZ00218236, AZ00214213, AZ00213628, AZ00213609, AZ00213415, AZ00213258, AZ00213256, and AZ00213227 at a Nursing Care Institution, conducted 26 December 2024.
Complaint Details
A complaint survey was conducted on December 26, 2024 for the investigation of intake numbers AZ00203867, AZ00218238, AZ00214215, AZ00213629, AZ00213610, AZ00213421, AZ00213257, AZ00214259, AZ00213227, AZ00220929, AZZ00218236, AZ00214213, AZ00213628, AZ00213609, AZ00213415, AZ00213258, AZ00213256, and AZ00213227. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Sep 9, 2024
Complaint Investigation
Date: Sep 9, 2024
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On-site complaint investigation of complaints AZ00215493 and AZ00215491 at a Nursing Care Institution, conducted 9 September 2024.
Complaint Details
The investigation of complaint AZ00215493 was conducted on 09/09/2024. The investigation of complaint AZ00215491 was conducted on 09/09/2024. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 26, 2024
Complaint Investigation
Date: Aug 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of verbal and physical abuse of resident #77 by a family member.
Complaint Details
The complaint was substantiated based on interviews with staff and the resident, who reported verbal abuse including derogatory name-calling and physical abuse including slapping and hitting with a tissue box by the resident's sister. The family member was prohibited from visiting the resident following the incident.
Findings
The facility failed to ensure resident #77 was free from verbal and physical abuse by a family member, resulting in emotional trauma. Interviews with staff and the resident confirmed the family member yelled, called the resident derogatory names, and physically struck the resident, leading to the family member being barred from visiting.
Deficiencies (1)
Failure to protect resident #77 from verbal and physical abuse by a family member.
Report Facts
Frequency of family visits: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #202 | Certified Nursing Assistant (CNA) | Reported family yelling and resident's report of being slapped |
| Staff #180 | Licensed Practical Nurse (LPN) | Conducted assessment of resident after incident and reported awareness of prior arguments |
| Staff #205 | Social Services Director (SSD) | Followed up with resident for socio-emotional assessment and managed family visitation restrictions |
| Staff #15 | Administrator | Stated expectations for staff to report abuse and reviewed facility abuse prevention policy |
Inspection Report — Aug 7, 2024
Date: Aug 7, 2024
Visit Reason
On-site other inspection of a Nursing Care Institution at Life Care Center of Paradise Valley conducted on 7 August 2024.
Findings
The inspection found three deficiencies related to emergency preparedness and fire safety, including failure to participate in mandated emergency drills, failure to conduct required fire drills, and failure to provide battery-operated emergency lighting to all emergency power supply equipment locations.
Deficiencies (3)
The facility failed to participate in mandated emergency drills, missing documentation for a full-scale community-based exercise or tabletop drills within the last year.
The facility failed to conduct all required fire drills per NFPA 101 during the first and second quarters of 2024 for the second shift.
The facility failed to provide battery-operated emergency lighting to all emergency power supply equipment locations, and the emergency lighting for the generator was not functioning or tested.
Report Facts
Deficiencies cited: 3
Inspection Report — Jul 18, 2024
Annual Inspection
Date: Jul 18, 2024
Visit Reason
On-site complaint investigation of complaints AZ00212632, AZ00212414, AZ00212205, AZ00211996, AZ00211754, AZ00211959, AZ00211740, AZ00213141 and AZ00213160, conducted in conjunction with the annual compliance survey at a Nursing Care Institution, conducted 15 through 18 July 2024.
Complaint Details
The State compliance survey was conducted July 15 through July 18, 2024, in conjunction with the investigation of complaint #AZ00212632, AZ00212414, AZ00212205, AZ00211996, AZ00211754, AZ00211959, AZ00211740, AZ00213141 and AZ00213160. The Federal Recertification Survey was conducted in conjunction with intake #AZ00212631, AZ00212413, AZ00212203, AZ00211994, AZ00211754, AZ00211958, AZ00211740, AZ00213139 and AZ00213158.
Findings
The inspection found 17 deficiencies including failure to ensure valid CPR and first aid certification for an occupational therapist, inaccurate reflection of a resident's advance directives in the medical record, failure to treat a resident with dignity and respect by a visitor, inadequate monitoring for side effects of psychotropic medication, failure to maintain current fingerprint clearance for a nurse, and deficiencies in discharge planning and respiratory care.
Deficiencies (17)
R9-10-403 — The facility failed to ensure the occupational therapist (OT/staff #88) had valid CPR and first aid certifications, with expired documentation and misunderstanding of certification requirements among staff.
R9-10-403 — The facility failed to ensure one resident's (#3) advance directives and orders were accurately reflected in the medical record, resulting in inconsistent code status documentation and lack of revised care plans.
§483.10(a) — The facility failed to ensure one resident (#25) was treated with dignity and respect by a visitor who yelled and cursed at the resident, causing distress and requiring staff intervention.
§483.10(c)(6) — The facility failed to ensure one resident's (#3) choice regarding advance directives and orders were accurately reflected in the medical record, risking staff not following the resident's wishes.
R9-10-406 — The facility failed to ensure one Registered Nurse (RN/staff #98) maintained a current fingerprint clearance card, with the card expired since June 7, 2024 while the nurse continued working.
§483.21(b) — The facility failed to implement a care plan intervention for monitoring medication side effects related to an antianxiety medication for one resident (#60), with no documentation of monitoring from June 13 to 24, 2024.
§483.21(b) — The facility failed to revise a care plan to include resident-specific nutritional goals for one resident (#76), despite significant unplanned weight loss and refusal of supplements.
§483.21(c)(1) — The facility failed to ensure discharge planning based on assessed needs and goals for one resident (#49), resulting in delays and lack of coordination for oxygen and durable medical equipment (DME) needs.
§483.25(i) — The facility failed to ensure one oxygen-dependent resident (#49) did not have an empty oxygen tank while in use, risking inadequate respiratory care.
§483.35 — The facility failed to ensure the occupational therapist (OT/staff #88) had valid CPR and first aid certifications, risking staff not being knowledgeable to provide emergency care.
§483.45(e) — The facility failed to adequately monitor for side effects related to psychotropic medication use for one resident (#60), with no documentation of side effect monitoring during medication administration.
R9-10-408 — The facility failed to ensure discharge planning coordination for one resident (#49), including lack of timely DME referrals and transportation arrangements, causing discharge delays.
R9-10-410 — The facility failed to ensure one resident (#25) was treated with dignity and respect by a visitor who yelled, cursed, and threatened the resident, causing distress and requiring staff intervention.
R9-10-411 — The facility failed to adequately monitor for side effects related to psychotropic medication use for one resident (#60), with no documentation of side effect monitoring during medication administration.
R9-10-414 — The facility failed to develop and implement a care plan intervention for monitoring medication side effects related to antianxiety medication for one resident (#60), with no documented monitoring.
R9-10-414 — The facility failed to review and revise a care plan to include resident-specific nutritional goals for one resident (#76), despite ongoing significant weight loss and refusal of supplements.
R9-10-419 — The facility failed to ensure one oxygen-dependent resident (#49) did not have an empty oxygen tank while in use, risking inadequate respiratory care and failure to monitor oxygen levels.
Report Facts
Deficiencies cited: 17
Complaints investigated: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #88 | Occupational Therapist | Failed to have valid CPR and first aid certifications |
| Staff #55 | Payroll Coordinator | Interviewed regarding CPR certification and fingerprint clearance |
| Staff #12 | Director of Nursing | Interviewed regarding CPR certification, advance directives, medication monitoring, and discharge planning |
| Staff #3 | Resident #3 | Advance directives inconsistencies |
| Staff #63 | Licensed Practical Nurse | Interviewed regarding resident #3 advance directives |
| Staff #98 | Registered Nurse | Fingerprint clearance expired |
| Staff #60 | Resident #60 | Medication side effect monitoring deficiencies |
| Staff #76 | Resident #76 | Care plan nutritional goals not revised |
| Staff #49 | Resident #49 | Discharge planning and respiratory care deficiencies |
| Staff #42 | Certified Nursing Assistant | Observed empty oxygen tank for resident #49 |
| Staff #25 | Resident #25 | Subject of visitor disrespect and threats |
| Staff #13 | Registered Nurse | Interviewed regarding visitor incident with resident #25 |
| Staff #75 | Licensed Practical Nurse | Interviewed regarding visitor incident with resident #25 |
| Staff #50 | Social Services | Interviewed regarding resident #25 incident and discharge planning |
| Staff #112 | Licensed Practical Nurse | Interviewed regarding medication side effect monitoring for resident #60 |
| Staff #77 | Registered Dietician | Interviewed regarding resident #76 weight loss |
Inspection Report — Jul 18, 2024
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to resident dignity and respect following an incident involving a visitor, discharge planning failures for a resident, and respiratory care concerns for an oxygen-dependent resident.
Findings
The facility failed to ensure a resident was treated with dignity and respect by a visitor, failed to develop an adequate discharge plan addressing oxygen and durable medical equipment needs for a resident, and failed to ensure an oxygen-dependent resident did not have an empty oxygen tank while in use. These deficiencies had the potential for minimal harm or delay in care.
Deficiencies (3)
Failed to ensure one resident was treated with dignity and respect by a visitor.
Failed to ensure a discharge plan based on assessed needs and goals was in place for one resident, resulting in delayed transfer/discharge.
Failed to ensure one oxygen-dependent resident did not have an empty oxygen tank while in use.
Report Facts
Resident sample size: 18
Oxygen order: 2
BIMS score: 13
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding visitor incident and discharge process | |
| Registered Nurse | Interviewed regarding visitor incident | |
| Licensed Practical Nurse | Interviewed regarding visitor incident and acting nurse supervisor duties | |
| Social Services Director | Interviewed regarding visitor incident and discharge planning | |
| Certified Nursing Assistant | Interviewed regarding visitor incident and oxygen tank observation | |
| Executive Director of Assisted Living Facility | Communicated concerns regarding discharge planning and DME setup |
Inspection Report — Jul 18, 2024
Complaint Investigation
Date: Jul 18, 2024
Visit Reason
The inspection was conducted following a complaint regarding a visitor's inappropriate behavior towards resident #25 and concerns about resident care and rights, as well as other identified deficiencies related to advance directives, care planning, discharge planning, respiratory care, staff competencies, and psychotropic medication monitoring.
Complaint Details
The complaint investigation was triggered by an incident on June 12, 2024, where a visitor yelled and cursed at resident #25, threatening to throw him out of a window, due to concerns about another resident's exposed clothing. The visitor was removed and restricted to lobby visits. The investigation included interviews with staff and residents, and review of policies. The visitor's behavior was unusual and not previously observed. Resident #25 was upset but denied inappropriate behavior.
Findings
The facility failed to ensure resident #25 was treated with dignity and respect by a visitor, failed to accurately reflect resident #3's advance directives in the medical record, failed to implement care plan interventions for monitoring medication side effects for resident #60, failed to revise care plans with resident-specific nutritional goals for resident #76, failed to ensure discharge planning met resident #49's needs including DME and transportation, failed to ensure resident #49 did not have an empty oxygen tank while in use, failed to ensure occupational therapist staff had valid CPR and first aid certifications, and failed to adequately monitor side effects related to psychotropic medication for resident #60.
Deficiencies (8)
Failed to ensure resident #25 was treated with dignity and respect by a visitor who yelled and cursed at the resident.
Failed to ensure resident #3's advance directives and orders were accurately reflected in the medical record.
Failed to implement care plan intervention for monitoring medication side effects related to anti-anxiety medication for resident #60.
Failed to revise care plan to include resident-specific nutritional goals for resident #76 despite significant weight loss.
Failed to ensure discharge planning for resident #49 addressed assessed needs including oxygen and durable medical equipment (DME) and transportation.
Failed to ensure resident #49 did not have an empty oxygen tank while in use.
Failed to ensure occupational therapist staff had valid CPR and first aid certifications.
Failed to adequately monitor side effects related to psychotropic medication (Ativan) for resident #60.
Report Facts
Resident sample size: 18
Ativan administrations: 10
Weight loss: 14.2
Weight loss: 15
BIMS score: 13
BIMS score: 15
BIMS score: 0
BIMS score: 6
BIMS score: 11
Oxygen liters per minute: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding visitor incident and care plan monitoring | |
| Registered Nurse (RN) | Interviewed regarding visitor incident and resident assessments | |
| Licensed Practical Nurse (LPN) | Interviewed regarding visitor incident and medication monitoring | |
| Certified Nursing Assistant (CNA) | Interviewed regarding visitor incident and oxygen tank monitoring | |
| Social Services Director (SSD) | Interviewed regarding discharge planning and DME coordination | |
| Registered Dietician (RD) | Interviewed regarding nutritional care and weight loss monitoring | |
| Payroll Coordinator | Interviewed regarding occupational therapist CPR and First Aid certification | |
| Occupational Therapist (OT) | Personnel file reviewed for CPR and First Aid certification |
Inspection Report — Jun 14, 2024
Complaint Investigation
Date: Jun 14, 2024
Visit Reason
On-site complaint investigation of multiple complaints including AZ00188742, AZ00206842, and AZ00208261 at a Nursing Care Institution, conducted 10 June 2024 through 14 June 2024.
Complaint Details
The investigation of complaints AZ00188742, AZ00206842, AZ00208261, AZ00178130, AZ00176282, AZ00190592, AZ00188777, AZ00175602, AZ00197073, AZ00177684, AZ00177532, AZ00182661, AZ00191287, AZ00172120, AZ00192258, AZ00207367, AZ00209154, AZ00187909, AZ00206856, AZ00208340, AZ00210030, AZ00209852, AZ00209601, AZ00201066, AZ00171737, AZ00178836, AZ00189594, AZ00188996, AZ00192730, AZ00192230, AZ00202604, AZ00209182, AZ00202194, AZ00191391, AZ00170936, AZ00172208, AZ00170991, AZ00196081, AZ00208845, AZ00180278, AZ00184608, AZ00189551 was conducted on June 10, 2024 through June 14, 2024. Federal complaints AZ00176281, AZ00190591, AZ00188776, AZ00175601, AZ00197069, AZ00177683, AZ00177531, AZ00182657, AZ00191286, AZ00172119, AZ00192254, AZ00207365, AZ00209153, AZ00187907, AZ00206852, AZ00208336, AZ00210029, AZ00209851, AZ00209600, AZ00201065, AZ00171735, AZ00178835, AZ00189592, AZ00188995, AZ00192729, AZ00192229, AZ00202603, AZ00209179, AZ00202193, AZ00191388, AZ00170935, AZ00172205, AZ00170988, AZ00196080, AZ00208844, AZ00180280, AZ00184607, AZ00189550, AZ00188742, AZ00206842, AZ00208261, AZ00178130 were also investigated during this period.
Findings
The inspection found two deficiencies related to failure to ensure residents were free from verbal abuse. The facility documented incidents of verbal aggression between residents and failed to prevent these occurrences.
Deficiencies (2)
§483.12 — The facility failed to ensure that two residents were free from verbal abuse, including incidents where residents shouted and used offensive language towards each other, requiring staff intervention and psychiatric evaluation.
R9-10-410 — The administrator failed to ensure that residents were not subjected to abuse, as evidenced by verbal aggression incidents between two residents that were not adequately prevented despite care plans and staff interventions.
Report Facts
Deficiencies cited: 2
Inspection Report — May 16, 2024
Complaint Investigation
Date: May 16, 2024
Visit Reason
On-site complaint investigation of intakes AZ00209865, AZ00199483, AZ00207839, AZ00207722, and AZ00209631 at a Nursing Care Institution, conducted 15-16 May 2024.
Complaint Details
A complaint survey was conducted on May 15-16, 2024 for the investigation of intake #AZ00209865, AZ00199483, AZ00207839, AZ00207722, AZ00209631. Federal comments also referenced intakes AZ00151895, AZ00209865, AZ00199483, AZ00207838, AZ00207722, AZ00209630.
Findings
The inspection found two deficiencies related to verbal abuse of Resident #8 by Certified Nursing Assistant Staff #30. Staff #30 was terminated for verbally abusing the resident and reported to the board of nursing.
Deficiencies (2)
§483.12 — The facility failed to ensure Resident #8 was free from verbal abuse by CNA Staff #30, who made threatening remarks. Staff #30 was terminated and reported to the board of nursing.
R9-10-410 — The administrator failed to ensure Resident #8 was not subjected to verbal abuse by CNA Staff #30, who was terminated following the incident. The facility updated the care plan and reinforced abuse policies.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #30 | Certified Nursing Assistant | Implicated in verbal abuse of Resident #8. |
| Staff #1 | Administrator | Conducted interview during investigation of verbal abuse incident. |
| Staff #6 | Director of Nursing | Conducted interview and confirmed termination of Staff #30 for verbal abuse. |
Inspection Report — May 16, 2024
Annual Inspection
Date: May 16, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulations related to resident abuse prevention and overall facility standards.
Findings
The facility failed to ensure one resident (#8) was free from verbal abuse by a staff member, resulting in minimal harm or potential for actual harm. The staff member involved was terminated following the investigation, and the facility updated the resident's care plan to address behavior issues.
Deficiencies (1)
Failure to protect resident #8 from verbal abuse by staff member (Staff #30).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #30 | Certified Nursing Assistant | Named in verbal abuse finding and subsequent termination. |
| Staff #6 | Director of Nursing | Conducted interview confirming termination of Staff #30 and facility expectations regarding abuse. |
| Staff #1 | Administrator | Participated in investigation interview regarding the verbal abuse incident. |
Inspection Report — Apr 8, 2024
Complaint Investigation
Date: Apr 8, 2024
Visit Reason
On-site complaint investigation of complaints AZ00208718, AZ00208618, and AZ00208721 at a Nursing Care Institution, conducted 8 April 2024.
Complaint Details
The investigation of complaint #s AZ00208718, AZ00208618, AZ00208721 was conducted on 4/8/2024. There were no deficiencies cited. Federal Comments also noted investigation of complaint #s AZ00208718, AZ00208615, AZ00208720 with no deficiencies cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Feb 14, 2024
Complaint Investigation
Date: Feb 14, 2024
Visit Reason
On-site complaint investigation of multiple complaints at a Nursing Care Institution, conducted 14 February 2024.
Complaint Details
The onsite complaint survey was conducted from 2/12/2024 through 2/15/2024 and investigated multiple complaints including AZ00168569, AZ00183779, AZ00191360, AZ00191527, AZ00191532, AZ00195573, AZ00201539, AZ00201636, AZ00202922, AZ00205632, AZ00205675, AZ00205799, AZ00205900, AZ00174861, AZ00166223, AZ00178675, AZ00179154, AZ00179217, AZ00186019, AZ00187324, AZ00166859, AZ00167095, AZ00167127, AZ00167349, AZ00168167, AZ00168298, AZ00168985, AZ00169828.
Findings
This inspection found nine deficiencies related to failure to notify family of resident condition changes, resident abuse, incomplete care plan updates, inadequate fall prevention measures, and insufficient infection control precautions.
Deficiencies (9)
§483.10(g)(14) — The facility failed to ensure communication was provided to the family when resident #369 had a change of condition, risking confusion between the family and the facility.
§483.12 — The facility failed to ensure resident #520 was free from abuse by resident #525, who punched the resident multiple times, resulting in potential harm to other residents.
§483.21(b) — The facility failed to update and revise care plans for residents #525 and #535 after incidents of resident-to-resident altercations, lacking interventions to mitigate further incidents.
§483.25(d) — The facility failed to provide a floor mat for fall prevention for resident #333 as required by the care plan, increasing risk of preventable falls.
§483.80 — The facility failed to ensure transmission-based precautions, including enhanced barrier precautions, signage, and PPE, were in place to prevent infection transmission, risking spread of infections.
R9-10-410 — The facility failed to ensure resident #520 was free from abuse by resident #525, who punched the resident multiple times, risking harm to other residents.
R9-10-412 — The facility failed to notify resident #369's family of a significant change in condition, resulting in lack of communication and potential confusion.
R9-10-414 — The facility failed to update care plans for residents #525 and #535 after resident-to-resident altercations, lacking interventions to prevent further incidents.
R9-10-422 — The facility failed to implement transmission-based precautions, including enhanced barrier signage and PPE, to prevent infection transmission, risking widespread infection.
Report Facts
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #87 | Social Services Director | Interviewed regarding notification of family for resident #369's change of condition. |
| Staff #110 | Social Services Assistant | Interviewed regarding notification of family for resident #369's change of condition. |
| Staff #94 | Director of Nursing | Interviewed regarding notification procedures and care plan updates. |
| Staff #25 | Certified Nursing Assistant | Interviewed regarding reporting and investigation of resident-to-resident abuse. |
| Staff #22 | Licensed Practical Nurse | Interviewed regarding resident-to-resident abuse and reporting procedures. |
| Staff #79 | Certified Nursing Assistant | Interviewed regarding fall prevention measures for resident #333. |
| Staff #88 | Licensed Practical Nurse | Interviewed and observed regarding fall prevention measures for resident #333. |
| Staff #43 | Assistant Director of Nursing/Infection Preventionist | Interviewed regarding infection control and transmission-based precautions. |
| Staff #450 | Executive Administrator | Interviewed regarding facility policy adherence for infection control. |
Inspection Report — Jan 19, 2024
Date: Jan 19, 2024
Visit Reason
On-site inspection of a Nursing Care Institution at Life Care Center of Paradise Valley conducted 19 January 2024 as an Other type inspection with worksheet type Nursing Care Institution.
Findings
The inspection identified six deficiencies related to emergency preparedness communication, exit door locking mechanisms, lint accumulation in laundry dryers, blocked fire extinguishers, door maintenance, and smoke barrier penetrations. All findings were acknowledged by management and plans of correction were provided.
Deficiencies (6)
The facility failed to maintain an emergency preparedness communication plan with current contact information for staff, service entities, next of kin, other facilities, and volunteers, as the plan included outdated vendor information.
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.2.2.2.4 — Two special locking exit doors required more than 15 pounds of force to release, exceeding the allowed limit and potentially delaying emergency egress.
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 — Two of three commercial laundry dryers had excessive lint accumulation approximately one to two inches thick, increasing fire risk.
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 — Two ABC type fire extinguishers were blocked by equipment, preventing ready access during emergencies.
NFPA 101 Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5 — Several doors failed to latch securely, including elevator fire doors, a 60-minute rated food storage room door, and a door to room 221, compromising smoke and heat containment.
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 — Several penetrations in smoke barriers were not sealed, allowing smoke and heat to potentially spread throughout the facility during a fire.
Report Facts
Deficiencies cited: 6
Inspection Report — Jan 18, 2024
Complaint Investigation
Date: Jan 18, 2024
Visit Reason
The inspection was conducted due to a complaint submitted by resident #1 on September 30, 2018, regarding the facility's failure to retain medical records as required by State law.
Complaint Details
Complaint was submitted by resident #1 on September 30, 2018 at 5:50 p.m. The complaint was substantiated by findings that the facility destroyed medical records before the required six-year retention period.
Findings
The facility failed to ensure that medical records for resident #1 were retained for the required six years after discharge, as the records were destroyed prematurely. The facility transitioned to Electronic Medical Records in 2019 and did not store records onsite before the transition.
Deficiencies (1)
Failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, specifically failure to retain medical records for resident #1 as required by State law.
Report Facts
Complaint submission date: Sep 30, 2018
Record retention period: 6
Survey completion date: Jan 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed on January 18, 2024 regarding record retention and transition to Electronic Medical Records |
Inspection Report — Jan 18, 2024
Annual Inspection
Date: Jan 18, 2024
Visit Reason
On-site complaint investigation and annual compliance survey conducted January 16-18, 2024, at a Nursing Care Institution, investigating multiple complaint intake numbers including AZ00204495, AZ00204360, and AZ00204198.
Complaint Details
The State compliance survey was conducted in conjunction with investigation of intake numbers AZ00204495, AZ00204360, AZ00204198, AZ00203594, AZ00201638, AZ00201495, AZ00200707, AZ00200170, AZ00199839, AZ00199201, AZ00199141, AZ00199009, AZ00198819, AZ00198817, AZ00198430, AZ00198097, AZ00186331, AZ00169494, AZ00151895, AZ00149459, AZ00145204, AZ00144117 and AZ00142773. The federal recertification survey was conducted in conjunction with investigation of intake numbers AZ00204494, AZ00204360, AZ00204198, AZ00203593, AZ00201637, AZ00201495, AZ00200707, AZ00200169, AZ00199837, AZ00199008, AZ00199200, AZ00199141, AZ00198818, AZ00198817, AZ00198430, AZ00198096, AZ00186328, AZ00169495, AZ00159470, AZ00154347, AZ00154306, AZ00154088, AZ00151895, AZ00149433, AZ00149459, AZ00145204, AZ00144177 and AZ00142773.
Findings
The inspection found two deficiencies related to the facility's failure to retain medical records for a resident as required by State law and federal regulations. Both deficiencies involved destruction of records before the required retention period.
Deficiencies (2)
R9-10-403 — The facility failed to ensure that the medical record for one resident was retained as required by State law, with records older than six years destroyed offsite despite the requirement to retain them.
§483.20(f)(5) and §483.70(i) — The facility failed to retain resident medical records for the required period, resulting in destruction of records before the six-year retention period mandated by State law.
Report Facts
Deficiencies cited: 2
Inspection Report — Jan 18, 2024
Plan of Correction
Date: Jan 18, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to retain medical records for a resident as required by State law.
Complaint Details
Complaint was submitted by resident #1 on September 30, 2018 at 5:50 p.m. The complaint was related to the failure to retain medical records as required by State law.
Findings
The facility failed to ensure that medical records for one resident were retained for the required six years after discharge, as the records had been destroyed prematurely. The facility transitioned to Electronic Medical Records in 2019 and used offsite storage, but did not retain records older than six years.
Deficiencies (1)
Failure to retain medical records for one resident as required by State law.
Report Facts
Years records retained: 6
Date of complaint: Sep 30, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| administrator | Interviewed on January 18, 2024 regarding record retention and facility transition to Electronic Medical Records. |
Inspection Report — Dec 29, 2023
Complaint Investigation
Date: Dec 29, 2023
Visit Reason
On-site complaint investigation of intake numbers AZ00204652, AZ00204623, AZ00204680, and AZ00204682 at a Nursing Care Institution, conducted 29 December 2023.
Complaint Details
A complaint survey was conducted on December 29, 2023 for the investigation of intake numbers AZ00204652, AZ00204623, AZ00204680, and AZ00204682. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Nov 29, 2023
Complaint Investigation
Date: Nov 29, 2023
Visit Reason
On-site complaint investigation of intakes AZ00199288, AZ00203513, AZ00202684, AZ00199287, AZ00203498, and AZ00202683 at a Nursing Care Institution, conducted 28 through 29 November 2023.
Complaint Details
A complaint survey was conducted on November 28 through 29, 2023 for the investigation of intake #s: AZ00199288, AZ00203513 and AZ00202684. A complaint survey was conducted on November 28 through 29, 2023 for the investigation of intake #s: AZ00199287, AZ00203498 and AZ00202683. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Report Facts
Complaints investigated: 6
Inspection Report — Nov 8, 2023
Complaint Investigation
Date: Nov 8, 2023
Visit Reason
On-site complaint investigation of multiple complaints including AZ00202310, AZ00172002, AZ00172003, AZ00163375, AZ00169826, AZ00170333, AZ00170692, AZ00171388, AZ00171614, AZ00172433, AZ00180875, AZ00182561, AZ00197766 and AZ00200068 at a Nursing Care Institution, conducted 6 through 8 November 2023.
Complaint Details
A complaint survey was conducted November 6 through 8, 2023 investigating intake numbers AZ00202310, AZ00172002, AZ00172003, AZ00163375, AZ00169826, AZ00170333, AZ00170692, AZ00171388, AZ00171614, AZ00172433, AZ00180875, AZ00182561, AZ00197766 and AZ00200068. Federal comments noted investigation of intake numbers AZ00202309, AZ00172002, AZ00172003, AZ00163375, AZ00169826, AZ00170333, AZ00170692, AZ00171388, AZ00171614, AZ00172433, AZ00180874, AZ00182560, AZ00197764 and AZ00200067.
Findings
The inspection found six deficiencies related to failure to prevent misappropriation of medications for multiple residents and failure to protect a resident from staff verbal abuse. The facility lacked policies and procedures to audit medication administration and failed to implement abuse prevention policies.
Deficiencies (6)
R9-10-403 — The facility failed to ensure physician ordered medications were not misappropriated for 10 residents, as medications were documented as dispensed but not administered according to the Medication Administration Record.
R9-10-403 — The facility failed to implement policies on abuse for one resident and on misappropriation of property for 10 residents, including inadequate investigation and follow-up of a staff verbal abuse incident.
§483.12 Freedom from Abuse, Neglect, and Exploitation — The facility failed to protect one resident from staff verbal abuse, resulting in an unsafe resident environment.
§483.12 — The facility failed to ensure medications were not misappropriated for 10 residents, risking inadequate medication supply to meet medical needs.
§483.12(b) — The facility failed to develop and implement policies to prohibit abuse, neglect, exploitation, and misappropriation of resident property, including investigation and training requirements.
R9-10-410 — The facility failed to protect one resident from staff verbal abuse, including failure to prevent and address the abusive behavior.
Report Facts
Deficiencies cited: 6
Complaints investigated: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #91 | Certified Nursing Assistant | Involved in verbal abuse incident with resident #91. |
| Staff #80 | Director of Nursing | Interviewed regarding lack of policy to audit controlled substance records. |
| Staff #100 | Licensed Practical Nurse | Interviewed about medication administration and documentation procedures. |
| Staff #75 | Licensed Practical Nurse | Interviewed about medication administration and documentation procedures. |
| Staff #38 | Licensed Practical Nurse | Interviewed about medication administration and documentation procedures. |
Inspection Report — Aug 21, 2023
Enforcement
Date: Aug 21, 2023
Visit Reason
Civil monetary penalty, action 00112713 (invoice INV-259153), assessed 21 August 2023.
Findings
A $500.00 penalty was assessed and paid in full on 12 November 2023.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Aug 8, 2023
Enforcement
Date: Aug 8, 2023
Visit Reason
Civil monetary penalty, action 00112813 (invoice INV-259229), assessed 8 August 2023.
Findings
A $500.00 penalty was assessed and paid in full on 24 September 2023.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Aug 1, 2023
Complaint Investigation
Date: Aug 1, 2023
Visit Reason
On-site complaint investigation of intake AZ00197971 at a Nursing Care Institution, conducted 1 August 2023.
Complaint Details
An onsite survey was conducted on August 1, 2023 for the investigation of intake #AZ00197971. There were no deficiencies cited. The complaint survey was conducted on August 1, 2023 for the investigation of intake #AZ00197971. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 17, 2023
Complaint Investigation
Date: Jul 17, 2023
Visit Reason
The inspection was conducted due to allegations of verbal abuse by staff towards residents, failure to implement abuse reporting policies, failure to timely report suspected abuse, failure to investigate abuse allegations, and failure to maintain mechanical lifts safely.
Complaint Details
The complaint investigation was triggered by allegations of verbal abuse by a Certified Nursing Assistant (CNA staff #14) towards resident #54, including cursing and rough handling. Additional allegations involved verbal abuse by CNA staff #33 towards resident #43. The investigation found failures in abuse reporting, investigation, and timely notification to the State Agency. The alleged perpetrators were suspended pending investigation. The facility failed to report some allegations to the State Agency and did not conduct thorough investigations.
Findings
The facility failed to ensure residents were free from verbal abuse by staff, failed to implement and follow abuse reporting and investigation policies, failed to timely report abuse allegations to the State Agency, and failed to maintain mechanical lifts in safe operating condition. Multiple residents reported verbal abuse incidents involving staff, and investigations were incomplete or not reported. Mechanical lifts had maintenance issues and were sometimes out of service.
Deficiencies (5)
Failed to protect resident #54 from staff verbal abuse including cursing and rough handling.
Failed to implement policy on abuse reporting and investigation for resident #43, resulting in continued abuse risk.
Failed to timely report suspected abuse allegations for resident #43 to proper authorities.
Failed to investigate verbal abuse allegation for resident #43 thoroughly, including interviews of witnesses and victim.
Failed to ensure mechanical lifts were maintained and in safe operating condition, risking resident injury.
Report Facts
Date survey completed: Jul 17, 2023
Number of residents affected: 3
Maintenance log dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #14 | Certified Nursing Assistant | Alleged perpetrator of verbal abuse towards resident #54 |
| Staff #33 | Certified Nursing Assistant | Alleged perpetrator of verbal abuse towards resident #43 |
| Staff #116 | Administrator | Informed of abuse allegations and responsible for reporting and investigation oversight |
| Staff #73 | Director of Nursing | Provided statements on abuse reporting expectations and prior concerns about staff #14 |
| Staff #41 | Social Services | Interviewed residents and involved in abuse allegation reporting |
| Staff #99 | Housekeeping/Maintenance Staff | Responsible for maintenance work orders and coordination for mechanical lifts |
| Staff #66 | Certified Nursing Assistant | Provided information on maintenance reporting process for equipment |
| Staff #78 | Licensed Practical Nurse | Provided information on use and checks of mechanical lifts |
Inspection Report — Jul 17, 2023
Annual Inspection
Date: Jul 17, 2023
Visit Reason
On-site complaint and annual compliance inspection conducted 7/11/2023 through 7/17/2023 at Life Care Center of Paradise Valley, including investigation of multiple complaint intake numbers (e.g., AZ00197649, AZ00197806, AZ00197654, AZ00197802, AZ00172433, AZ00172002, AZ00172003, AZ00171614, AZ00171388, AZ00169826, AZ00163375, AZ00159470, AZ00154347, AZ00154306, AZ00154088, AZ00151895, AZ00149433, AZ00145205, AZ00144117, AZ00142773).
Complaint Details
The State compliance survey was conducted 7/11/2023 through 7/17/2023, in conjunction with the investigation of intake numbers AZ00197649, AZ00197806, AZ00197654, AZ00197802, AZ00172433, AZ00172002, AZ00172003, AZ00171614, AZ00171388, AZ00169826, AZ00163375, AZ00159470, AZ00154347, AZ00154306, AZ00154088, AZ00151895, AZ00149433, AZ00145205, AZ00144117 and AZ00142773. The following deficiencies were cited.
Findings
The inspection identified 38 deficiencies related to resident rights, advance directives, abuse reporting and investigation, medication administration, infection control, care planning, and equipment maintenance. Deficiencies included failure to inform residents of their rights, incomplete advance directive orders, failure to report and investigate abuse allegations, medication errors, inadequate infection control practices, and lack of qualified staff in activities and social services.
Deficiencies (35)
R9-10-403 — The facility failed to ensure that three residents (#57, #3, and #28) were informed of their rights during their stay, including lack of review at resident council meetings and staff not knocking before entering rooms.
R9-10-403 — The facility failed to ensure physician orders regarding advance directives were accurate for resident #128, including missing physician and witness signatures on DNR forms and conflicting code status documentation.
R9-10-403 — The facility failed to notify the Ombudsman and provide written explanation of transfer reasons and bed-hold policy for resident #39 transferred to hospital.
R9-10-403 — The facility failed to implement abuse reporting and investigation policies for resident #43, including not reporting verbal abuse allegations to the State Agency and incomplete investigations.
R9-10-403 — The facility failed to ensure medications were secured and not left unattended on the medication cart or at the bedside for resident #43.
R9-10-403 — The facility failed to maintain infection prevention and control during continence care for resident #33, including failure to change gloves before touching clean areas.
R9-10-403.E — The facility failed to report allegations of abuse for residents #43 and #54 as required by state law.
R9-10-403.F — The facility failed to report suspected abuse for residents #43 and #54 according to state requirements.
R9-10-403.F — The facility failed to investigate an allegation of verbal abuse for resident #43, lacking interviews with witnesses and thorough documentation.
The facility failed to ensure the right to personal privacy was respected for resident #51, including staff entering rooms without knocking or waiting for permission.
§483.10(c) — The facility failed to inform resident #47 of treatment risks and benefits regarding psychotropic medication prior to administration.
§483.10(g) — The facility failed to ensure residents #57, #3, and #28 were informed of their rights during their stay, with resident council minutes lacking documentation of rights review.
§483.10(c) — The facility failed to ensure physician orders regarding advance directives were accurate for resident #128, including missing signatures and conflicting code status documentation.
§483.10(i) — The facility failed to maintain walls in resident #54's room in good condition, with peeling and chipped paint posing a non-homelike environment.
§483.12 — The facility failed to ensure resident #54 was free from staff verbal abuse, including cursing and threatening behavior by a CNA.
§483.12(b) — The facility failed to implement abuse reporting and investigation policies for resident #43, risking continued abuse.
§483.12(c) — The facility failed to report allegations of abuse for resident #43, risking unreported abuse.
§483.12(c) — The facility failed to investigate an allegation of verbal abuse for resident #43, risking ongoing abuse.
§483.15(c) — The facility failed to notify resident #39 in writing of transfer reasons and failed to provide the Ombudsman a copy of the notice.
§483.15(d) — The facility failed to provide resident #39 with written notice of the bed-hold policy upon transfer to hospital.
§483.20(e) — The facility failed to refer resident #31 with serious mental illness to the appropriate state-designated mental health authority for review.
§483.24(c) — The facility failed to ensure the activities program was directed by a qualified professional, with staff #36 lacking required qualifications.
R9-10-406.I — The facility failed to ensure a qualified social worker was employed full-time, with staff #41 lacking required credentials.
§483.25(b) — The facility failed to provide appropriate care and treatment for pressure ulcers for residents #39 and #24, risking worsening and new ulcers.
R9-10-406.I — The facility failed to ensure the activities program was directed by a qualified professional, with staff #36 lacking required qualifications.
§483.25(e) — The facility failed to provide catheter care and treatment as ordered for resident #35, including incomplete cleansing and flushing documentation.
§483.45(g)(h) — The facility failed to ensure medications were secured and not left unattended on the medication cart or at the bedside.
§483.45(e) — The facility failed to conduct behavior monitoring for resident #47 prescribed anxiety medication, risking unaddressed escalating behaviors.
The facility failed to ensure resident #175 was free from significant medication errors, including administration of incorrect levetiracetam dosage.
R9-10-410.B — The facility failed to ensure resident #54 was free from staff verbal abuse, including cursing and threatening behavior by a CNA.
R9-10-410.B — The facility failed to ensure the right to personal privacy was respected for resident #51, with staff entering rooms without knocking or waiting.
R9-10-410.B — The facility failed to inform resident #47 of treatment risks and benefits regarding psychotropic medication prior to administration.
R9-10-414.B — The facility failed to provide nursing care to assist resident #39 in maintaining highest practicable well-being, including repositioning and proper use of slings.
R9-10-421 — The facility failed to prevent and respond to medication errors for resident #175, including administration of incorrect levetiracetam dosage.
R9-10-425 — The facility failed to maintain mechanical lifts in safe operating condition, risking resident injury, with overdue maintenance and malfunctioning equipment.
Report Facts
Deficiencies cited: 38
Complaints investigated: 20
Facility licensed beds: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #116 | Administrator | Administrator was informed of abuse allegations and interviewed regarding resident rights and abuse reporting. |
| Staff #73 | Director of Nursing | DON interviewed regarding resident rights, abuse reporting, medication administration, and infection control. |
| Staff #12 | Assistant Director of Nursing | ADON mentioned by residents regarding knocking before entering rooms. |
| Staff #36 | Assistant to Social Services / Activities Director | Staff #36 interviewed regarding resident rights review and activities program qualifications. |
| Staff #41 | Social Services Director | Social Services Director interviewed regarding abuse reporting and PASARR screenings. |
| Staff #52 | Licensed Practical Nurse | LPN observed and interviewed regarding medication administration errors and medication security. |
| Staff #50 | Certified Nursing Assistant | CNA observed and interviewed regarding infection control during continence care and knocking before entering rooms. |
| Staff #33 | Certified Nursing Assistant | Alleged perpetrator in verbal abuse allegations. |
| Staff #14 | Certified Nursing Assistant | Alleged perpetrator in verbal abuse allegations toward resident #54. |
| Staff #92 | Registered Nurse | RN interviewed regarding psychotropic medication consents and behavior monitoring. |
| Staff #86 | Licensed Practical Nurse | LPN interviewed regarding advance directives process. |
| Staff #27 | Licensed Practical Nurse | LPN interviewed regarding catheter care orders and documentation. |
| Staff #41 | Social Services Director | Social Services Director interviewed regarding abuse reporting and investigation. |
| Staff #8 | Certified Nursing Assistant | CNA observed assisting resident with transfers and continence care. |
| Staff #57 | Certified Nursing Assistant | CNA observed assisting resident with transfers and medication administration. |
| Staff #66 | Certified Nursing Assistant | CNA interviewed regarding maintenance reporting. |
| Staff #78 | Licensed Practical Nurse | LPN interviewed regarding equipment checks and maintenance. |
| Staff #100 | Director of Marketing | Staff interviewed regarding notification of transfer reasons. |
| Staff #111 | Certified Nursing Assistant | CNA observed entering resident room without knocking. |
| Staff #380 | Certified Nursing Assistant | CNA reported verbal abuse incident to social services. |
Inspection Report — Jul 17, 2023
Routine
Date: Jul 17, 2023
Visit Reason
Routine inspection of Life Care Center of Paradise Valley to assess compliance with regulatory requirements including resident rights, medication management, abuse prevention, infection control, and facility maintenance.
Findings
The facility had multiple deficiencies including failure to respect resident privacy, inadequate informed consent for psychotropic medication, lack of resident rights notification, inaccurate advance directives documentation, poor maintenance of resident rooms, verbal abuse by staff, failure to report and investigate abuse allegations, failure to notify Ombudsman of resident transfer, incomplete PASARR referrals, unqualified activities director and social worker, inadequate pressure ulcer care, catheter care deficiencies, lack of behavior monitoring for psychotropic medication, medication errors, unsecured medications, infection control lapses during continence care, and unsafe mechanical lifts.
Deficiencies (20)
Failed to ensure the right to personal privacy was respected for one resident (#51).
Failed to ensure one resident (#47) was informed of treatment risks and benefits regarding psychotropic medication prior to administration.
Failed to ensure three residents (#57, #3, and #28) were informed of their rights during their stay.
Failed to ensure physician orders regarding advance directives were accurate for one resident (#128).
Failed to ensure walls in the resident room were maintained and in good condition for one resident (#54).
Failed to ensure one resident (#54) was free from staff verbal abuse.
Failed to implement policy on abuse reporting and investigation for one resident (#43).
Failed to timely report allegations of abuse for one resident (#43).
Failed to investigate an allegation of verbal abuse regarding one resident (#43).
Failed to notify in writing the reason for transfer and failed to provide the Ombudsman a copy of the notice of transfer for one resident (#39).
Failed to ensure that one resident (#39) received a bed-hold policy when transferred to the hospital.
Failed to ensure one resident (#31) with serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review.
Failed to ensure activities program was directed by a qualified professional.
Failed to ensure appropriate pressure ulcer care and prevention for residents (#39 and #24).
Failed to ensure catheter care and treatment was provided as ordered for one resident (#35).
Failed to ensure behavior monitoring was conducted for one resident (#47) prescribed anxiety medication.
Failed to ensure one resident (#175) was free from significant medication errors (levetiracetam overdose).
Failed to ensure medications were secured and not left unattended on medication cart or at bedside.
Failed to maintain infection prevention and control during continence care for one resident (#33).
Failed to ensure mechanical lifts for resident use were maintained and in safe operating condition.
Report Facts
Medication error dose: 2000
Medication order dose: 1000
Medication order dose: 500
Pressure ulcer measurements: 3
Pressure ulcer measurements: 2
Pressure ulcer measurements: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #52 | Licensed Practical Nurse | Administered incorrect medication dose to resident #175 and left medications unattended |
| Staff #14 | Certified Nursing Assistant | Alleged verbal abuse and rough care of resident #54 |
| Staff #41 | Social Services Director | New social worker providing oversight, involved in PASARR and abuse reporting |
| Staff #73 | Director of Nursing | Interviewed regarding multiple deficiencies including abuse reporting, medication errors, and care standards |
| Staff #36 | Activities Director | Did not meet qualifications for activities professional |
| Staff #50 | Certified Nursing Assistant | Observed infection control lapses during continence care |
| Staff #8 | Certified Nursing Assistant | Observed infection control lapses during continence care |
| Staff #99 | Housekeeping/Maintenance Staff | Described maintenance process for mechanical lifts and facility repairs |
| Staff #78 | Licensed Practical Nurse | Described mechanical lift use and maintenance |
| Staff #92 | Registered Nurse | Discussed behavior monitoring for psychotropic medications |
| Staff #111 | Certified Nurse Assistant | Discussed repositioning and catheter care for resident #24 |
| Staff #27 | Licensed Practical Nurse | Discussed catheter care and flushing for resident #35 |
Inspection Report — Jul 14, 2023
Date: Jul 14, 2023
Visit Reason
On-site inspection of a Nursing Care Institution at Life Care Center of Paradise Valley conducted 14 July 2023. The inspection type was Other and the worksheet type was Nursing Care Institution.
Findings
The inspection found two deficiencies related to the failure to maintain rated and corridor doors properly, which could allow smoke and fire to spread and cause harm to patients and staff.
Deficiencies (2)
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1 — The facility failed to maintain rated doors protecting hazardous areas, including a damaged door between the kitchen and corridor and a split laminate door for the soiled utility room, compromising smoke containment and fire safety.
NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5 — The facility failed to maintain corridor doors, with gaps and latch failures in multiple rooms that would not stop smoke from traveling, risking patient and staff safety.
Report Facts
Deficiencies cited: 2
Inspection Report — Jun 30, 2023
Complaint Investigation
Date: Jun 30, 2023
Visit Reason
On-site complaint investigation of intake #AZ00197221 and #AZ00197220 at a Nursing Care Institution, conducted 30 June 2023.
Complaint Details
An onsite survey was conducted on June 30, 2023 for the investigation of intake #AZ00197221. A complaint survey was conducted on June 30, 2023 for the investigation of intake #AZ00197220.
Findings
The inspection found two deficiencies related to failure to provide necessary services to a resident resulting in physical harm and failure to maintain premises free from conditions causing injury. Both deficiencies involved Resident #9 who sustained a femoral fracture during a manual transfer when mechanical lifts were unavailable.
Deficiencies (2)
§483.12 — The facility failed to provide services to Resident #9 necessary to avoid physical harm, resulting in a major injury (femoral fracture) during a manual transfer when mechanical lifts were unavailable.
R9-10-425 — The facility premises and equipment were not maintained free from conditions causing physical injury, as Resident #9 was manually transferred without a mechanical lift due to dead batteries, leading to a fracture.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #7 | Certified Nursing Assistant | Staff #7 manually transferred Resident #9 when mechanical lift batteries were dead, leading to injury. |
| Staff #33 | Certified Nursing Assistant | Staff #33 described lift use protocols and training during interviews. |
| Staff #44 | Certified Nursing Assistant | Staff #44 described mechanical lift policies and battery charging procedures. |
| Staff #55 | Licensed Practical Nurse | Staff #55 explained mechanical lift transfer policies and maintenance responsibilities. |
| Staff #5 | Director of Nursing | Staff #5 discussed abuse reporting and follow-up related to the incident. |
Report
Report
13 CMS Surveys
CMS Survey — Jun 30, 2023
Jun 30, 2023
CMS Survey — Jul 17, 2023
Jul 17, 2023
CMS Survey — Nov 8, 2023
Nov 8, 2023
CMS Survey — Jan 18, 2024
Jan 18, 2024
CMS Survey — Feb 14, 2024
Feb 14, 2024
CMS Survey — May 16, 2024
May 16, 2024
CMS Survey — Jun 14, 2024
Jun 14, 2024
CMS Survey — Jul 18, 2024
Jul 18, 2024
CMS Survey — Aug 26, 2024
Aug 26, 2024
CMS Survey — Jun 19, 2025
Jun 19, 2025
CMS Survey — Jul 17, 2023
Jul 17, 2023
CMS Survey — Jan 18, 2024
Jan 18, 2024
CMS Survey — Jul 18, 2024
Jul 18, 2024
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