Inspection Report Summary
The most recent inspection on September 3, 2024, found no deficiencies during a complaint investigation. Earlier inspections showed a pattern of deficiencies mainly related to documentation issues, including caregiver training, first aid/CPR, resident acceptance, tuberculosis screening, medication administration, and training programs for fall prevention. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. Most complaint investigations were unsubstantiated, with no deficiencies cited in several cases. The inspection history suggests some improvement over time, with the latest inspections showing no cited deficiencies after prior issues.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Capacity: 30
Deficiencies: 0
Sep 3, 2024
Visit Reason
An on-site investigation of multiple complaints was conducted with no deficiencies cited.
Findings
An on-site investigation of multiple complaints was conducted with no deficiencies cited.
Complaint Details
Complaints AZ00208090, AZ00213794, AZ00213954, AZ00214912
Inspection Report
Complaint Investigation
Capacity: 30
Deficiencies: 0
Aug 7, 2024
Visit Reason
An on-site investigation of complaint AZ00214225 was conducted with no deficiencies cited.
Findings
An on-site investigation of complaint AZ00214225 was conducted with no deficiencies cited.
Complaint Details
Complaint AZ00214225
Inspection Report
Complaint Investigation
Capacity: 30
Deficiencies: 4
Feb 7, 2024
Visit Reason
Deficiencies found during compliance inspection and complaint investigation related to caregiver training documentation, first aid/CPR documentation, resident acceptance documentation, and tuberculosis screening.
Findings
Deficiencies found during compliance inspection and complaint investigation related to caregiver training documentation, first aid/CPR documentation, resident acceptance documentation, and tuberculosis screening.
Complaint Details
Complaints AZ00201246, AZ00201247, AZ00205807, AZ00205808
Deficiencies (4)
| Description |
|---|
| A. A manager shall ensure that: 1. A caregiver: b. Provides documentation of: i. Completion of a caregiver training program approved by the Department |
| A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid and cardiopulmonary resuscitation (CPR) training |
| B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days |
| R9-10-113. Tuberculosis Screening |
Inspection Report
Complaint Investigation
Capacity: 30
Deficiencies: 1
Sep 26, 2023
Visit Reason
One deficiency cited related to medication administration compliance during complaint investigation.
Findings
One deficiency cited related to medication administration compliance during complaint investigation.
Complaint Details
Complaint AZ00201075
Deficiencies (1)
| Description |
|---|
| 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 |
Inspection Report
Complaint Investigation
Capacity: 30
Deficiencies: 0
Aug 15, 2023
Visit Reason
Complaint investigation conducted with no deficiencies cited.
Findings
Complaint investigation conducted with no deficiencies cited.
Complaint Details
Complaint AZ00199380
Inspection Report
Complaint Investigation
Capacity: 30
Deficiencies: 1
Apr 24, 2023
Visit Reason
One deficiency found related to fall prevention and fall recovery training program.
Findings
One deficiency found related to fall prevention and fall recovery training program.
Complaint Details
Complaint AZ00194365
Deficiencies (1)
| Description |
|---|
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs |
Inspection Report
Annual Inspection
Capacity: 30
Deficiencies: 5
Mar 30, 2023
Visit Reason
Five deficiencies found during on-site compliance inspection related to service plan updates, evacuation drill documentation, resident orientation, storage of toxic materials, and opioid prescribing documentation.
Findings
Five deficiencies found during on-site compliance inspection related to service plan updates, evacuation drill documentation, resident orientation, storage of toxic materials, and opioid prescribing documentation.
Deficiencies (5)
| Description |
|---|
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes |
| A. A manager shall ensure that: 6. Documentation of each evacuation drill is created, is maintained for at least 12 months |
| B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating |
| 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 |
| R9-10-120. Opioid Prescribing and Treatment F. Documentation of authorized opioid administration |
Inspection Report
Capacity: 30
Deficiencies: 0
Dec 1, 2022
Visit Reason
No deficiencies found during on-site amendment inspection to change capacity.
Findings
No deficiencies found during on-site amendment inspection to change capacity.
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