Inspection Reports for Mary Grace Care Home II
11234 E Ramblewood Cir, Mesa, AZ 85212, AZ, 85212
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Inspection Report
Complaint Investigation
Capacity: 4
Deficiencies: 5
Jan 14, 2025
Visit Reason
State-compiled facility profile showing 2 inspections from 2024-10 to 2025-01 with deficiency history including a complaint investigation.
Findings
Across two inspections, one complaint investigation found five deficiencies related to personnel compliance, tuberculosis screening, documentation of services, medical record maintenance, and service plan completeness. The earlier inspection found no deficiencies.
Complaint Details
An on-site investigation of complaint AZ00219626 was conducted on January 14, 2025, resulting in five deficiencies cited related to personnel compliance, tuberculosis screening, documentation, medical record maintenance, and service plan completeness.
Deficiencies (5)
| Description |
|---|
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411. Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S 'a7 36-411, for one of three personnel sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population. |
| 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 eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113; Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three personnel sampled. The deficient practice posed a potential illness risk to residents. |
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and Based on record review, observation, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of three residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. |
| A. A manager shall ensure that: 1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1; Based on documentation review and interview, the manager failed to ensure that a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of three residents sampled. The deficient practice posed a risk as the Department was unable to verify services were provided to the resident. |
| F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 3. Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; and Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving personal care services included incontinence care that ensured that a resident maintained the highest practicable level of independence when toileting, for one of three residents sampled. |
Report Facts
Inspections on page: 2
Total deficiencies: 5
Complaint inspections: 1
Total capacity: 4
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