Inspection Reports for Mary Grace Care Home III
9836 East Tahoe Avenue Mesa, AZ 85212, AZ, 85212
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Inspection Report
Annual Inspection
Census: 8
Capacity: 5
Deficiencies: 5
Oct 23, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-11 to 2025-10 with deficiency history
Findings
Across three inspections, two inspections found no deficiencies, while one inspection in February 2024 identified five deficiencies related to emergency responder forms, management designation, documentation of services, and medication administration records.
Deficiencies (5)
| Description |
|---|
| 36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document C. Each assisted living center and assisted living home must maintain a standardized form for each resident that includes the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. Each assisted living center and assisted living home shall periodically update this form for each resident as necessary. Based on record review and interview, the manager failed to ensure that for five of five residents sampled, a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for each resident. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A review of R1's, R2's, R3's, R4's, and R5's medical records did not contain the completed emergency responder patient information documentation. 2. In an interview, E1 provided a sample copy of the emergency responder patient information the facility. However, the sample form was blank. 3. In an interview, the Compliance Officer asked E1 if E1 felt confident that E4 was competent to fill out the form if emergency services were called to the facility. E1 stated, "No." 4. In an interview, E1 acknowledged the standardized emergency responder patient information form was not completed and maintained for R1, R2, R3, R4, and R5. |
| B. A manager: 3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is: b. Present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises. Based on observation, documentation review, and interview, the manager failed to ensure a qualified caregiver, who had been designated in writing, was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. Upon arrival to the facility at approximately 1:55 PM, the Compliance Officer observed E4 and E5 were the only personnel members present on the premises and working at the facility with eight residents. 2. After completing the Notice of Inspection Rights with E4, the Compliance Officer requested resident medical records and personnel records for review. E4 was unable to provide requested documentation. E4 asked the Compliance Officer to wait for E2 to arrive. 3. While waiting for E2 to arrive, the Compliance Officer observed a posting titled, "Designation of Authority." However, E4 and E5 were not listed on this posting as a manager's designee. E5 reported E5 was an assistant caregiver. 4. In an interview, the Compliance Officer asked E4 how E4 was aware of the specific services the residents required since E4 did not know where the residents' service plans and activities of daily living documentation were located. E4 responded that if there is a question, E4 calls E1 or E2 for assistance. 5. E2 arrived to the facility at approximately 2:45 PM. E2 facilitated the inspection from that point. 6. In an interview, E1 acknowledged the manager failed to ensure a qualified caregiver, designated in writing, was present on the premises and accountable for the assisted living facility when the manager was not present. |
| 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 and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record for five of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's, R2's, R3's, R4's, and R5's medical records revealed service plans indicating the services that were to be provided to each resident. However, the Compliance Officer observed no documentation of the services provided to each resident. 2. In an interview, E2 reported the Activities of Daily Living (ADL) documentation was completed online. The Compliance Officer asked E2 to see the documentation. E2 had a difficult time accessing the records in the computer, but was able to print them off. The Compliance Officer asked if the caregivers had access to the computer. E2 reported they did not. When asked how the caregivers document ADL's, E2 reported the caregivers did not document ADL's. E2 reported E2's son in the Philippines (O1) completed the daily documentation. E2 reported E2 and/or E2's son in the Philippines call the caregivers at the home at the end of each day to get a report from the caregivers on the services provided to each resident that day. O1 then documents the services provided to each resident in the computer. 3. A review of R2's medical record revealed a service plan dated October 27, 2023. The service plan indicated R2 required shower assistance two times per week. 4. The Compliance Officer requested a copy of R2's ADL documentation for the month of February 2024. Upon review, the Compliance Officer observed documentation that R2 received a partial bath daily. There was no documentation that R2 received shower assistance two times per week. 5. In an interview, E1 reported R2 does receive assistance with showers two times per week. E1 reported the shower documentation must have been mistakenly left off the ADL documentation. 6. In an interview, E1 reported the services were provided to each resident as required by the service plan. However, E1 acknowledged the services provided to R1, R2, R3, R4, and R5 were not documented by a caregiver as required. |
| C. A manager shall ensure that a resident's medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual administering medication, for four of four residents sampled. The deficient practice posed a risk as the required information could not be verified and the Department was provided false and misleading information. Findings include: 1. A review of R1's, R3's, R4's, and R5's medical records revealed medication administration records (MAR) for the month of February 2024. The Compliance Officer observed all medications documented as administered to R1, R3, R4, and R5 in February 2024 were documented using the same initials, indicating the same personnel member administered all medication. 2. In an interview, E3 revealed E3 did provide medication administration to R1, R3, R4, and R5. However, E3 reported E3 administers medications directly from the medication organizer. E3 reported E2 fills the medication organizers for the week and signs the MAR for the week. 3. In an interview, E1 acknowledged R1's, R3's, R4's, and R5's MAR did not contain documentation of medication administered that included the name and signature of the individual who actually administered the medication. |
| 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. Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for four of four residents sampled. The deficient practice posed a risk as the Department was provided false and misleading information. Findings include: 1. A review of R1's February 2024 medication administration record (MAR) revealed the following medications were documented as administered on February 27, 2024, prior to the administration of the medications: -Sertraline 100 milligrams (mg) at 8:00 PM, and -Laxative Plus 100 mg at 8:00 PM. 2. A review of R1's February 2024 MAR revealed the following medications were documented as administered on February 28, 2024 and February 29, 2024, prior to the administration of the medications: -Sertraline 100 milligrams (mg) at 8:00 AM and 8:00 PM, and -Laxative Plus 100 mg at 8:00 AM and 8:00 PM. 3. A review of R3's February 2024 MAR revealed the following medication was documented as administered on February 27, 2024, prior to the administration of the medication: -Metformin 500 mg at 8:00 PM. 4. A review of R3's February 2024 MAR revealed the following medications were documented as administered on February 28, 2024 and February 29, 2024, prior to the administration of the medications: -Celebrex 100 mg at 8:00 AM and 8:00 PM; -Metformin 500 mg at 8:00 AM and 8:00 PM; -Levothyroxine 50 micrograms (mcg) at 7:00 AM; and -Januvia 100 mg at 8:00 AM. 5. A review of R3's February 2024 MAR revealed the following medications were documented as administered on February 30, 2024. However, February 30, 2024 is not a valid date on the calendar: -Metformin 500 mg at 8:00 AM and 8:00 PM; -Levothyroxine 50 mcg at 7:00 AM; and -Januvia 100 mg at 8:00 AM. 6. A review of R4's February 2024 MAR revealed the following medication was documented as administered on February 27, 2024, prior to the administration of the medication: -Escitalopram 20 mg at 8:00 PM; -Tamsulosin 0.4 mg at 8:00 PM; -Carvedilol 3.125 mg at 8:00 PM; -Senna 8.6 mg at 8:00 PM. 7. A review of R4's February 2024 MAR revealed the following medications were documented as administered on February 28, 2024 and February 29, 2024, prior to the administration of the medications: -Aspirin 81 mg at 8:00 AM; -Escitalopram 20 mg at 8:00 PM; -Tamsulosin 0.4 mg at 8:00 PM; -Spironolactone 25 mg at 8:00 AM; -Carvedilol 3.125 mg at 8:00 AM; -Furosemide 40 mg at 8:00 AM; and -Senna 8.6 mg at 8:00 PM. 8. A review of R4's February 2024 MAR revealed the following medications were documented as administered on February 30, 2024. However, February 30, 2024 is not a valid date on the calendar: -Carvedilol 3.125 mg at 8:00 PM -Furosemide 40 mg at 8:00 AM; and -Senna 8.6 mg at 8:00 AM and 8:00 PM. 9. A review of R5's February 2024 MAR revealed the following medication was documented as administered on February 27, 2024, prior to the administration of the medication: -Trazodone 50 mg at 8:00 PM; -Senna 8.6 mg at 8:00 PM. 10. A review of R5's February 2024 MAR revealed the following medications were documented as administered on February 28, 2024 and February 29, 2024, prior to the administration of the medications: -Trazodone 50 mg at 8:00 PM; -Amlodipine 10 mg at 8:00 AM; and -Senna 8.6 mg at 8:00 PM. 11. In an interview, E1 acknowledged the aforementioned medication was documented as administered prior to the medications being administered to R1, R3, R4, and R3 and R4 had medication documented as administered on February 30, 2024. |
Report Facts
Inspections on page: 3
Total deficiencies: 5
Census: 8
Total capacity: 5
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