The most recent inspection on June 25, 2024, resulted in an enforcement action with a $500 fine that has been paid in full. Earlier inspections showed a pattern of deficiencies related to staff qualifications, documentation, policy implementation, meal service compliance, and safety issues such as food handling and storage of poisonous materials. Prior enforcement actions included fines totaling $1,250 for insufficient skilled staff, unauthorized service provision, and repeat documentation problems. Complaint investigations did not identify any substantiated complaints but noted several deficiencies during combined complaint and compliance inspections. The facility’s inspection history indicates ongoing challenges with staffing and documentation, with enforcement actions continuing into the most recent inspection.
Deficiencies (last 2 years)
Deficiencies (over 2 years)5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Three deficiencies found related to abuse reporting, policy implementation, and meal service compliance during complaint and annual compliance inspection.
Findings
Three deficiencies found related to abuse reporting, policy implementation, and meal service compliance during complaint and annual compliance inspection.
Deficiencies (3)
Description
J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation has occurred on the premises or while... — Abuse reporting documentation
F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 1. Policies and procedures are established... — Policy and procedure implementation
A. A manager shall ensure that: 2. Meals and snacks provided by the assisted living facility are served according to posted menus; — Meal service compliance
The facility was found to have multiple violations including insufficient skilled staff, unauthorized service provision by an assistant caregiver, and a repeat documentation deficiency. Civil fines totaling $1250.00 were assessed and agreed upon by the licensee.
Fines & Penalties (3)
Amount
Reason
Status
$500.00
Insufficient staff with skills and knowledge to meet the needs of a resident, with occurrence of actual harm.
—
$250.00
One resident did not have documentation to ensure the required services were within the scope that the Facility was authorized to provide (repeat deficiency).
—
$500.00
One assistant caregiver was assigned to provide services the assistant caregiver did not have the documented skills and knowledge to perform.
Seven deficiencies found related to notification failures, caregiver qualifications, resident documentation, caregiver assignments, documentation of services, food safety, and storage of poisonous materials during complaint and compliance inspection.
Findings
Seven deficiencies found related to notification failures, caregiver qualifications, resident documentation, caregiver assignments, documentation of services, food safety, and storage of poisonous materials during complaint and compliance inspection.
Deficiencies (7)
Description
A. A governing authority shall: 7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a cha... — Notification of management changes
A. A manager shall ensure that: 5. An assisted living facility has a manager, caregivers, and assistant caregivers with the qualifications, experience... — Caregiver qualifications
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 cale... — Resident documentation
C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: b. Is only assigned to provide the assisted living services the caregiver or... — Assignment of caregivers
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 — Documentation of services
C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 1. Food is free from spoilage, filth, or other contamination... — Food safety
A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a lock... — Storage of poisonous materials
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