Inspection Reports for Robson Reserve at Sun Lakes
9508 E Riggs Rd, Sun Lakes, AZ 85248, United States, AZ, 85248
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Inspection Report
Complaint Investigation
Capacity: 149
Deficiencies: 10
Jan 22, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-07 to 2025-01 with deficiency history including complaint and annual compliance inspections.
Findings
Across four inspections, including complaint and annual compliance types, deficiencies were found related to tuberculosis screening, service plan updates, disaster and evacuation drills, and resident care documentation. Some deficiencies were repeats from prior inspections, while others posed health and safety risks.
Complaint Details
The January 22, 2025 inspection included investigation of complaints AZ00220935, AZ00221603, AZ00218689, and AZ00217430. Three complaint inspections were conducted in total as noted in summary stats.
Deficiencies (10)
| Description |
|---|
| A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident's date of occupancy, and 2. As specified in R9-10-113. Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for six of eight residents sampled. The deficient practice posed a TB exposure risk to residents. |
| C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: m. Cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide; Based on observation, documentation review, and interview, the manager failed to establish, document, and implement a policy and procedure to protect the health and safety of a resident that cover methods by which an assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide which is a health and safety risk. |
| A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident's date of occupancy, and 2. As specified in R9-10-113. Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of eight residents' medical records reviewed. The deficient practice posed a potential TB exposure risk to residents. |
| 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 in the requirements in subsections (A)(3)(a) through (f): a. No later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition; and Based on record review and interview, the manager failed to ensure one of one sampled resident's written service plan was updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, which posed a health and safety risk. |
| 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 in the requirements in subsections (A)(3)(a) through (f): b. As follows: ii. At least once every six months for a resident receiving personal care services, and Based on record review and interview, the manager failed to ensure that one of four sampled residents who were receiving personal care services had a written service plan reviewed and updated at least once every six months, which posed a health and safety risk. |
| 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 in the requirements in subsections (A)(3)(a) through (f): b. As follows: iii. At least once every three months for a resident receiving directed care services; and Based on record review and interview, the manager failed to ensure that three of four sampled residents who were receiving directed care services had a written service plan reviewed and updated at least once every three months, which posed a health and safety risk. |
| C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d); Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccination for pneumonia according to A.R.S. 'a7 36-406(1)(d), which required the facility to make the vaccination available to the resident on site on a yearly basis; for one of three sampled resident's medical records reviewed who had resided at the assisted living facility for more than 12 months, which posed a health and safety risk. |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2): 1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or Based on record review and interview, the manager failed to ensure that for three of three sampled residents who were unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner signed a determination stating that the resident's needs were being met. This determination was to be completed at onset and at least once every six months throughout the duration of the resident's condition to determine if the resident's needs could be met which was based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. |
| A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented; Based on documentation reviewed and interview, the manager failed to ensure an employee disaster drill was conducted at least once every three months on each shift and documented which posed a safety risk. |
| A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. |
Report Facts
Inspections on page: 4
Total deficiencies: 10
Complaint inspections: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Named in multiple deficiency findings and interviews regarding tuberculosis screening, service plans, disaster drills, and evacuation drills | |
| E2 | Named in multiple deficiency findings and interviews regarding tuberculosis screening, service plans, and resident care documentation | |
| E3 | Named in tuberculosis screening deficiency interview |
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