Inspection Report Summary
The most recent inspection on January 14, 2025, identified three deficiencies related to caregiver service provision, emergency alert availability, and injury reporting during a complaint investigation. Earlier inspections showed mostly no deficiencies, with a notable exception in August 2023 when several deficiencies were cited involving documentation, service plans, medication policies, and meal service, which led to enforcement actions including fines of $250.00 for repeat medication storage plan issues. Complaint investigations were generally unsubstantiated except for the January 2025 case that resulted in the cited deficiencies. The facility’s inspection record shows some improvement since the multiple issues and enforcement actions in 2023, but recent findings indicate ongoing challenges with caregiver services and emergency procedures.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% better than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 3
Jan 14, 2025
Visit Reason
Three deficiencies found related to caregiver service provision, emergency alert availability, and injury reporting during complaint investigation.
Findings
Three deficiencies found related to caregiver service provision, emergency alert availability, and injury reporting during complaint investigation.
Complaint Details
Investigation of complaints AZ00221645 and AZ00221675
Deficiencies (3)
| Description |
|---|
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident's service area |
| E. A manager shall ensure that: 1. A bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies is available |
| D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or assistant caregiver immediately reports the incident |
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 0
Oct 21, 2024
Visit Reason
No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Complaint Details
Investigation of complaint AZ00217000
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 0
Oct 1, 2024
Visit Reason
No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Complaint Details
Investigation of complaint AZ00216335
Inspection Report
Annual Inspection
Capacity: 92
Deficiencies: 0
Aug 19, 2024
Visit Reason
No deficiencies found during on-site compliance inspection and complaint investigation.
Findings
No deficiencies found during on-site compliance inspection and complaint investigation.
Complaint Details
Investigation of complaints AZ00214358 and AZ00214415
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 0
May 30, 2024
Visit Reason
No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Complaint Details
Investigation of complaints AZ00207530 and AZ00204904
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Sep 5, 2023
Summary
The enforcement action resulted in a fine of $250.00 which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Fine associated with enforcement action #00112574 | Paid |
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Aug 9, 2023
Summary
The enforcement outcome involved a civil fine for the repeat deficiency identified during the inspection on August 9, 2023, which was a repeat of a prior deficiency from August 29, 2022.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Civil fine for repeat deficiency related to medication storage in a resident's room service plan. | — |
Inspection Report
Annual Inspection
Capacity: 92
Deficiencies: 7
Aug 9, 2023
Visit Reason
Seven deficiencies found related to documentation, service plans, vaccination notification, resident acceptance, medication policies, and meal/snack service during compliance inspection and complaint investigation.
Findings
Seven deficiencies found related to documentation, service plans, vaccination notification, resident acceptance, medication policies, and meal/snack service during compliance inspection and complaint investigation.
Complaint Details
Investigation of complaint AZ00198001
Deficiencies (7)
| Description |
|---|
| A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes: a. An identification of each concern about quality management |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: f. For a resident storing medication in their bedroom, how the medication is stored |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by the nurse or other authorized person |
| C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccinations for preventable diseases |
| 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, does not meet admission criteria |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 2. Policies and procedures for medication administration are reviewed and approved by a medical practitioner, registered nurse, or pharmacist |
| A. A manager shall ensure that: 2. Meals and snacks provided by the assisted living facility are served according to posted menus |
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