Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 15
Jul 16, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-05-11 to 2024-07-16 with deficiency history including complaint and annual compliance inspections.
Findings
Across all inspections, multiple deficiencies were identified including failures in staff training, policy implementation, resident care plans, medication administration documentation, and compliance with fingerprinting and tuberculosis screening requirements. Some inspections found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted, including complaints AZ00213092, AZ00207745, AZ00208149, AZ00208665, AZ00189181, and AZ00189132, with deficiencies cited in several inspections.
Deficiencies (15)
| Description |
|---|
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition: Failed to administer a training program for all staff regarding fall prevention and fall recovery. |
| K. A manager shall provide written notification to the Department of a resident's death as required by A.R.S. § 11-593 within one working day: Failed to provide timely written notification of a resident's death to the Department. |
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411: Failed to document good faith efforts to contact previous employers and verify fingerprint clearance cards for multiple employees. |
| C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect resident health and safety: Failed to ensure all required policies and procedures were established, documented, and implemented. |
| A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented before providing services: Failed to verify and document caregiver skills and knowledge before providing physical health services for multiple caregivers. |
| A. A manager shall ensure that: 8. Evidence of freedom from infectious tuberculosis is provided on or before service start: Failed to ensure evidence of freedom from infectious tuberculosis for one employee. |
| G. A manager may terminate residency of a resident as follows: Residency agreements did not comply with termination policy requirements under R9-10-807(G). |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan reviewed and updated as required: Failed to ensure timely review and update of resident service plans for personal and directed care services. |
| A. A manager shall ensure that: 6. A resident is provided a diet that meets nutritional needs as specified in the service plan: Failed to provide a resident a diet meeting nutritional needs per service plan, including allergy considerations. |
| R9-10-120. Opioid Prescribing and Treatment: Failed to document patient's need for opioid and effect of opioid administration as required. |
| C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed: Failed to ensure policies and procedures were reviewed and updated as required. |
| A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented before providing physical health services: Failed to verify and document skills and knowledge for multiple caregivers. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that policies and procedures are reviewed and approved by a medical practitioner, registered nurse, or pharmacist: Failed to ensure medication administration policies were reviewed and approved. |
| B. A manager shall ensure that: 1. A resident receives orientation to the exits and evacuation route within 24 hours of acceptance: Failed to provide orientation to exits and evacuation route for multiple residents. |
| D. When a resident has an accident, emergency, or injury requiring medical services, a manager shall ensure documentation of actions taken to prevent recurrence: Failed to document preventive actions for accidents or injuries for multiple residents. |
Report Facts
Inspections on page: 4
Total deficiencies: 15
Complaint inspections: 4
Total capacity: 121
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