Inspection Report Summary
The most recent inspection on July 16, 2024, found two deficiencies related to fall prevention training and failure to provide required death notification. Earlier inspections showed a pattern of deficiencies primarily involving caregiver skills verification, policy implementation, and documentation, with enforcement actions including civil fines for repeated caregiver verification issues. Complaint investigations were mostly unsubstantiated except for the July 2024 inspection, which identified specific training and notification issues. Enforcement actions included fines of $250 in mid-2023 and June 2024, with no license suspensions or immediate jeopardy findings listed in the available reports. The facility’s record shows ongoing challenges with staff training and documentation, with some repeated issues but no clear worsening or improvement trend.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
103% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 2
Date: Jul 16, 2024
Visit Reason
Two deficiencies found related to fall prevention training and failure to provide required death notification.
Complaint Details
Complaint AZ00213092
Findings
Two deficiencies found related to fall prevention training and failure to provide required death notification.
Deficiencies (2)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
K. A manager shall provide written notification to the Department of a resident's death if required
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Jun 4, 2024
Summary
The enforcement resulted in a civil fine due to a repeat deficiency where two of four caregivers sampled did not have documented skills and knowledge, posing a health and safety risk to residents.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to ensure caregiver or assistant caregiver skills and knowledge were verified and documented before providing physical health services, posing a health and safety risk to residents; repeat deficiency from prior inspection. | — |
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 8
Date: Apr 9, 2024
Visit Reason
Eight deficiencies found during complaint and compliance inspection including failures in policy implementation, caregiver verification, residency agreements, service plans, diet, and opioid documentation.
Complaint Details
Complaints AZ00207745, AZ00208149, AZ00208665
Findings
Eight deficiencies found during complaint and compliance inspection including failures in policy implementation, caregiver verification, residency agreements, service plans, diet, and opioid documentation.
Deficiencies (8)
A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411
C. A manager shall ensure that policies and procedures are: 1. 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
A. A manager shall ensure that: 8. A manager, caregiver, or employee has or is expected to have monitoring for infectious tuberculosis
G. A manager may terminate residency of a resident as follows: 1. Without notice, if the resident exhibits behavior that is an immediate threat
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that is reviewed and updated
A. A manager shall ensure that: 6. A resident is provided a diet that meets nutritional needs as specified in the service plan
R9-10-120. Opioid Prescribing and Treatment F. Documentation of opioid administration in medical record
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
No deficiencies cited during this complaint investigation.
Complaint Details
Complaints AZ00197800, AZ00200579, AZ00204287
Findings
No deficiencies cited during this complaint investigation.
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Jul 14, 2023
Summary
The enforcement resulted in a civil fine of $250 for the violation related to personnel recordkeeping deficiencies.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Failure to ensure personnel records for three employees contained documented verification of skills and knowledge. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Jun 6, 2023
Summary
The enforcement action resulted in a $250 fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Enforcement action fine | Paid |
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 5
Date: May 11, 2023
Visit Reason
Five deficiencies found related to policy review, caregiver skills verification, medication administration policies, resident evacuation orientation, and care after resident emergencies.
Complaint Details
Complaints AZ00189181, AZ00189132
Findings
Five deficiencies found related to policy review, caregiver skills verification, medication administration policies, resident evacuation orientation, and care after resident emergencies.
Deficiencies (5)
C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed
A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented
B. If an assisted living facility provides medication administration, a manager shall ensure policies and procedures are reviewed and approved
B. A manager shall ensure that: 1. A resident receives orientation to the exits and evacuation routes
D. When a resident has an accident, emergency, or injury needing medical services, a manager shall ensure a caregiver or assistant caregiver provides required care
Enforcement Action
Enforcement
Total: $0.00
Date: Nodate Enforcement
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