Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 15
Mar 27, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2023-01-23 to 2025-03-27 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies were found related to tuberculosis training, vaccination documentation, fall prevention training, caregiver verification, service plan coordination, medication administration policies, and disaster plan documentation. Several deficiencies posed risks to resident health and safety and included repeat and unresolved issues.
Complaint Details
Multiple complaint investigations were conducted including complaints AZ00220229, AZ00208897, AZ00210065, AZ00210101, AZ00210252, AZ00210299, AZ00205992, AZ00198964, AZ00199312, AZ00191753, AZ00195866, and AZ00190217 with findings of deficiencies in several but no deficiencies in others.
Deficiencies (15)
| Description |
|---|
| R9-10-113.A.1-2. Tuberculosis Screening: Failed to ensure annual training and education related to recognizing the signs and symptoms of tuberculosis was provided to all personnel sampled. |
| R9-10-811.C.17. Medical Records: Failed to ensure resident medical records contained documentation showing pneumonia vaccination was offered every 12 months to residents reviewed. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition: Failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. |
| C. 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 and according to policies and procedures: Failed to verify and document caregiver skills and knowledge for one former caregiver sampled. |
| C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 7. Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan: Failed to include coordination of communications in service plans for residents sampled. |
| C. A manager shall ensure that policies and procedures are established, documented, and implemented to protect the health and safety of a resident: Failed to establish and document required policies and procedures including job descriptions, orientation, CPR training, and others. |
| E. A manager shall ensure that documentation required by this Article is provided to the Department within two hours after a Department request: Failed to provide required documentation timely including caregiver training, CPR training, fingerprint clearance verification, medical records, medication administration policies, and disaster plan review. |
| A. A manager shall ensure that a caregiver provides documentation of completion of a caregiver training program approved by the Department or the Board of Examiners: Failed to ensure caregiver provided approved training documentation. |
| C. A manager shall ensure that a personnel record for each employee or volunteer includes documentation of cardiopulmonary resuscitation training, if required: Failed to ensure documentation of CPR training with demonstration for caregivers sampled. |
| C. A manager shall ensure that a personnel record for each employee or volunteer includes documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C): Failed to ensure documentation of fingerprint clearance card verification for employees sampled. |
| B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation dated within 90 calendar days including care needs: Failed to ensure required documentation was submitted for residents sampled. |
| C. A manager shall not accept or retain an individual if the individual requires continuous behavioral health services: Accepted and retained an individual requiring continuous behavioral health services not authorized by the facility. |
| C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 3. Cognitive stimulation and activities to maximize functioning: Failed to include cognitive stimulation and activities in service plans for residents sampled. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that policies and procedures for medication administration are reviewed and approved by a medical practitioner, registered nurse, or pharmacist: Failed to ensure medication administration policies were reviewed and approved. |
| A. A manager shall ensure that documentation of the disaster plan review includes date/time, participants, critique, and recommendations: Failed to document required elements of disaster plan review. |
Report Facts
Inspections on page: 7
Total deficiencies: 17
Complaint inspections: 6
Total capacity: 121
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