Inspection Report
Complaint Investigation
Capacity: 133
Deficiencies: 17
Oct 31, 2024
Visit Reason
State-compiled facility profile showing 8 inspections from 2023-03-01 to 2024-10-31 with deficiency history including complaint and annual compliance investigations.
Findings
Across all inspections, multiple deficiencies were found related to staff training, resident service plans, reporting of incidents, storage of toxic materials, and documentation of care and policies. Several deficiencies were repeats from prior inspections, indicating ongoing compliance challenges.
Complaint Details
This page includes multiple complaint investigations with deficiencies cited related to complaints AZ00215722, AZ00216112, AZ00217727, AZ00218130, AZ00215061, AZ00215453, AZ00214614, AZ00206992, AZ00210416, AZ00213360, AZ00214405, AZ00214076, AZ00214176, AZ00207422, and AZ00194036.
Deficiencies (17)
| Description |
|---|
| 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 including initial and continued competency training. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that is reviewed and updated at least once every six months for a resident receiving personal care services - Failed to update service plan at least every six months for one of five personal care residents sampled. |
| A. A manager shall ensure that poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents - Failed to store toxic materials in locked area inaccessible to residents. |
| R9-10-113. Tuberculosis Screening - Failed to annually provide training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by the health care institution. |
| J. If a manager has a reasonable basis to believe abuse, neglect or exploitation has occurred, the manager shall report the suspected abuse according to A.R.S. § 46-454 - Failed to immediately report suspected abuse. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that when initially developed and updated is signed and dated by the resident or resident's representative - Failed to ensure service plans were signed and dated by resident or representative for three of seven residents sampled. |
| 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 notifies the resident's emergency contact and primary care provider - Failed to immediately notify primary care provider after resident incidents. |
| C. A manager shall ensure that policies and procedures are reviewed at least once every three years and updated as needed - Failed to ensure policies and procedures were reviewed and updated as required. |
| D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement that includes the manager's signature and date signed - Failed to have manager's signature and date on residency agreements before or at time of acceptance for two residents. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that includes how medication will be stored and controlled for residents storing medication in their unit - Failed to include medication storage and control in service plan for one resident. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that when initially developed and updated is signed and dated by the resident or representative, manager, and nurse or medical practitioner - Failed to ensure service plans were signed and dated by required parties for three residents. |
| A. A manager shall ensure that the disaster plan required is reviewed at least once every 12 months - Failed to review and document disaster plan within past 12 months. |
| A. A manager shall ensure that the premises and equipment are cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection - Failed to maintain cleanliness of residents' unit carpets. |
| A. A manager shall ensure that poisonous or toxic materials stored by the facility are maintained in labeled containers in a locked area and inaccessible to residents - Failed to maintain poisonous or toxic materials in locked areas inaccessible to residents. |
| A. A manager shall ensure that if pets or animals are allowed, dogs or cats are vaccinated against rabies - Failed to ensure a cat residing at the facility was vaccinated against rabies. |
| A. A manager shall ensure that a caregiver's or assistant caregiver's skills and knowledge are verified and documented before providing physical or behavioral health services - Failed to verify and document caregiver's skills and knowledge before providing services for one caregiver. |
| 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 documents any action taken to prevent the incident from occurring in the future - Failed to document preventive actions after incidents for multiple residents. |
Report Facts
Inspections on page: 8
Total deficiencies: 18
Complaint inspections: 8
Total capacity: 133
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Named in multiple findings including training, reporting, and documentation deficiencies | |
| E2 | Named in findings related to training and reporting deficiencies | |
| E3 | Named in findings related to service plans, toxic material storage, and cleanliness | |
| E4 | Named in findings related to caregiver skills verification and training | |
| E5 | Named in findings related to training and incident documentation | |
| E7 | Named in training documentation deficiencies | |
| E8 | Named in training documentation deficiencies | |
| O1 | Provided personnel records during inspection | |
| O3 | Acknowledged lack of documentation in interviews |
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