Inspection Report
Complaint Investigation
Capacity: 136
Deficiencies: 20
Jan 13, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022-12 to 2025-01 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies were found related to emergency responder documentation, resident orientation, notification procedures, staff training, policy implementation, and facility safety. Several repeat deficiencies were noted, and some inspections found no deficiencies.
Complaint Details
The page includes multiple complaint investigations with deficiencies cited in investigations dated 2023-05-04, 2023-09-06/07, 2024-09-06, 2024-09-18, and 2025-01-13.
Deficiencies (20)
| Description |
|---|
| 36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document - Failed to provide emergency responder with a complete written document including HIPAA release for resident R2. |
| B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance - Failed to ensure orientation for 5 of 10 sampled residents. |
| 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 an assistant caregiver: 1. Immediately notifies the resident's emergency contact and primary care provider - Failed to notify for resident R2. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition - Failed to administer fall prevention and recovery training for all staff; no documentation for E7. |
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411 - Failed to ensure fingerprint clearance card or application for three personnel (E8, E9, E10). |
| C. A manager shall ensure that policies and procedures are: 1.m. Cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident - Failed to establish policy for whereabouts of residents. |
| 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 for two caregivers (E6, E7). |
| A. A manager shall ensure that: 10. Before providing assisted living services, caregiver provides current documentation of first aid and CPR training specific to adults - Failed for two personnel (E5, E12). |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3.f. Includes how medication will be stored and controlled - Failed for one resident (R9). |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4.b.ii. Reviewed and updated at least once every six months for residents receiving personal care services - Failed for resident R4. |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who is confined to a bed or chair without PCP signed determination every six months - Failed for residents R2 and R4. |
| D. A manager shall ensure that: 1. A current drug reference guide is available for use by personnel members - Failed to have current drug reference guide. |
| A. A manager shall ensure that: 2. The disaster plan is reviewed at least once every 12 months - Failed to review disaster plan. |
| A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented - Failed to conduct and document drills on all shifts. |
| A. A manager shall ensure that: 5.a. An evacuation drill for employees and residents is conducted at least once every six months - Failed to conduct evacuation drills including residents. |
| A. A manager shall ensure that: 11. Poisonous or toxic materials are maintained in labeled containers in a locked area inaccessible to residents - Failed to secure poisonous materials in unlocked housekeeping cart. |
| A. A manager shall ensure that: 14.b. Pets or animals are licensed consistent with local ordinances - Failed to ensure dog O4 was licensed. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition - Failed to administer fall prevention and recovery training for all staff; no documentation for E4, E6, and E7. |
| A. A governing authority shall: 3.b. Designate, in writing, a manager with a certificate as an assisted living facility manager - Failed to designate a certified manager; facility was without a manager for 30 days. |
| A. A manager shall ensure that: 10. Before providing assisted living services, caregiver provides current documentation of first aid and CPR training specific to adults - Failed for three personnel (E4, E7, E9). |
Report Facts
Inspections on page: 7
Total deficiencies: 20
Complaint inspections: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Named in multiple findings including emergency responder documentation, orientation, notification, fingerprint clearance, disaster drills, and poisonous materials | |
| E2 | Named in multiple findings including training, service plans, drug reference guide, and evacuation drills | |
| E3 | Named in fall prevention training and CPR training findings | |
| E4 | Named in fall prevention training and CPR training deficiencies | |
| E5 | Named as person 'in charge' and in CPR training deficiency | |
| E6 | Named in caregiver skills verification and fall prevention training deficiencies | |
| E7 | Named in fall prevention training, caregiver skills verification, and CPR training deficiencies | |
| E8 | Maintenance Director | Named in fingerprint clearance card deficiency |
| E9 | Named in fingerprint clearance and CPR training deficiencies | |
| E10 | Named in fingerprint clearance deficiency | |
| E12 | Named in CPR training deficiency | |
| O1 | Compliance officer who verified fingerprint clearance card status | |
| O4 | Dog residing at facility found unlicensed |
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