6 Reports
Inspection Report — Mar 17, 2025
Date: Mar 17, 2025
Visit Reason
On-site inspection of type Other at a Nursing Care Institution, conducted 17 March 2025.
Findings
No deficiencies were found during this inspection.
Inspection Report — Mar 13, 2025
Annual Inspection
Date: Mar 13, 2025
Visit Reason
On-site complaint investigation and annual compliance survey conducted 11 through 13 March 2025 at a Nursing Care Institution, investigating complaints AZ00186696, AZ00189254, AZ00189082, AZ00187545, AZ00186599, and AZ00189202.
Complaint Details
The state compliance survey was conducted 03/11/2025 through 03/13/2025, in conjunction with the investigation of complaints AZ00186696, AZ00189254, AZ00189082, AZ00187545, AZ00186599, AZ00189202. The Recertification survey was conducted 03/11/2025 through 03/13/2025, in conjunction with the investigation of complaints AZ00186695, AZ00186599, AZ00187545, AZ00189082, AZ00189253, AZ00189202.
Findings
Five deficiencies were cited during this combined complaint and annual inspection. No specific evidence details were provided for the deficiencies.
Deficiencies (5)
R9-10-403 — No evidence text provided for the deficiency related to policies and procedures for physical and behavioral health services including medication handling.
Automated data processing requirement — No evidence text provided for the deficiency related to encoding and transmitting resident assessment data within required timeframes.
Labeling and storage of drugs and biologicals — No evidence text provided for the deficiency related to proper labeling, storage, and access controls for drugs and biologicals.
Infection control program — No evidence text provided for the deficiency related to establishing and maintaining an infection prevention and control program.
R9-10-422 — No evidence text provided for the deficiency related to the infection control program's corrective measures to prevent spread of infections and communicable diseases.
Report Facts
Deficiencies cited: 5
Complaints investigated: 6
Inspection Report — Aug 20, 2024
Complaint Investigation
Date: Aug 20, 2024
Visit Reason
On-site complaint investigation of intakes AZ00214591, AZ00214539, AZ00214587, and AZ00214535 at a Nursing Care Institution, conducted 20 August 2024.
Complaint Details
An onsite complaint survey was conducted on August 20, 2024 of intake #AZ00214591, AZ00214539. Federal comments also note an onsite complaint survey of intake #AZ00214587, AZ00214535. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 4
Inspection Report — Dec 1, 2023
Date: Dec 1, 2023
Visit Reason
On-site inspection of a Nursing Care Institution classified as 'Other' conducted from 27 November to 1 December 2023 at VI AT SILVERSTONE.
Findings
The inspection found two deficiencies related to emergency preparedness training and medical gas safety training documentation. Both deficiencies were acknowledged by management and plans of correction were provided.
Deficiencies (2)
Based on document review and staff interview, the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness plan. This failure may cause harm to patients and staff during an emergency.
Gas Equipment - Qualifications and Training of Personnel — The facility failed to document new and existing staff training on the handling and risks of medical gases, including oxygen cylinders. Lack of this training could cause harm to patients and staff.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 29, 2023
Annual Inspection
Date: Nov 29, 2023
Visit Reason
On-site complaint investigation of complaints AZ00192439 and AZ00192405, conducted in conjunction with the annual compliance survey at a Nursing Care Institution from November 27 to 29, 2023.
Complaint Details
The State compliance survey was conducted November 27-28, 2023, in conjunction with investigation of complaints AZ00192439 and AZ00192405. The recertification survey was conducted November 27-29, 2023, in conjunction with investigation of complaints AZ00192404, AZ00192438, and AZ00202771.
Findings
The inspection found two deficiencies related to failure to ensure a resident was free from abuse by an employee. The facility documented no mood changes in the resident and took corrective action by terminating the involved staff member.
Deficiencies (2)
§483.12 — The facility failed to ensure resident #1 was free from abuse by an employee, including lack of documentation of the alleged incident and inappropriate language used by staff #52 towards the resident. The staff member was terminated following an internal investigation.
R9-10-410 — The administrator failed to ensure resident #1 was not subjected to abuse by an employee, as evidenced by the same incident involving staff #52 and inadequate documentation and response. Abuse training was provided but the staff member was terminated for unprofessional behavior.
Report Facts
Deficiencies cited: 2
Complaints investigated: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #52 | Registered Nurse | Involved in abuse incident with resident #1 and terminated for unprofessional behavior. |
| Staff #30 | Director of Nursing | Reported the alleged abuse incident to Arizona Department of Health Services and conducted internal investigation. |
| Staff #55 | Housekeeper | Witnessed the alleged abuse incident and reported it to Human Resources. |
| Staff #53 | Human Resources | Received initial report of alleged abuse and initiated investigation process. |
Inspection Report — Aug 2, 2023
Date: Aug 2, 2023
Visit Reason
On-site infection control survey at a Nursing Care Institution conducted on August 2, 2023.
Findings
The inspection found two deficiencies related to failure to maintain proper infection control practices, including unclean toilet seat risers and improperly stored oxygen tubing, which could lead to infection risks.
Deficiencies (2)
R9-10-403.C — The facility failed to ensure infection control standards by not cleaning the toilet seat riser for two residents and not properly storing oxygen tubing for two residents, risking cross contamination and infection outbreaks.
§483.80 — The facility failed to maintain an infection prevention and control program by not ensuring the toilet seat riser was cleaned and oxygen tubing properly stored, increasing the risk of spreading infections.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #21 | Certified Nursing Assistant | Interviewed about cleaning responsibilities for toilet seat riser. |
| Staff #11 | Housekeeper | Interviewed about cleaning responsibilities and nurse notification for toilet seat riser. |
| Staff #22 | Director of Nursing | Interviewed about expectations for cleaning durable medical equipment and oxygen tubing storage. |
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