Inspection Report
Annual Inspection
Capacity: 10
Deficiencies: 5
Apr 24, 2025
Visit Reason
State-compiled facility profile showing 2 inspections from 2023-05 to 2025-04 with deficiency history
Findings
Two annual compliance inspections were conducted, one in May 2023 with five deficiencies found related to staff training, documentation, vaccination records, and facility safety, and a subsequent inspection in April 2025 with no deficiencies cited.
Deficiencies (5)
| Description |
|---|
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition: Failed to administer a training program for all staff regarding fall prevention and fall recovery. |
| E. A manager shall ensure that, unless otherwise stated: 1. Documentation required by this Article is provided to the Department within two hours after a Department request; and: Failed to provide required documentation to the Department within two hours after request. |
| C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8);: Failed to ensure personnel record included documentation of freedom from infectious tuberculosis for one employee. |
| C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);: Failed to ensure resident medical record contained documentation of notification of vaccination availability for influenza and pneumonia. |
| F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility;: Failed to ensure alarms on exit doors alerted employees of resident egress. |
Report Facts
Inspections on page: 2
Total deficiencies: 5
Total capacity: 10
Loading inspection reports...
