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Source: AZ State Licensing Agency
The following deficiencies were found during the on-site compliance inspection conducted on January 6, 2026:
Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a health and safety risk to residents and employees if the disaster plan was not up-to-date to adequately meet the needs of the residents during a disaster. Findings include: 1. A review of facility documentation revealed no documentation the facility's disaster plan was reviewed at least once every 12 months, as required. 2. In an interview, E1 acknowledged the facility did not have documentation the disaster plan was reviewed at least once every 12 months. 3. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided
Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed no documentation of disaster drills conducted at the facility in the last 12 months. 2. In an exit interview the findings were reviewed with E1 and E2 and no additional information was provided.
Based on the documentation review and interview, the manager failed to ensure that a quality management plan was implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to manage services provided effectively. Findings include: 1. A review of facility documents revealed no documentation of a quality management plan. 2. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.
No deficiencies were found during the on-site compliance inspection conducted on February 12, 2024. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.
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