AZ Dept. of Health Services · Inspection Report

THE ENCLAVE AT CHANDLER SENIOR LIVING

📍 4950 West Chandler Boulevard, Chandler, AZ 85226

INSP-0090518 10/26/2023 - 10/27/2023 Complaint;Compliance (Annual) Complete 7 deficiencies

Inspection Details

Inspection #
INSP-0090518
Inspection Date(s)
10/26/2023 - 10/27/2023
Status
Complete
Inspection Type
Complaint;Compliance (Annual)
Worksheet Type
Assisted Living Center
Certificate Number
AL10888C
Location Type
—

Initial Comments

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00193773 conducted on October 26-27, 2023:

Statement of Deficiency

7 deficiencies found
Deficiency #1
✓ Plan Provided
▼
Rule
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: f. For a resident who will be storing medication in the resident's bedroom or residential unit, how the medication will be stored and controlled;
Evidence
Based on record review and interview, the manager failed to ensure a written service plan included how a medication would be stored and controlled, for one of one sampled resident who was storing medications in the resident's unit, which posed a health and safety risk. Findings include: 1. In interview, E2 reported that R1 was allowed to manage R1's own medications. 2. R1's current service plan dated July 24, 2023 failed to state how R1's medications would be stored and controlled in R1's unit. 3. In an interview, E2 acknowledged the sampled resident was allowed to self-administer R1's own medications, however, R1's service plan did not include how R1's medications would be stored and controlled.
Plan of Correction
Permanent Correction Date
2023-10-27
Deficiency #2
✓ Plan Provided
▼
Rule
A. A manager shall ensure that: 3. Documentation of the disaster plan review required in subsection (A)(2) includes: a. The date and time of the disaster plan review; b. The name of each employee or volunteer participating in the disaster plan review; c. A critique of the disaster plan review; and d. If applicable, recommendations for improvement;
Evidence
Based on documentation review and interview, the manager failed to ensure there was the required documentation of the annual disaster plan review. Findings included: 1. At the beginning of the compliance inspection E1 received a list of the required documents that would be reviewed during this inspection. Later in the compliance inspection, the compliance officer requested and was provided documentation of the annual disaster plan meeting that was dated July 6, 2023. There was no documentation that included the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. 2. In an interview, E1 acknowledged the disaster plan meeting was lacking the required documentation. Technical assistance was provided during the compliance inspection conducted on October 26-27, 2022.
Plan of Correction
Permanent Correction Date
2023-10-27
Deficiency #3
✓ Plan Provided
▼
Rule
A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and
Evidence
Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of the facility's documentation revealed evacuation drills were conducted on July 20, 2023 and October 13, 2023 during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during the past 12 months. 2. In an interview, E1 acknowledged an evacuation drill for employees and residents was not conducted at least every six months, as required, during the past 12 months.
Plan of Correction
Permanent Correction Date
2023-10-27
Deficiency #4
✓ Plan Provided
▼
Rule
A. A manager shall ensure that: 3. Garbage and refuse are: a. Stored in covered containers lined with plastic bags, and
Evidence
Based on observation and interview, the manager failed to ensure that garbage and refuse were stored in covered containers. Findings include: 1. During a facility tour, in the memory care's prep kitchen, E2 and the compliance officer observed a large uncovered gray trash bin half-full of trash sitting next to the prep food counter. This trash container was not in use at the time of the observation. 2. In an interview, E1 and E2 acknowledged the uncovered trash.
Plan of Correction
Permanent Correction Date
2023-10-27
Deficiency #5
✓ Plan Provided
▼
Rule
A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents;
Evidence
Based on observation and interview, the manager failed to ensure the hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of the assisted living facility used by residents. Findings include: 1. During a facility tour of randomly selected residents' areas, E2 and the compliance officer observed in R3's, R4's, and R5's bathrooms the hot water registered on the compliance officer's thermometer from 122.9 to 125.6\'ba F. 2. In an interview, E2 acknowledge the facility's hot water was over 120\'ba F in areas of the facility that were used by residents.
Plan of Correction
Permanent Correction Date
2023-10-27
Deficiency #6
✓ Plan Provided
▼
Rule
A. A manager shall ensure that: 9. Soiled linen and soiled clothing stored by the assisted living facility are maintained separate from clean linen and clothing and stored in closed containers away from food storage, kitchen, and dining areas;
Evidence
Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in closed containers, which posed a health risk. Findings include: 1. During a facility tour, E2 and the compliance officer observed in the facility's memory care laundry room there was stored an open uncovered large basket full of soiled linen sitting on the floor of the laundry room. An employee reported the laundry needed washing. 2. In an interview, E2 acknowledged the soiled linen in the memory care laundry room that was not being stored in a closed container as required.
Plan of Correction
Permanent Correction Date
2023-10-27
Deficiency #7
✓ Plan Provided
▼
Rule
A. A manager shall ensure that: 11. 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;
Evidence
Based on observation and interview, the manager failed to ensure poisonous or toxic materials that were stored by the facility were maintained in a locked area, which posed a health and safety risk. Findings include: 1. During a facility tour of the memory care unit, E2 and the compliance officer observed the unlocked memory care central laundry room there was stored in an unlocked cabinet bathroom cleaner and glass cleaner. 2. In an interview, E2 acknowledged the unlocked poisonous or toxic materials.
Plan of Correction
Permanent Correction Date
2023-10-27