BROOKDALE FLAGSTAFF

INSP-0159557

Complete

Date: 10/10/2025

Type: Modification

Worksheet: Assisted Living Center

SOD Sent: 2025-10-10

Summary:

On October 10, 2025, an off-site desktop review to change the licensed capacity from 74 directed care to 21 directed care and 53 personal care was completed.

✓ No deficiencies cited during this inspection.

INSP-0132556

Complete

Date: 6/10/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-06-30

Summary:

The following deficiency was found during the on-site investigation of complaints 00131852 and 00130714 conducted on June 10, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services 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; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on the record review, documentation review, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of R1's medical record revealed that R1 received directed care services. 3. A record review revealed an incident report dated May 25, 2025. The incident report revealed that R1 eloped from the facility through the memory care exit door. At the time of the elopement, the memory care door was not controlled or alerted. 4. In an interview, E1 reported that a church service was taking place in the memory care. When the church members were breaking down their equipment and leaving, R1 followed the church members out of the unit and went outside in front of the facility. A facility staff member noticed that R1 was missing and found R1 sitting on a rock. E1 acknowledged there were means of exiting the facility to an outside area, which did not control or alert employees of the egress of a resident from the facility. 5. During the investigation, the Compliance Officer observed all doors were controlled or alerted.

Temporary Solution:

The memory care door that R1 exited from was checked on 5/25/2025 and the egress door alarm worked properly.

Permanent Solution:

On 5/26/2025 the Executive Director retrained all staff on the proper operation of the egress system at the entry/exit of the unit, including not sharing the keypad code with anyone who does not work at the facility, concealing the keypad when letting someone in and looking behind them to verify the door closes securely (Attachment 1 – Training Session Attendance Form). On 5/26/2025 the Executive Director retrained church visitors on only using designated exit/entrances and to not take the memory care residents if staff is not available to stay with them while they are out of the secured memory care area. The AL manager also suggested for the church to consider doing a church service within the secured memory care area

Person Responsible:

Haralambos Babaletskos, AL Manager/executive director

INSP-0130050

Complete

Date: 4/24/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-05-14

Summary:

The following deficiencies were found during the on-site investigation of complaint 00126264 conducted on April 24, 2025:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

R9-10-806.A.8.a-b. Personnel A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for two of four employees sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of E4's and E6's personnel records revealed completion of two-step TST testing. However, no documentation of assessing risks of prior exposure to infectious TB and determining if the E4 and E6 had signs or symptoms of TB was available for review. Based on E4's and E6's hire dates, this documentation was required. 3. In an interview, E1 acknowledged E4 and E6 did not provide documentation of freedom from infectious TB as specified in R9-10-113. This is a repeat deficiency from the inspection conducted on December 27, 2023.

Temporary Solution:

Immediate action taken: for the employees who were out of compliance (E4 and E6), the AL manager and designee contacted the employees and completed a risk assessment screening for them on 4/25/2025. Additionally, a full employee audit was conducted and employees that may have been missing the TB risk assessment screening had one completed and signed by a medical professional. Employees are required to have TB risk screening completed upon hire within required timeframe. See attachment labeled “Attachment #1

Permanent Solution:

Ongoing monitoring system: The manager or designee will audit 5 employee records weekly for 12 weeks to visually verify that the TB risk assessment screening is filed in the employee record. See attachment labelled “Attachment #2” to see ongoing progress. Started auditing on 4/28/2025

Person Responsible:

Haralambos Babaletskos - AL manager

Deficiency #2

Rule/Regulation Violated:

R9-10-808.A.3.b. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: b. The level of service the resident is expected to receive;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan included the level of service the resident was expected to receive, for one of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a written service plan dated March 15, 2025. The service plan did not include the level of service R1 received. 2. In an interview, E1 and E2 acknowledged R1's service plan did not include the level of service the resident received.

Temporary Solution:

Immediate action taken: for the resident who was out of compliance (R1), the level of care was added to the resident’s service plan immediately after the compliance office left on 4/24/2025. Additionally, an audit was initiated for resident service plans to correct any other service plans that were missing this required information with corrections made where appropriate. Health and Wellness Director or designee will add level of care to service plans at time assessment is performed and verify presence upon completion. See attachment labelled “Attachment #3.”

Permanent Solution:

Ongoing monitoring system: The manager or designee will audit 5 resident records weekly for 12 weeks to visually verify that the level of care is included in the resident’s service plans. See attachment labelled “Attachment #5”. Audits started on 4/28/2025

Person Responsible:

Haralambos Babaletskos - AL manager

Deficiency #3

Rule/Regulation Violated:

R9-10-808.A.3.f. Service Plans 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/Findings:

Based on interview and record review, the manager failed to ensure a service plan included how the medication was stored and controlled, for one of one resident sampled, who stored medication in the resident's residential unit. The deficient practice posed a health and safety risk. Findings include: 1. In an interview, E2 reported that R2 received personal care services and self-administered medication. 2. A review of R2's medical record revealed a written service plan dated February 12, 2025. This service plan did not include how the medication would be stored and controlled in R2's room. 3. In an interview, E1 and E2 acknowledged that the service plan did not indicate how the medications would be stored and controlled. This is a repeat deficiency from the inspection conducted on January 4, 2023.

Temporary Solution:

Immediate action taken: for the resident who was out of compliance (R2), the storage method was added to the resident’s service plan on 4/25/2025. Audit of Service Plans for residents who self-medicate completed on 4/30/2025 to verify method of storage was present. Health and Wellness Director or designee will add method of storage and control to service plans for residents who self-medicate at time assessment is completed. Also see attachment labelled “Attachment #4”.

Permanent Solution:

Ongoing monitoring system: The manager or designee will audit 5 resident records weekly for 12 weeks to visually verify that if a resident self-administers medications, the storage method is included in the resident’s service plans. See attachment labelled “Attachment #5”. Audits started on 4/28/25

Person Responsible:

Haralambos Babaletskos - AL manager

INSP-0115651

Complete

Date: 4/2/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-05-08

Summary:

The following deficiencies were found during the on-site investigation of cases 00124977, 00124970, 00124915, and 00124916 conducted on April 2, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-803.C.1.g. Administration C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: g. Cover how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure that policies and procedures were implemented to protect the health and safety of a resident that covered how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings include: 1. A review of the facility’s policy and procedure revealed a policy titled “Analysis of Behavior Expression in Residents with Dementia” which reflected “ 2. …The interventions identified to address the behavioral expression of the resident should be record on the resident service plan along with a corresponding resident log notation…”. 2. A review of a facility’s documentation revealed a document titled “Incident Investigation” dated March 31, 2025, which revealed a resident-to-resident physical altercation between R1 and R2, and the residents were separated. 3. A review of a facility’s documentation revealed a document titled “Incident Investigation” dated March 31, 2025, which revealed a resident-to-resident physical altercation between R3 and R4. Intervention identified “Immediately separated R3 and R4, and started a 1:1 sitter for R3 at all times until advised otherwise. Removed R3’s cane from the room. R3 ambulates around the community without assistive devices. Notified PCP of R3 behaviors and requested for the Psych provider to review R3’s medication list. Urine sample collected and sent to rule out UTI for R3.” 4. A review of R3’s medical record revealed a service plan dated March 14, 2025, which did not reflect the interventions implemented for R3’s behavior. 5. A review of R1’s medical record revealed a service plan dated March 21, 2025, which reflected “Behavior management: Resident will be able to manage their behaviors with assistance. Resident engages in the following behaviors (demonstrates anxious/disruptive/aggressive behavior requiring additional attention, including throwing objects). However, R1’s service plan did not include interventions implemented for R1’s behavior. 6. In an interview, E1 reviewed R1’s and R3’s service plans and the facility’s procedure and acknowledged that the facility’s policy and procedures were not implemented.

Temporary Solution:

Interventions were added to R1s service plan on 5/13/25. Executive Director (“ED”) re-in-serviced the nurse and Resident Care Coordinator on policy for Analysis of Behavioral Expressions in Residents with Dementia on 5/13/25. Health and Wellness Director or designee will review alert charting during working days for behavioral expressions and verify appropriate interventions are in place.

Permanent Solution:

Health and Wellness Director or designee will review alert charting during working days for behavioral expressions and verify appropriate interventions are in place.

Person Responsible:

Haralambos Babaletskos (AL Manager, executive director)

INSP-0107895

Complete

Date: 3/25/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-04-01

Summary:

No deficiencies were found during the on-site investigation of complaints 00123805, 00123713, and 00123809 conducted on March 25, 2025.

✓ No deficiencies cited during this inspection.

INSP-0101587

Complete

Date: 3/17/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-04-09

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00105482, 00105618, and 00121659 conducted on March 17, 2025:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

R9-10-817.C.1. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 1. Food is free from spoilage, filth, or other contamination and is safe for human consumption;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure food stored by the facility was free from spoilage and was safe for human consumption. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. The Compliance Officer observed the following food stored in the activity room refrigerator:-A block of cheese had greenish/blackish mold spots on the sides and in the middle with an expiration date of November 30, 2024;-A jar of pickles had cloudy liquid with an expiration date of September 25, 2009;-A Greek yogurt was watery with an expiration date of January 11, 2025;-A container of sour cream was watery and had a foul odor with an expiration date of January 6, 2025; and-American Cheese slices with dried white spots on the sides with an expiration date of November 30, 2024. 2. In an interview, E1 acknowledged that food stored by the facility was not free from spoilage.

Temporary Solution:

Immediate action: All expired items were removed from the refrigerators.

Permanent Solution:

The manager or designee will inspect all refrigerators weekly for 12 weeks for any expired foods or items and will remove any expired foods or items immediately.

Person Responsible:

Haralambos Babaletskos

Deficiency #2

Rule/Regulation Violated:

R9-10-819.A.1.a. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that premises and equipment were cleaned and disinfected. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed in R4's bathroom, the extended toilet seat had a thick layer of dried fecal matter on the back and sides. 2. During an environmental inspection of the facility, the Compliance Officer observed the carpets in the hallways and R3's and R4's room had large dark stains on the carpet. 3. During an environmental inspection of the facility, the Compliance Officer observed a strong pungent odor of urine in the East Wing on the first floor and in R2's room. 4. In an interview, E1 acknowledged the premises were not cleaned or disinfected.

Temporary Solution:

1. Immediate action taken: The soiled commode noted in the deficiency was cleaned immediately. After discussing the worn condition of the commode with the resident and his family, a new, equivalent replacement commode was purchased on 3/18/2025. When the new replacement commode (arrived on 3/25/2025, the existing one was discarded and the new one was installed).
2. Immediate action taken: The manager noted the stains mentioned by the surveyor and carpet extraction was successful in removing the stains. The stain removal and carpet extraction was completed on 3/20/2025 (see attached photos on page labelled “Page #1”)
3. Immediate action taken: The manager noted the strong pungent smell in the said resident’s room. The carpet was extracted and the odors were addressed by thoroughly cleaning the carpet on 3/20/25.

Permanent Solution:

The manager or designee will review the deep carpet cleaning rotation to verify resident rooms and hallways are cleaned as scheduled for 12 weeks.

Person Responsible:

Haralambos Babaletskos

Deficiency #3

Rule/Regulation Violated:

R9-10-819.A.11. Environmental Standards 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/Findings:

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the compliance inspection, the Compliance Officer observed the following toxins that were not stored in a locked area:In the Activity room:-A container of "Tide" Detergent;-A spray bottle of "Peroxide" Multi-surface cleaner and disinfectant;-A spray bottle of "Oasis 7 Orange Force" multi-surface cleaner; and-A container of "Cerma Bryte" stove cleaner. In R5's bathroom:-A container of "Clorox" wipes;-A half-gallon bottle of bleach;-A bottle of "Clorox" cleaner spray; and-A container of "Lysol' disinfectant. 2. In an interview, E1 acknowledged the materials in the resident bedrooms and activity room were unlocked and were accessible to residents. This is a repeat deficiency from an inspection conducted on January 31, 2024.

Temporary Solution:

1. Immediate action taken: For the chemicals that were found unsecured in the activity room, it was found that the lock in the cabinet they were in was not functioning. All chemicals were removed from that area and stored in a designated area.
2. Immediate action taken: The chemicals found in resident R5’s bathroom were immediately removed.

Permanent Solution:

System in place for ongoing compliance: The manager or designee will inspect 5 resident apartments and all common areas each week to for 12 weeks to verify adherence to the rule.
Staff training to be completed within the next 30 days, regarding securing chemicals and reporting to the manager or designee when noticing any toxic chemicals in resident rooms and in any other area

Person Responsible:

Haralambos Babaletskos

INSP-0064479

Complete

Date: 11/7/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-12-23

Summary:

The following deficiency was found during the investigation of complaint AZ00217949 conducted on November 7, 2024.

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

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:
2. Documents the following:
a. The date and time of the accident, emergency, or injury;
b. A description of the accident, emergency, or injury;
c. The names of individuals who observed the accident, emergency, or injury;
d. The actions taken by the caregiver or assistant caregiver;
e. The individuals notified by the caregiver or assistant caregiver; and
f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.

Evidence/Findings:

Based on record review, documentation review and interview, the manager failed to ensure that when a resident has an accident, emergency, or injury that results in the resident needing medical services, a caregiver documents all of the information required in subsections a. through f. of this rule.

Findings include:
1. Review of the record for R1 revealed that on October 19, 2024 the resident experienced a medical emergency that required medical services. The documentation failed to include the following information: The names of individuals who observed the emergency; All of the individuals notified by the caregiver; Any action taken to prevent the emergency from occurring in the future.
2. During an interview, E1 acknowledged the required documentation was not available for review.

INSP-0064478

Complete

Date: 8/16/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-09-23

Summary:

No deficiencies were found during the investigation of complaints AZ00214454 and AZ00213937 conducted on August 16, 2024.

✓ No deficiencies cited during this inspection.

INSP-0064475

Complete

Date: 1/31/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-03-07

Summary:

An on-site investigation of complaints AZ00205713 and AZ00205272 was conducted on January 31, 2024 and the following deficiencies were cited:

Deficiencies Found: 10

Deficiency #1

Rule/Regulation Violated:

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

Evidence/Findings:

Based on documentation review, record review and interview, the manager failed to ensure documentation required by Article 8 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. The Compliance Officer requested, at 10:15 AM, documentation to be provided for the facility's complaint investigations.

2. The Compliance Officer conducted the exit interview with E9 and E10 at 4:00 PM and the following documentation had not been provided to the Department for review:
-E7's caregiver certificate

3. In an interview, E10 acknowledged the aforementioned documentation was not provided to the Department within two hours after a Department request. E10 reported E7 had a caregiver certification but the facility did not have a copy of it and E7 was at a second job and was unable to provide the requested document.

Deficiency #2

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A caregiver:
b. Provides documentation of:
i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers;

Evidence/Findings:

Based on record review, documentation review and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for five individuals hired as caregivers. The deficient practice posed a risk if E2, E3, E6, E7, or E8 were not qualified to provide the required services.

Findings include:

1. A review of E2's personnel record revealed E2 applied for and was hired as a caregiver. However, no caregiver certificate for E2 was provided for review.

2. A review of https://azcg.tmutest.com/search revealed no evidence E2 had completed a caregiver training program.

3. A review of E3's personnel record revealed E3 applied for and was hired as a caregiver. However, no caregiver certificate for E3 was provided for review.

4. A review of https://azcg.tmutest.com/search revealed no evidence E3 had completed a caregiver training program.

5. A review of E6's personnel record revealed E6 applied for and was hired as a caregiver. However, no caregiver certificate for E6 was provided for review.

6. A review of https://azcg.tmutest.com/search revealed no evidence E6 had completed a caregiver training program.

7. A review of E7's personnel record revealed E7 applied for and was hired as a caregiver. However, no caregiver certificate for E7 was provided for review.

8. A review of https://azcg.tmutest.com/search revealed no evidence E7 had completed a caregiver training program.

9. A review of E8's personnel record revealed E8 applied for and was hired as a caregiver. However, no caregiver certificate for E8 was provided for review.

10. A review of https://azcg.tmutest.com/search revealed no evidence E8 had completed a caregiver training program.

11. A review of facility documentation revealed a document that included the personnel members, job titles and hire dates, as requested for the complaint investigation. The document stated the hire dates for each personnel member sampled as well as the following:
"Job Titles (see attached JDs):
-E1 - Medication Technician
-E2 - Caregiver
-E3 - Caregiver
-E4 - Medication Technician
-E5 - Medication Technician
-E6 - Caregiver
-E7- Medication Technician (-missing AL Caregivers Cert)
-E8 - Caregiver
-E9 - Health and Wellness Director II"

12. In an interview, E10 reported E2, E3, E6, and E8 were all assistant caregivers. E10 acknowledged the applications and provided documention all stated the aforementioned personnel were caregivers, not assistant caregivers. E10 reported E7 was a certified caregiver but E7's caregiver certificate was unable to be located. E10 acknowledged the facility could not provide caregiver certificates for five of the eight caregivers sampled.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
2. An assistant caregiver:
b. Interacts with residents under the supervision of a manager or caregiver;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver.The deficient practice posed a risk as E3 was not qualified to provide the required services.

Findings include:

A.R.S. \'a7 36-401.A.42. "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity.

1. A review of facility documentation revealed a document titled "Incident Investigation," dated January 26, 2024. The document contained a section titled "Associate Interview" that stated the following: "E3: Reported to E10 that E3 was a witness of the following. [sic] E3 was assisting E1 in getting R2 into and out of the shower, E3 reported being in and out of R2's bathroom/shower to check on E1. During E3 going in to check on E1 and R2, E3 witnessed R2 using profanity during the shower by saying "what the fuck, oh lord", repeating this statement several times (this is routinely the case for R2, making such statements during a shower.)"

2. In an interview, E3 reported E3 was a caregiver. E3 reported E1 and E3 worked the memory care unit alone on the evening of January 25, 2024, when the aforementioned incident occurred. E3 reported E3 was in and out of R2's bathroom, to assist E1 in providing a shower to R2. E3 reported E3 assisted other residents with showers, preparing for bed and transferring into bed, while E1 assisted R2 with R2's shower. E3 reported E3 worked alone with residents on a regular basis and was not supervised by another personnel.

3. In an interview, E10 reported E3 was hired as an assistant caregiver, though E3's personnel record stated E3 had applied for and been hired as a caregiver. E10 acknowledged E1 and E3 worked alone in the memory care unit on the night of January 25, 2024 and E3 provided care to other residents, unsupervised. E10 reported the facility recently developed an assistant caregiver job description and acknowledged four of the nine personnel members sampled were assistant caregivers, not caregivers, and often worked independent of being supervised by a certified caregiver.

Deficiency #4

Rule/Regulation Violated:

A. A manager shall ensure that:
4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented:
a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and
b. According to policies and procedures;

Evidence/Findings:

Based on documentation review, record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for eight of eight caregivers or assistant caregivers sampled.

Findings include:

1. A documentation review of the facility's policies and procedures revealed a document titled "Resident Assistant Orientation/Med-Tech & Skills Checklist." The document consisted of four pages of checklists that listed trainings, competency evaluations and spaces for initials as well as signatures.

2. A review of E1's personnel record revealed an application for employment as a caregiver. Documentation to demonstrate E1's skills and knowledge were verified was not provided for review.

3. A review of E2's personnel record revealed an application for employment as a caregiver. Documentation to demonstrate E2's skills and knowledge were verified was not provided for review.

4. A review of E3's personnel record revealed an application for employment as a caregiver. Documentation to demonstrate E3's skills and knowledge were verified was not provided for review.

5. A review of E4's personnel record revealed an application for employment as a caregiver. Documentation to demonstrate E4's skills and knowledge were verified was not provided for review.

6. A review of E5's personnel record revealed an application for employment as a caregiver. Documentation to demonstrate E5's skills and knowledge were verified was not provided for review.

7. A review of E6's personnel record revealed an application for employment as a caregiver. Documentation to demonstrate E6's skills and knowledge were verified was not provided for review.

8. A review of E7's personnel record revealed an application for employment as a caregiver. Documentation to demonstrate E7's skills and knowledge were verified was not provided for review.

9. A review of E8's personnel record revealed an application for employment as a caregiver. Documentation to demonstrate E8's skills and knowledge were verified was not provided for review.

10. In an interview, E10 reported to be unaware of the requirement of skills and knowledge being verified. E10 reported the facility did not document any skills and knowledge verification through a checklist or otherwise. E10 reported the facility completed a background check on the personnel members but acknowledged no verification of skills and knowledge was conducted for any caregiver or assistant caregiver. E10 acknowledged the facility had the "Resident Assistant Orientation/Med-Tech & Skills Checklist" available in the policy manual but acknowledged the facility had not completed the document for any caregivers or assistant caregivers hired since E10 became the assisted living manager at this facility.

Deficiency #5

Rule/Regulation Violated:

A. A manager shall ensure that:
10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Evidence/Findings:

Based on documentation review, record review and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training, for two of nine employees. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of the facility's policies and procedures manual, revised dated November 2022, revealed a policy titled "CPR and First Aid Training." The policy stated "Cardiopulmonary Resusitation (CPR) and First Aid Training are required for Arizona nurses, caregivers, managers or volunteers who provide direct care to residents." The policy went on to state "The CPR and first aid certificates will be renewed according to the approved trainer guidelines but no later than 2 years from the issued date of the certificates."

2. A review of E8's personnel record revealed E8 was hired as a caregiver. E8's personnel record revealed a CPR training card, dated December 4, 2022. However, the CPR training card was from an online-only program.

3. A review of E9's personnel record revealed E9 worked in the facility as a Health and Wellness Director. E9's record revealed a CPR training card dated January 4, 2022, issued from National Health and Safety Association. The card stated "Valid 2 years." An additional CPR training certificate was in E9's personnel record, however, the date of issue was January 16, 2024.

4. In an interview, E9 reported to be under the impression E9's CPR certification from National Health and Safety Association was valid until the end of January 2024. E9 acknowledged there was a gap in between January 3, 2024 and January 16, 2024, when E9 was recertified in CPR.

5. In an interview, E10 acknowledged the gap in between E9's CPR certification and E9's newer CPR certification. E10 also acknowledged E8's CPR certificate was issued from an online-only CPR program and that program did not include a hands-on demonstration.

6. In a telephonic interview, on February 1, 2024, O1 reported the card issued from National Health and Safety Association was valid for two years from the issue date, therefore the CPR training card expired on January 3, 2024, not at the end of January 2024. O1 also reported E8's CPR training certificate was from an online only program and never included a hands-on demonstration.

Deficiency #6

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
b. The manager;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan was signed and dated by the manager, for one of eight residents sampled.

Findings include:

1. A review of R1's medical record revealed an updated service plan, dated in December of 2023, for directed care services. However, the service plan was not signed and dated by the manager.

2. In an interview, E10 acknowledged the service plan was not signed and dated by the manager.

Deficiency #7

Rule/Regulation Violated:

B. A manager shall ensure that:
1. A resident is treated with dignity, respect, and consideration;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration.

Findings include:

1. A review of facility documentation revealed a document titled "Incident Investigation," dated January 26, 2024. The document contained a section titled "Associate Interview" that stated the following: "E3: Reported to E10 that E3 was a witness of the following. [sic] E3 was assisting E1 in getting R2 into and out of the shower, E3 reported being in and out of R2's bathroom/shower to check on E1. During E3 going in to check on E1 and R2, E3 witnessed R2 using profanity during the shower by saying "what the fuck, oh lord", repeating this statement several times (this is routinely the case for R2, making such statements during a shower.) E1 was witnessed responding "I am not your fucking god, I am just here to give you a fucking shower." E3 then left and came back when the shower was done. After assisting R2 out of the shower, E3 witnessed E1 using the back of E1's hand, slapping R2 on the shoulder several times. R2 responded "quit hitting me" and E1 responded "if I do I will leave a bruise." The document continued with a response from E1: "When inquired on the specific report (that E1 made statements of "I am not your fucking god" and "I am here to give you a fucking shower"), E1 admitted to have said that on the shower of 1/25/24."

2. In an interview, E3 reported E3 witnessed E1 curse and slap R2 during a shower. E3 acknowledged E1 did not treat R2 with dignity or respect.

3. In an interview, R2 was unable to recount the incident in question.

4. In an interview, E10 reported E1 had been suspended, pending facility investigation regarding the above-named incident. E10 acknowledged E1 had admitted to cursing at the resident and slapping R2 on R2's shoulder. E10 acknowledged E1 had not treated R2 with dignity or respect.

Deficiency #8

Rule/Regulation Violated:

F. When medication is stored by an assisted living facility, a manager shall ensure that:
1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Evidence/Findings:

Based on observation, record review and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Findings include:

1. The Compliance Officer observed the following medication in R1's bedroom:
-Flonase on a table
-Various prescription and over-the-counter medications in a plastic drawer beside the bed

2. A review of R1's medical record revealed a service plan. The service plan revealed R1's medications were to be stored in the facility's medication storage area. The service plan stated "R1 is a directed level of care. Staff to order, store and administer medication in a cup, which is given to the resident along with fluid of choice."

3. The Compliance Officer observed the following medication in R3's bedroom:
-Antacid tablets

4. The Compliance Officer observed the following medication in R3's and R11's shared bathroom's medicine cabinet:
-Pepto Bismol
-Cough and Chest Congestion DM

5. A review of R3's medical record revealed a service plan. The service plan revealed R3's medications were to be stored in the facility's medication storage area. The service plan stated "R3 is a personal level of care. Staff to order, store and administer medication in a cup, which is given to the resident along with fluid of choice."

6. A review of R11's medical record revealed a service plan. The service plan revealed R11's medications were to be stored in the facility's medication storage area. The service plan stated "R11 is a personal level of care. Staff to order, store and administer medication in a cup, which is given to the resident along with fluid of choice."

7. The Compliance Officer observed the following medication in R6's bathroom drawer:
-8 boxes of Lidocaine Topical Gel
-6 boxes of Diclofenac Sodium Topical Gel
-Lotrimen Ultra
-Aspercreme
-Clearlax

8. The Compliance Officer observed the following medication in R6's bathroom medicine cabinet:
-Bayer Aspirin
-Vaporub
-Clotrimazole USP 1%
-Athlete's Foot Cream

9. A review of R6's medical record revealed a service plan. The service plan revealed R6's medications were to be stored in the facility's medication storage area. The service plan stated "R6 is a personal level of care. Staff to order, store and administer medication in a cup, which is given to the resident along with fluid of choice."

10. In an interview, E10 acknowledged the medications in R1's, R3's and R8's bedrooms and R3's and R11's shared bathroom were unlocked, accessible to residents, and were not stored in a separate locked room, closet, cabinet or self-contained unit.

Deficiency #9

Rule/Regulation Violated:

A. A manager shall ensure that:
10. Oxygen containers are secured in an upright position;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas.

Findings include:

1. The Compliance Officer observed 10 oxygen containers stored upright in R3's bedroom. One oxygen container was on a two-wheel vertical medical cylinder cart and five oxygen containers were secured in an oxygen storage box. However, four oxygen containers were in a separate regular brown box and were not secured.

2. The Compliance Officer observed 17 oxygen containers stored upright in R4's and R9's shared bedroom. One oxygen container was on a two-wheel vertical medical cylinder cart and 12 oxygen containers were secured in an oxygen storage rack. However, four oxygen containers were not secured.

3. The Compliance Officer observed ten oxygen containers stored upright in R7's and R10's shared bedroom. Two oxygen containers were on two-wheel vertical medical cylinder carts and six oxygen containers were secured in an oxygen storage rack. However, two oxygen containers were not secured.

4. In an interview, E10 acknowledged there were unsecured oxygen containers throughout the facility.

Deficiency #10

Rule/Regulation Violated:

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/Findings:

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. The Compliance Officer observed the following unlocked toxic on R3's bathroom counter:
-Heavy Duty Alkaline Bathroom Cleaner and Disinfectant
The bottle contained a toxic warning label.

2. The Compliance Officer observed the following unlocked toxic on R6's kitchen counter:
-LA's Awesome Kitchen Cleaner
The bottle contained a toxic warning label.

3. The Compliance Officer observed the following unlocked toxic in the upstairs hallway laundry room:
-Oasis 137 Orange Force
The bottle contained a toxic warning label.

4. In an interview, E10 acknowledged the unlocked materials in the resident bedrooms and laundry room belonged to the facility, were unlocked and were accessible to residents.

INSP-0064474

Complete

Date: 12/27/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-01-31

Summary:

This revised Statement of Deficiencies (SOD) replaces the SOD sent on January 31, 2024. The following deficiencies were found during the compliance inspection and investigation of complaints AZ00200626, AZ00201265, AZ00203168, and AZ00203670 conducted on December 27, 2023.

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:

A manager shall ensure that:
1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes:
e. The frequency of submitting a documented report required in subsection (2) to the governing authority;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a quality management plan was established and documented that included the frequency of submitting a documented report to the governing authority.

Findings include:
1. The facility quality management plan indicated that a report would be submitted to the governing authority after a "periodic review".
2. During an interview, E1 acknowledged that a facility quality management plan was not established that included the frequency of submitting a documented report to the governing authority.

Deficiency #2

Rule/Regulation Violated:

A. A manager shall ensure that:
8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis:
a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and
b. As specified in R9-10-113;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that three of four sample personnel records contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113.

Findings include:
1. The record for E2 (Caregiver, hired June 26, 2023) contained documentation indicating that only one TB test was administered within the past 12 months. No other TB test documentation conducted within the past 12 months was found in the record.
2. The record for E3 (Caregiver, hired July 20, 2023) contained documentation indicating that only one TB test was administered within the past 12 months. No other TB test documentation conducted within the past 12 months was found in the record.
3. The record for E4 (Caregiver, hired January 16, 2023) contained documentation indicating that only one TB test was administered within the past 12 months. No other TB test documentation conducted within the past 12 months was found in the record.
4. During an interview, E1 acknowledged that the employees worked more than 8 hours per week and the documentation did not reflect that the employee records contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, prior to providing services to residents.

Deficiency #3

Rule/Regulation Violated:

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/Findings:

Based on record review, observation and interview, the manager failed to ensure that one of one sample service plans for residents who were storing medication in their bedrooms, included how the medication would be stored and controlled.

Findings include:
1. During an interview, E1 indicated that R4 self-administered their own medications and stored the medications in their room.
2. The record for R4 contained a current service plan that indicated the resident's medication would have "safe storage".
3. During an interview, E1 acknowledged the service plan did not indicate how the resident's medication would be stored and controlled in their room.

Deficiency #4

Rule/Regulation Violated:

B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2):
1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or

Evidence/Findings:

Based on record review and interview for one of one sample personal care resident records, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident remain in the facility and a signed and dated statement from a medical practitioner indicating that the resident's needs were being met by the facility as per their scope of services, at least once every six months throughout the duration of the resident's condition.

Findings include:
1. During an interview, E1 indicated that R4 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted.
2. The resident's record did not contain a request from the resident or their representative to remain in the facility and the last statement from the medical practitioner that the resident's needs were being met as per the facility's scope of services, was dated May 24, 2022. Based on the resident's date of acceptance this documentation was required.
3. During an interview, E1 acknowledged that the required documentation was not in the resident's record.

Deficiency #5

Rule/Regulation Violated:

B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure for one of one sample records, that medication administered to a resident was administered in compliance with a medication order.

Findings include:
1. The record for R1 contained documentation indicating that on June 26, 2023 at approximately 8pm the resident was given Dilitiazem instead of her regular dosage of Cephalexin. A notation in the record indicated "..the med tech reported to be giving the incorrect medication to the resident."
2. During an interview, E1 acknowledged that a medication prescribed to the resident was not administered in compliance with the medication order.

Deficiency #6

Rule/Regulation Violated:

A. A manager shall ensure that:
10. Oxygen containers are secured in an upright position;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that oxygen cylinders were secured.

Findings include:
1. Five small oxygen cylinders were observed sitting on the floor, unsecured in resident apartment #114.
2. Three large oxygen cylinders were observed sitting on the floor, unsecured in resident apartment #116.
3. Four small oxygen cylinders were observed sitting on the closet floor, unsecured in resident apartment #219.
4. During an interview, E1 acknowledged the oxygen cylinders were not secured.

INSP-0064471

Complete

Date: 1/4/2023

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2023-01-19

Summary:

An on-site complaint investigation for complaint AZ00183156 was conducted on January 4, 2023. Two of two allegations were unable to be substantiated and no deficiencies were found.

✓ No deficiencies cited during this inspection.

INSP-0064472

Complete

Date: 1/4/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-01-19

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on January 4, 2023:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

A manager shall ensure that:
1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes:
e. The frequency of submitting a documented report required in subsection (2) to the governing authority;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a quality management plan is established, documented and implemented that includes the frequency of submitting a documented report to the governing authority.

Findings include:
1. The facility quality management plan did not include the frequency of submitting a documented report to the governing authority.
2. During an interview, E1 stated, "We create a monthly report."
3. During an interview, E1 acknowledged the required documentation was not available for review.

Deficiency #2

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A caregiver:
b. Provides documentation of:
i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that one of two sample employee records for staff who were providing caregiver services, contained documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers.

Findings include:
1. The record for E2 (hired September 9, 2021) did not contain documentation reflecting that the employee had completed a caregiver training program.
2. During an interview, E1 stated, "She works with the residents as a caregiver."
3. During an interview, E1 acknowledged E2 provided caregiver services without documentation of completion of a caregiver training program.

Deficiency #3

Rule/Regulation Violated:

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/Findings:

Based on record review, observation and interview, the manager failed to ensure that one of one sample service plans for residents who were storing medication in their bedrooms, included how the medication would be stored and controlled.

Findings include:
1. During an interview, E1 indicated that R3 self-administered their own medications and stored the medications in their room.
2. The record for R3 contained a service plan dated November 11, 2022 that did not include how the resident's medication would be stored and controlled.
3. During an interview, E1, acknowledged the service plan did not indicate how the resident's medication would be stored and controlled in their room.

Deficiency #4

Rule/Regulation Violated:

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);

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that two of two sample resident records contained documentation of notification to the resident of the availability of vaccination for pneumonia.

Findings include:
1. The record belonging to R1 contained no documentation indicating that the resident had been notified of the availability of the pneumonia vaccination on a yearly basis. No additional documentation indicating when the resident had been offered, refused or received the vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
2. The record belonging to R2 contained no documentation indicating that the resident had been notified of the availability of the pneumonia vaccination on a yearly basis. No additional documentation indicating when the resident had been offered, refused or received the vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
3. During an interview, E1 acknowledged that the vaccination had been made available to the resident on a yearly basis, however, the record did not contain the required documentation.

Deficiency #5

Rule/Regulation Violated:

B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2):
1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or

Evidence/Findings:

Based on record review and interview for one of one sample personal care resident records, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident remain in the facility and a signed and dated statement from a medical practitioner at least once every six months, indicating that the resident's needs were being met by the facility as per their scope of services.

Findings include:
1. During an interview, E1 indicated that R2 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted.
2. The resident's record did not contain a request from the resident or their representative to remain in the facility and the last statement from the medical practitioner that the resident's needs were being met as per the facility's scope of services, was dated May 24, 2022. Based on the resident's date of acceptance this documentation was required.
3. During an interview, E1 acknowledged that the required documentation was not in the resident's record.

Deficiency #6

Rule/Regulation Violated:

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;

Evidence/Findings:

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.

Findings include:
1. Twelve months of facility disaster drill documentation was requested. Review of the disaster drill documentation provided revealed that disaster drills were conducted for each shift on the following dates: January 28, 2022, May 16, 2022 and September 28, 2022. No other disaster drill documentation was available for review.
2. During an interview, E1 acknowledged the requested documentation was not available for review.

Deficiency #7

Rule/Regulation Violated:

A. A manager shall ensure that:
6. Documentation of each evacuation drill is created, is maintained for at least 12 months after the date of the evacuation drill, and includes:
a. The date and time of the evacuation drill;
b. The amount of time taken for employees and residents to evacuate the assisted living facility;
c. If applicable:
i. An identification of residents needing assistance for evacuation, and
ii. An identification of residents who were not evacuated;
d. Any problems encountered in conducting the evacuation drill; and
e. Recommendations for improvement, if applicable;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill included an identification of residents needing assistance for evacuation, and an identification of residents who were not evacuated.

Findings include:
1. Review of 12 months of facility evacuation drill documentation revealed that the documentation failed to identify the following: An identification of residents needing assistance for evacuation and an identification of the residents who were not evacuated.
2. During an interview, E1 stated, "We do have non-ambulatory and directed care residents here who would need assistance and some who do not evacuate."
3. During an interview, E1 acknowledged the required documentation was not available for review.

Deficiency #8

Rule/Regulation Violated:

A. A manager shall ensure that:
14. If pets or animals are allowed in the assisted living facility, pets or animals are:
b. Licensed consistent with local ordinances; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that one pet that is allowed in the facility, was licensed consistent with local ordinances.

Findings include:
1. Documentation for a dog (O1) residing in the facility, failed to reflect that the dog was licensed.
2. During a telephone interview with the local authority it was determined that the dog required a license.
3. During an interview, E1 acknowledged that facility documentation failed to indicate the dog had a current license.

This is a repeat deficiency from the compliance inspection conducted on December 2, 2021.

Facility Information

Inspection History

INSP-0159557

Summary:

INSP-0132556

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0130050

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0115651

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0107895

Summary:

INSP-0101587

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0064479

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

INSP-0064478

Summary:

INSP-0064475

Summary:

Deficiencies Found: 10

Deficiency #1

Rule/Regulation Violated: