COUNTRYSIDE SENIOR LIVING

Assisted Living Center | Assisted Living

Facility Information

Address 22773 East Ocotillo Road, Queen Creek, AZ 85142
Phone 4803524530
License AL11483C (Active)
License Owner COUNTRYSIDE AT OCOTILLO, LLC
Administrator ROSE LEIB
Capacity 50
License Effective 5/14/2025 - 5/13/2026
Services:
2
Total Inspections
6
Total Deficiencies
2
Complaint Inspections

Inspection History

INSP-0094321

Complete
Date: 8/13/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-08-28

Summary:

An on-site investigation of complaint AZ00213985 was conducted on August 13, 2024, and the following deficiencies were cited :

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:
36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document
A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following:
1. The reason or reasons the emergency responder was requested on behalf of the resident.
2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered.
3. The name, address and telephone number of the resident's current pharmacy.
4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive.
5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative.
6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known.
7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week.
8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act r
Evidence/Findings:
Based on documentation review and interview, the assisted living center failed to provide the required documentation to an emergency responder when an emergency responder had been contacted.

Findings include:

1. A review of facility documentation revealed a "Transfer/Move Out Report" dated July 16, 2024. The documentation included all information required except the reason the emergency responder was requested on behalf of the resident.

2. In an interview, E1 acknowledged documentation to an emergency responder when an emergency responder had been contacted had not included the reason the emergency responder was requested on behalf of the resident.

Deficiency #2

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:
c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication;
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a resident's service plan included the amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication, for one of three residents sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided.

Findings include:

1. A review of R1's medical record revealed a service plan dated August 1, 2023 (sic). The service plan stated "Independent" on the first page for medication services. However, on the third page of the service plan, under additional instructions, it states "as of 6/14 resident will receive assistance with med management. Medications are stored."

2. In an interview, E1 reported the service plan was actually for June 14, 2024. E1 reported instead of filling out a new service plan, E1 made a copy of R1's previous service plan and added the note under additional instructions.

3. Further review of R1's service plan revealed signatures of the resident and manager. However, the date the resident signed the service plan was not available on the service plan.

4. In an interview, E1 acknowledged R1's service plan had not included clear indication of medication services being provided to R1.

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:
5. When initially developed and when updated, is signed and dated by:
a. The resident or resident's representative;
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, for one of three residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan dated August 1, 2023 (sic). The service plan revealed signatures of the resident and manager. However, the date the resident signed the service plan was not available on the service plan.

2. In an interview, E1 reported the service plan was actually for June 14, 2024. E1 reported instead of filling out a new service plan, E1 made a copy of R1's previous service plan and added the note under additional instructions.

3. In an interview, E1 acknowledged R1's service plan had not been dated when signed by the resident.

Deficiency #4

Rule/Regulation Violated:
C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes:
6. Documentation:
a. Of the resident's weight, or
b. From a medical practitioner stating that weighing the resident is contraindicated; and
Evidence/Findings:
Based on record review, documentation review and interview, the manager failed to ensure service plans for residents included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of two residents receiving directed care services.

Findings include:

1. A review of R3's personnel record revealed a service plan. However, the service plan did not include documentation of the resident's weight.

2. A review of facility documentation revealed a document titled "Monthly Weight Report." The document revealed weights taken for all residents during the months of June and July 2024.

3. In an interview, E1 acknowledged R3's service plan had not included documentation of the resident's weight.

INSP-0094320

Complete
Date: 6/11/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-07-08

Summary:

An on-site investigation of complaints AZ00207052 and AZ00210941 was conducted on June 11, 2024, and the following deficiencies were cited:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:
36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document
A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following:
1. The reason or reasons the emergency responder was requested on behalf of the resident.
2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered.
3. The name, address and telephone number of the resident's current pharmacy.
4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive.
5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative.
6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known.
7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week.
8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act r
Evidence/Findings:
Based on documentation review, record review, and interview, the assisted living facility failed to provide the required documentation to an emergency responder, for one of one sampled resident for whom an emergency responder had been contacted.

Findings include:

1. A review of facility documentation revealed an incident report dated May 6, 2024 for an unwitnessed fall. The documentation stated 911 was called. The incident report indicated R2 had been transported to the hospital after being found on the floor.

2. In an interview, E1 was asked for documentation of the required documentation given to the responders. E1 reported it was not done.

Deficiency #2

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:
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 when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistant caregiver documented the action taken to prevent the accident, emergency, or injury from occurring in the future which posted a health and safety risk.

Findings include:

1. A review of the facility's documentation revealed a report dated May 6, 2024 regarding R2's fall. The report stated R2 had an unwitnessed fall. However, the documentation of any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review. Documentation stated that 911 was called.

2. Review of R2's medical record revealed that R2 required directed care and medication administration services and was ambulatory.

3. In an interview, E1 acknowledged the facility failed to document action taken to prevent the injury from reoccurring in the future

Data sourced from AZ CareCheck - Arizona Department of Health Services

Report generated: 2025-11-27T18:02:54.915Z