ESTANCIA ASSISTED LIVING AT DANA PARK, LLC

INSP-0158672

Complete

Date: 8/27/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-10-03

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00142278, 00142288, 00107361, and 00107427 conducted on August 27, 2025 :

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

A.R.S. § 36-411.A-H. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service. E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked. F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card. G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety. H. For the purposes of this section: 1. "Direct supportive services": (a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including: (i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair. (ii) Assistance with self-administration of medication. (iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room. (iv) Transportation services, including van services. (b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution. 2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised. 3. "Home health services" has the same meaning prescribed in section 36-151.

Evidence/Findings:

Based on record review and interview, for two of two employees reviewed, the governing authority failed to make a documented good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in the facility. The deficient practice posed a safety risk to residents. Findings include: 1. A.R.S. § 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. A review of E1's personnel record did not include documentation of the facility's good-faith effort to contact E1's previous employers. 3. A review of E2's personnel record did not include documentation of the facility's good-faith effort to contact E2's previous employers. 4 . In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Temporary Solution:

Maryam Rashid, Office Manager looked through our records and found the verification of employment for Victoria Moore and Payah Pyne. It has been uploaded in the attachments.

Permanent Solution:

During future inspections, Maryam Rashid will ensure that the verification of employment gets submitted with all the other documents.

Person Responsible:

Maryam Rashid, Office Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident’s date of occupancy, and 2. As specified in R9-10-113

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of four residents sampled. The deficient practice posed a 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 R3's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R3 had signs or symptoms of TB. Based on R3's date of acceptance, this documentation was required. 3. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Temporary Solution:

Maryam Rashid, Office Manager went through our documentation and found the appendix 3 for Betty Alexander. The document has been attached.

Permanent Solution:

Maryam Rashid will ensure that moving forward the appendix 3 will be uploaded together into our database on Synwkise with the resident's tb test

Person Responsible:

Maryam Rashid, Office Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-808.A.2.a-c. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 2. Is developed with assistance and review from: a. The resident or resident’s representative, b. The manager, and c. Any individual requested by the resident or the resident’s representative;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner who reviewed the service plan. This posed a health and safety risk if the resident or resident's representative, the manager, and the nurse or medical practitioner did not acknowledge the services that were to be provided. Findings include: 1. A review of R3's medical record did not include documentation the resident's service plan was signed and dated by the resident or resident's representative and manager for the service plan dated August 20, 2025. Based on R3's admission date, this documentation was required to be complete. 2. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Temporary Solution:

Maryam Rashid, Office Manager has collected the signatures of the POA and manager for the service plan. Please see the attachment for the signed service plan

Permanent Solution:

Maryam Rashid will ensure that signatures have been collected anytime a service plan is sent out and follow up the POA if it still has not been signed.

Person Responsible:

Maryam Rashid, Office Manager

Deficiency #4

Rule/Regulation Violated:

R9-10-811.C.17. Medical Records 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 a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza( flu) and pneumonia according to A.R.S. § 36-406(1)(d), which required the facility to make the vaccinations available to the resident on site on a yearly basis; for one of four sampled resident records that were reviewed who had resided at the assisted living facility for more than 12 months. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R3's medical record did not include current documentation of notification of the resident or representative of the availability of the flu and pneumonia vaccine. Based on R3's acceptance date, this documentation was required. 3. In an exit interview the findings were reviewed with E4 and no additional information was provided.

Temporary Solution:

We reached out to the POA of Betty Alexander to see if he wants her to receive the flu and pneumonia shots and he refused on 10/13/125.

Permanent Solution:

Every year, we will follow up with the POA and see if the POA would like the resident to receive the flu and pneumonia shots.

Person Responsible:

Maryam Rashid, Office Manager

Deficiency #5

Rule/Regulation Violated:

R9-10-819.A.4. Emergency and Safety Standards 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. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's personnel schedule revealed there were two shifts. 2. A review of the facility's disaster drills revealed documentation of a disaster drill conducted on the following dates and times:-February 11, 2025 at 9:30 am-May 11, 2025 at 10:00 am 3. In an interview, E4 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented. 4. In an exit interview the findings were reviewed with E4 and no additional information was provided.

Temporary Solution:

Upon reviewing the documents that was submit to the inspector, two employee employee disaster drills were submitted, one for each shift that were working at that home during that time. The two employee disaster drills that were submitted are attached.

Permanent Solution:

Maryam Rashid will ensure that each employee completes an employee disaster drill every 3 months.

Person Responsible:

Maryam Rashid, Office Manager

INSP-0096861

Complete

Date: 6/24/2024

Type: Complaint

Worksheet: Assisted Living Home

SOD Sent: 2024-06-25

Summary:

An on-site investigation of complaint AZ00212150 was conducted on June 24, 2024, and no deficiencies were cited :

✓ No deficiencies cited during this inspection.

INSP-0096860

Complete

Date: 5/8/2024

Type: Complaint

Worksheet: Assisted Living Home

SOD Sent: 2024-05-14

Summary:

An on-site investigation of complaint AZ00209979 was conducted on May 8, 2024 , and the following deficiencies were cited :

Deficiencies Found: 2

Deficiency #1

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 that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of two personnel sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of the facility's policies and procedures (reviewed and approved April 20, 2023) revealed a policy titled, "Personnel." The policy stated, " ... A caregiver is required to meet all the requirements for an assistant caregiver as well as the following: ... C. Have their CPR and First Aid Card provided by a hand on service (can not be completed online)."

2. A review of E2's personnel record revealed current documentation of E2's CPR/First Aid training from the "National CPR Foundation" issued July 8, 2023 and valid for two years. However, the CPR training did not include a hands-on demonstration of techniques as required.

3. In an email exchange, a representative from the "National CPR Foundation," stated, "Our courses are online only."

4. In an interview, E1 and E2 acknowledged E2's personnel record did not include current CPR training with hands-on demonstration as required.

Deficiency #2

Rule/Regulation Violated:

C. A manager shall ensure that:
1. A caregiver or an assistant caregiver:
a. Provides a resident with the assisted living services in the resident's service plan;
b. Is only assigned to provide the assisted living services the caregiver or assistant caregiver has the documented skills and knowledge to perform;
c. Provides assistance with activities of daily living according to the resident's service plan;
d. If applicable, suggests techniques a resident may use to maintain or improve the resident's independence in performing activities of daily living;
e. Provides assistance with, supervises, or directs a resident's personal hygiene according to the resident's service plan;
f. Encourages a resident to participate in activities planned according to subsection (E); and
g. Documents the services provided in the resident's medical record;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with the activities of daily living according to the resident's service plan for two of two residents sampled. The deficient practice posed a risk to the health and safety of the resident as the resident was not provided with the services required.

Findings include:

1. A review of R1's medical record revealed a service plan dated January 23, 2024. Under the title, "Mobility" the service plan stated, "Bed Ridden, Wheel Chair, Hoyer Lift, Fall Risk, Needs Supervision; Requires Positioning: Yes, 2 hour(s)."

2. A review of R1's "Tasks and ADL's Log" revealed positioning was not listed as a service provided to R1.

3. A review of R2's medical record revealed a service plan dated February 26, 2024. Under the title, "Mobility" the service plan stated, "Bed Ridden, Wheel Chair, Fall Risk; Requires Positioning: Yes, 2 hour(s)."

4. A review of R2's "Tasks and ADL's Log" revealed positioning was not listed as a service provided to R2.

5. In an interview, E1 reported R1 and R2 were repositioned at every brief change, which was documented as being provided at 6:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM.

6. In an interview, E1 and E2 acknowledged R1 and R2 did not receive assisted living services according to R1's and R2's service plan, as being repositioned at every brief change was not provided every two hours. E1 and E2 also acknowledged the repositioning services in R1's and R2's service plan were not documented as required.

INSP-0096859

Complete

Date: 12/29/2023

Type: Initial Monitoring

Worksheet: Assisted Living Home

SOD Sent: 2024-01-25

Summary:

No deficiencies were found during the on-site abbreviated initial follow-up inspection conducted on December 29, 2023.

✓ No deficiencies cited during this inspection.

INSP-0096858

Complete

Date: 10/19/2023

Type: Compliance (Initial)

Worksheet: Assisted Living Home

SOD Sent: 2023-10-23

Summary:

No deficiencies were found during the on-site initial inspection conducted on October 19, 2023.

✓ No deficiencies cited during this inspection.

ESTANCIA ASSISTED LIVING AT DANA PARK, LLC

Facility Information

Inspection History

INSP-0158672

Summary:

Deficiencies Found: 5

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:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0096861

Summary:

INSP-0096860

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

INSP-0096859

Summary:

INSP-0096858

Summary: