SCOTTSDALE PERSONAL CARE FACILITY

2025 · 38 cited

1. The facility failed to have a program to inspect, test, and maintain the fire sprinkler system and keep records of inspection, testing, and maintenance of the fire sprinkler system.

   Life Safety CodeCited Dec 29, 2025Corrected —

2. The facility failed to inspect, test, and maintain fire sprinkler system components.

   Life Safety CodeCited Dec 29, 2025Corrected —

3. The facility failed to store oxygen provided by the facility in a safe and sanitary manner.

   Life Safety CodeCited Dec 29, 2025Corrected —

4. The facility failed to obtain pressure tests of gas piping in the facility.

   Life Safety CodeCited Dec 29, 2025Corrected —

5. The facility failed to inspect, test, and maintain fire alarm system components.

   Life Safety CodeCited Dec 29, 2025Corrected —

6. The facility failed to have a program to inspect, test, and maintain the fire alarm system and keep records of inspection, testing, and maintenance of the fire alarm system.

   Life Safety CodeCited Dec 29, 2025Corrected —

7. The facility failed to ensure the sensitivity of smoke detectors was checked according to NFPA 72.

   Life Safety CodeCited Dec 29, 2025Corrected —

8. The facility failed to review the plan at least annually to reflect changes in information, within 30 days following a disaster, within 30 days after a drill, and within 30 days after a change in rule or policy.

   Life Safety CodeCited Dec 29, 2025Corrected —

9. The facility failed to register with 2-1-1 Texas to assist the state in identifying persons who may need assistance in a disaster.

   Life Safety CodeCited Dec 29, 2025Corrected —

10. The facility failed to include a section addressing sheltering arrangements in the emergency preparedness and response plan.

    Life Safety CodeCited Dec 29, 2025Corrected —

11. The facility failed to provide the required emergency preparedness and response plan training and conduct drills.

    Life Safety CodeCited Dec 29, 2025Corrected —

12. The facility failed to keep walls and ceilings in good condition.

    Health VisitCited Jun 11, 2025Corrected —

13. The facility failed to ensure that food prepared on-site provided a kitchen or dietary area meeting minimum requirements.

    Health VisitCited Jun 11, 2025Corrected —

14. The facility failed to have evidence showing that the manager completed the required 12 hours of annual continuing education.

    Health VisitCited Jun 11, 2025Corrected —

15. The facility failed to ensure that the manager was on duty and managing only one facility, or for small type A facilities responsible for no more than 16 residents in no more than four facilities and available when off- site.

    Health VisitCited Jun 11, 2025Corrected —

16. The facility failed to document that staff were competent and trained prior to assuming their responsibilities.

    Health VisitCited Jun 11, 2025Corrected —

17. The facility failed to ensure that specific on-the-job training required for attendants in this type facility was completed in the required timeframe.

    Health VisitCited Jun 11, 2025Corrected —

18. The facility failed to conduct criminal history checks of employees and applicants.

    Health VisitCited Jun 11, 2025Corrected —

19. The facility failed to search the employee misconduct registry and nurse aide registry before hiring to determine if the individual is unemployable.

    Health VisitCited Jun 11, 2025Corrected —

20. The provider failed to have a written admission agreement between the facility and the resident explaining details concerning services and charges and that also included a statement concerning possible Medicare benefits.

    Health VisitCited Jun 11, 2025Corrected —

21. The facility failed to obtain the required resident identifying information, such as each resident's full name and SSN at the time of admission.

    Health VisitCited Jun 11, 2025Corrected —

22. The facility failed to either assess a resident or to develop, approve, sign, or follow a service plan within the allowable time.

    Health VisitCited Jun 11, 2025Corrected —

23. The facility failed to have the required written resident policies.

    Health VisitCited Jun 11, 2025Corrected —

24. The facility failed to notify the resident, and if it applies, the resident's legally authorized representative, of HHSC's licensure rules and the facility's policies regarding restraint and seclusion.

    Health VisitCited Jun 11, 2025Corrected —

25. The facility failed to ensure that a licensed person or a trained, authorized, and delegated person administered medications to residents who choose not to or cannot self-administer their medications.

    Health VisitCited Jun 11, 2025Corrected —

26. The facility failed to list each resident's medications on a specific medication profile record documenting the required medication details (e.g., strength and dosage).

    Health VisitCited Jun 11, 2025Corrected —

27. The facility policies and procedures did not address the prevention of the diversion of controlled drugs.

    Health VisitCited Jun 11, 2025Corrected —

28. The facility failed to keep discontinued medications separate from current medications or failed to meet requirements for appropriate disposal of discontinued medications.

    Health VisitCited Jun 11, 2025Corrected —

29. The facility failed to describe and document an injury, accident, or illness in the manner required.

    Health VisitCited Jun 11, 2025Corrected —

30. The facility failed to procure food from acceptable sources, or failed to handle food, subject to spoilage, as required.

    Health VisitCited Jun 11, 2025Corrected —

31. The facility failed to assure freezers and refrigerators were kept at the proper temperatures.

    Health VisitCited Jun 11, 2025Corrected —

32. The facility failed to ensure effective hair restraints were worn to prevent food contamination.

    Health VisitCited Jun 11, 2025Corrected —

33. The facility failed to post a copy of the most recent inspection report.

    Health VisitCited Jun 11, 2025Corrected —

34. The facility failed to report incidents of abuse, neglect, or exploitation to HHSC's state office, or failed to follow its own internal policies regarding abuse, neglect, or exploitation.

    Health VisitCited Jun 11, 2025Corrected —

35. The facility failed to immediately make an oral report of alleged ANE or send a written report of the investigation to HHSC when required.

    Health VisitCited Jun 11, 2025Corrected —

36. The facility failed to provide written notice at the time of admission about advance directive policies to either a resident or to a resident's surrogate decision-maker.

    Health VisitCited Jun 11, 2025Corrected —

37. The facility failed to ensure that all employees providing services were screened for tuberculosis within two weeks of employment and annually.

    Health VisitCited Jun 11, 2025Corrected —

38. The facility failed to search the NAR and EMR annually.

    Health VisitCited Jun 11, 2025Corrected —