Inspection Report
Complaint Investigation
Capacity: 103
Deficiencies: 41
Oct 20, 2025
Visit Reason
State-compiled facility profile showing 24 inspections from 2023-03-28 to 2025-10-20 with deficiency history and enforcement actions.
Findings
Multiple inspections found the facility out of compliance with various regulations including medication administration, resident rights, environmental standards, personnel qualifications, and documentation. Deficiencies were repeated across inspections, indicating ongoing issues with resident safety, care, and facility conditions.
Deficiencies (41)
| Description |
|---|
| R9-10-817.B.3.b. Medication Services: Failed to ensure medication was administered in compliance with a medication order for one of three residents sampled. |
| R9-10-120.F.4.a-c. Opioid Prescribing and Treatment: Failed to document resident's need for opioid and monitor effect before and after administration for two residents. |
| R9-10-803.A.10. Administration: Failed to ensure health, safety, or welfare of a resident; included unwanted sexual advances and roach infestation. |
| R9-10-806.A.5.a-c. Personnel: Failed to ensure caregiver qualifications to meet resident needs, resulting in unmet medical and skin care needs. |
| R9-10-806.A.8.a-b. Personnel: Failed to ensure employees provided evidence of freedom from infectious tuberculosis for seven of ten employees reviewed. |
| R9-10-807.D.10. Residency and Residency Agreements: Failed to ensure residency agreements included manager's signature and date signed for two of nine residents. |
| R9-10-808.A.3.a. Service Plans: Failed to include description of resident's medical or health problems in service plan for one of nine residents. |
| R9-10-808.A.4.a. Service Plans: Failed to update service plan within 14 days after significant change in resident's condition for one resident. |
| R9-10-810.B.1. Resident Rights: Failed to ensure resident was treated with dignity, respect, and consideration; included roach infestation and sexual harassment. |
| R9-10-811.B.1-2. Medical Records: Failed to ensure safeguards to prevent unauthorized access to electronic medical records. |
| R9-10-814.F.1. Personal Care Services: Failed to include skin maintenance in service plan to prevent and treat injuries and infections for one resident. |
| R9-10-817.B.3.b. Medication Services: Failed to ensure medication administered in compliance with medication order for one resident. |
| R9-10-820.A.1.a. Environmental Standards: Failed to ensure premises and equipment are cleaned and disinfected according to policies to prevent illness. |
| R9-10-820.A.1.b. Environmental Standards: Failed to ensure premises free from conditions causing physical injury; included trip hazards and unlocked medications. |
| R9-10-820.A.2. Environmental Standards: Failed to implement and document effective pest control program; ongoing cockroach infestation. |
| R9-10-821.D.7.b. Physical Plant Standards: Failed to ensure clean linen including mattress pads and sheets for residents. |
| R9-10-808.C.1.g. Service Plans: Failed to document services provided in resident's medical record correctly for five residents. |
| R9-10-817.A.1.a-g. Medication Services: Failed to follow procedures for assisting resident in procuring medication. |
| R9-10-817.B.3.b. Medication Services: Failed to document medication administration correctly in resident's medical record. |
| R9-10-808.C.1.g. Service Plans: Failed to document services provided in resident's medical record for one resident. |
| R9-10-810.B.1. Resident Rights: Failed to ensure resident treated with dignity, respect, and consideration; roach infestation and unsanitary conditions observed. |
| R9-10-819.A.1.a. Environmental Standards: Failed to ensure premises and equipment cleaned and disinfected to prevent illness; roach infestation noted. |
| A. A manager shall ensure that premises and equipment are free from conditions causing physical injury; illegal drug activity and unsafe conditions noted. |
| 36-420. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition: Failed to provide appropriate first aid to non-injured resident who had fallen. |
| C. A manager shall ensure policies and procedures protect health and safety by awareness of resident whereabouts; failed to track resident whereabouts leading to risk. |
| J. Duty to report abuse, neglect and exploitation: Failed to document reports of suspected abuse and neglect as required. |
| A. A governing authority shall ensure compliance with A.R.S. § 36-411; failed to ensure valid fingerprint clearance for employee. |
| B. Medication Services: Failed to ensure medication administered in compliance with order and documented properly for one resident. |
| D. Notification of emergency contacts: Failed to immediately notify emergency contact and primary care provider after resident injury. |
| R9-10-120. Opioid Prescribing and Treatment: Failed to document resident's need for opioid and effect of opioid administered for one resident. |
| C. Policies and procedures: Failed to establish policies to be aware of resident whereabouts; risk of residents being unaccounted for. |
| J. Duty to report abuse, neglect and exploitation: Failed to document reports of suspected abuse and neglect as required. |
| A. A manager shall ensure premises free from conditions causing physical injury; known illegal drug activity and resident exposure to illegal substances. |
| C. A manager shall not accept or retain individual if primary condition is behavioral health issue; accepted residents with behavioral health as primary condition. |
| A. A manager shall ensure resident provides evidence of freedom from infectious tuberculosis within required timeframe; failed for multiple residents. |
| B. A manager shall ensure documentation dated within 90 days before acceptance includes medical needs; failed for multiple residents. |
| C. A manager shall ensure resident's medical record contains documentation of assisted living services provided; failed for multiple residents. |
| A. A manager shall ensure manager provides current first aid and CPR training documentation; failed for one employee. |
| C. A manager shall ensure caregiver documents services provided in medical record; failed for multiple residents. |
| A. A manager shall ensure resident has written service plan updated within 14 days after significant change; failed for multiple residents. |
| D. A manager shall ensure caregiver documents actions to prevent future accidents; failed for multiple residents. |
Report Facts
Inspections on page: 24
Total deficiencies: 53
Complaint inspections: 23
Total capacity: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tedd Glazebrok | ALF Manager | Named in relation to multiple findings including residency agreement and environmental deficiencies |
| Tedd J Glazebrook | Alf Manager | Named as person responsible for residency agreement deficiency |
| Rebecca W. | Business Office Manager | Involved in attempts to obtain resident signature on residency agreement |
| Eric M. | Operations Manager | Involved in attempts to obtain resident signature on residency agreement and staffing adjustments |
| Jessica | LTC CM | Involved in attempts to obtain resident signature on residency agreement and discharge notices |
| E1 | Interviewed and acknowledged multiple deficiencies including TB documentation, medication administration, and environmental issues | |
| E2 | Interviewed and acknowledged multiple deficiencies including TB documentation, medication administration, and resident dignity issues | |
| E3 | Interviewed and acknowledged medication administration and documentation deficiencies | |
| E4 | Interviewed regarding medication administration and TB documentation | |
| E5 | Housekeeper | Reported roach infestation and unsanitary conditions |
| E9 | Reported on physical therapy and resident fall follow-up | |
| E10 | Interviewed regarding findings and facility policies | |
| E11 | Acknowledged deficiencies in service plans and environmental issues | |
| E12 | Interviewed regarding findings |
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