Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 31
Oct 2, 2025
Visit Reason
State-compiled facility profile showing 14 inspections from 2023 to 2025 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility exhibited deficiencies related to abuse prevention, care planning, infection control, emergency preparedness, food safety, staffing accuracy, and compliance with regulatory requirements. Several complaint investigations found no deficiencies, while others cited multiple violations including failure to protect residents from abuse and inadequate care documentation.
Complaint Details
Multiple complaint investigations were conducted, including investigations of numerous complaint intake numbers. Some complaint inspections found no deficiencies, while others cited multiple deficiencies related to abuse, neglect, reporting failures, and care planning.
Deficiencies (31)
| Description |
|---|
| §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; |
| §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. |
| §483.20(f) Automated data processing requirement- §483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS. |
| §483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. |
| §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3. A resident is not subjected to: R9-10-410.B.3.a. Abuse; |
| R9-10-423.A. An administrator shall ensure that: R9-10-423.A.3. If a nursing care institution contracts with a food establishment, as defined in 9 A.A.C. 8, Article 1, to prepare and deliver food to the nursing care institution: R9-10-423.A.3.b. The nursing care institution is able to store, refrigerate, and reheat food to meet the dietary needs of a resident; |
| R9-10-423.B. A registered dietitian or director of food services shall ensure that: R9-10-423.B.1. Food is prepared: R9-10-423.B.1.a. Using methods that conserve nutritional value, flavor, and appearance; and |
| [The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.] The emergency preparedness program must include, but not be limited to, the following elements:] (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least annually. |
| [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. |
| Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING ... |
| Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. |
| Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. |
| Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. |
| Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. |
| Health Care Facilities Code - Other List in the REMARKS section any NFPA 99 requirements (excluding Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags, but are deficient. |
| R9-10-403.C. An administrator shall ensure that: R9-10-403.C.2. Policies and procedures for physical health services and behavioral health services are established, documented, and implemented to protect the health and safety of a resident that: R9-10-403.C.2.e. Cover infection control; |
| R9-10-406.F. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: R9-10-406.F.3. Documentation of: R9-10-406.F.3.d. Orientation and in-service education as required by policies and procedures; |
| R9-10-406.H. An administrator shall ensure that: R9-10-406.H.4. A plan to provide in-service education specific to the duties of a personnel member is developed, documented and implemented; |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.1. A resident has privacy in: R9-10-410.B.1.c. Room accommodations, and |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3. A resident is not subjected to: R9-10-410.B.3.i. Restraint; |
| R9-10-412.B. A director of nursing shall ensure that: R9-10-412.B.4. Documentation of nursing personnel present on the the nursing care institution's premises each day is maintained and includes: R9-10-412.B.4.a. The date, |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: R9-10-414.B.1. Is developed, documented, and implemented for the resident within seven calendar days after completing the resident's comprehensive assessment required in subsection (A)(1); |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: R9-10-414.B.3. Ensures that a resident is provided nursing care institution services that: R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. |
| R9-10-423.A. An administrator shall ensure that: R9-10-423.A.3. If a nursing care institution contracts with a food establishment, as defined in 9 A.A.C. 8, Article 1, to prepare and deliver food to the nursing care institution: R9-10-423.A.3.b. The nursing care institution is able to store, refrigerate, and reheat food to meet the dietary needs of a resident; |
| R9-10-403.C. An administrator shall ensure that: R9-10-403.C.2. Policies and procedures for physical health services and behavioral health services are established, documented, and implemented to protect the health and safety of a resident that: R9-10-403.C.2.a. Cover resident screening, admission, transport, transfer, discharge planning, and discharge; |
| R9-10-403.E. If abuse, neglect, or exploitation of a resident is alleged or suspected to have occurred before the resident was admitted or while the resident is not on the premises and not receiving services from a nursing care institution's employee or personnel member, an administrator shall report the alleged or suspected abuse, neglect, or exploitation of the resident as follows: R9-10-403.E.1. For a resident 18 years of age or older, according to A.R.S. § 46-454; or |
| R9-10-403.F. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe that abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from a nursing care institution's employee or personnel member, an administrator shall: R9-10-403.F.5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (F)(2) that includes: R9-10-403.F.5.d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and |
| §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. |
| R9-10-412.B. A director of nursing shall ensure that: R9-10-412.B.4. Documentation of nursing personnel present on the the nursing care institution's premises each day is maintained and includes: R9-10-412.B.4.d. The actual number of hours each nursing personnel member worked that day; |
| §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. |
Report Facts
Inspections on page: 14
Total deficiencies: 46
Complaint inspections: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NINA LOUIS | Administrator | Named as facility administrator in facility information |
| Director of Nursing | Director of Nursing | Referenced in multiple deficiency findings and interviews related to care and abuse investigations |
| NINA LOUIS | Administrator | Referenced in interviews regarding abuse reporting and facility policies |
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