Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 5, 2025
Visit Reason
The inspection was conducted due to complaints alleging verbal abuse by a staff member toward Resident #60, an allegation of physical abuse and lack of injury assessment for Resident #66, failure to encode and transmit Minimum Data Set (MDS) assessments for two residents (#3 and #12), and concerns about food safety and storage practices.
Complaint Details
The complaint investigation substantiated verbal abuse by Staff #99 toward Resident #60, including use of derogatory language and gestures. Staff #99 was suspended immediately and later terminated. The investigation also found failure to assess injury for Resident #66 after an abuse allegation. Multiple staff interviews and facility records supported these findings.
Findings
The facility substantiated the verbal abuse allegation against Staff #99 toward Resident #60, resulting in immediate suspension and eventual termination of the staff member. The facility failed to conduct a proper injury assessment for Resident #66 after an abuse allegation. The facility also failed to encode and transmit MDS assessments timely for two residents, impacting regulatory compliance. Additionally, the facility failed to maintain food at safe temperatures and did not properly label or date food items in storage, risking food safety violations.
Deficiencies (5)
Failed to protect Resident #60 from verbal abuse by a staff member who used derogatory language and gestures.
Failed to ensure a thorough investigation and injury assessment for Resident #66 after an allegation of abuse.
Failed to encode and transmit Minimum Data Set (MDS) assessments for Residents #3 and #12 according to regulatory requirements.
Failed to ensure food and drinks were palatable and maintained at safe and appetizing temperatures.
Failed to properly label, date, and monitor refrigerated and stored food items in the kitchen.
Report Facts
Deficiencies cited: 5
Food temperature: 48.3
Food temperature: 133.1
Food temperature: 51.1
Food temperature: 37.6
Food temperature: 173.8
Food temperature: 41.6
Food temperature: 126
Food temperature: 133
Food temperature: 154
Food temperature: 122
Food temperature: 57
Food temperature: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #99 | Licensed Practical Nurse (LPN) | Named in verbal abuse finding against Resident #60; suspended and terminated. |
| Staff #106 | Certified Nursing Assistant (CNA) | Reported verbal abuse incident involving Staff #99 and Resident #60. |
| Staff #57 | Director of Nursing (DON) | Interviewed regarding abuse investigations and MDS transmission failures. |
| Staff #65 | Administrator | Interviewed regarding abuse investigations and facility policies. |
| Staff #47 | Nutrition Care Manager | Interviewed and observed food temperature and storage practices. |
| Staff #200 | Licensed Practical Nurse (LPN) | Interviewed regarding verbal abuse incident involving Staff #99 and Resident #60. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 20, 2025
Visit Reason
The inspection was conducted due to an allegation of abuse reported by Resident #34, specifically that a Certified Nursing Assistant pulled the resident's hair on or about May 14, 2025.
Complaint Details
The complaint was related to an allegation by Resident #34 that a CNA pulled her hair on May 14, 2025. The facility conducted an investigation but failed to properly submit the self-report to the State Agency. The allegation was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure that the allegation of abuse was properly reported to the State Agency. Although the Director of Nursing stated she submitted a self-report online, no evidence showed the complaint was finalized or included in the facility's self-reports. The facility completed a five-day investigation but was unable to substantiate the allegation due to lack of evidence.
Deficiencies (1)
Failure to timely report suspected abuse of Resident #34 to the State Agency.
Report Facts
Residents Affected: 1
Investigation duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported submitting self-report online and involved in investigation |
| President of Health Services | Vice President (VP) | Abuse coordinator and provided statements about reporting and investigation |
| Social Worker | Social Worker | Conducted interviews and involved in abuse investigation |
Inspection Report
Routine
Deficiencies: 12
Date: Aug 30, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, use of restraints, care planning, oxygen therapy, infection control, staff training, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to notify a resident of a room change, inadequate assessment and care planning for restraints and oxygen use, lack of physician orders for oxygen administration, improper infection control practices, missing daily staff postings, unsafe food storage, environmental maintenance issues, and incomplete staff training on resident rights, abuse prevention, and infection control.
Deficiencies (12)
Failed to notify resident #37 prior to room change and obtain consent.
Failed to assess and care plan for use of power wheelchair seatbelt and bed rails for resident #44.
Failed to develop timely care plan for oxygen use for resident #38.
Failed to ensure physician order for oxygen administration for resident #50 and failed to document oxygen administration.
Failed to post daily nurse staffing information on 4th floor.
Stored undated and partially uncovered food in nourishment refrigerator on 3rd floor.
Indwelling catheter bag found on floor increasing risk of infection.
Failed to disinfect blood pressure cuffs between resident use.
Enhanced Barrier Precautions signs were missing on 4th floor resident rooms.
Staff failed to perform hand hygiene between resident contacts and upon leaving rooms.
Facility environment had water stains on ceiling tiles, brown stains on door frames, and leaking temperature probe.
Two staff (#70 RN and #19 housekeeper) lacked annual training on abuse, neglect, exploitation, resident rights, dementia management, and infection control.
Report Facts
Facility census: 52
Power outage timeframe: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #38 | Social Worker | Involved in room change notification issue for resident #37 |
| Staff #76 | Licensed Practical Nurse | Interviewed regarding restraint assessment and oxygen administration |
| Staff #12 | Director of Nursing | Interviewed regarding restraint policy, oxygen administration, and hand hygiene |
| Staff #60 | Licensed Practical Nurse | Interviewed regarding oxygen therapy for resident #38 |
| Staff #68 | Assistant Director of Nursing | Interviewed regarding oxygen therapy and infection control |
| Staff #29 | Licensed Practical Nurse | Observed and interviewed regarding oxygen administration and infection control |
| Staff #35 | Registered Dietician | Interviewed regarding food storage issues |
| Staff #11 | Certified Nursing Assistant | Interviewed regarding catheter bag placement |
| Staff #1 | Certified Nursing Assistant | Interviewed regarding catheter bag placement |
| Staff #49 | Registered Nurse | Interviewed regarding daily staff posting |
| Staff #22 | Certified Nursing Assistant | Observed failing to perform hand hygiene |
| Staff #16 | Certified Nursing Assistant | Observed failing to perform hand hygiene |
| Staff #205 | Senior Maintenance Engineer | Interviewed regarding facility maintenance issues |
| Staff #110 | Administrator | Interviewed regarding facility environment and staff training |
| Staff #59 | Administrator | Interviewed regarding staff training and infection control |
| Staff #90 | Human Resources Assistant | Interviewed regarding staff training requirements |
| Staff #40 | VP of Human Resources and Risk Management | Interviewed regarding staff training policies and updates |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jan 20, 2023
Visit Reason
The inspection was conducted based on complaint investigations related to failure to obtain informed consent for psychotropic medication, failure to timely report and respond to abuse allegations, failure to complete PASARR screening, failure to follow physician orders for insulin administration, failure to maintain RN coverage, inaccurate nurse staffing postings, and failure to monitor refrigerator temperatures.
Complaint Details
The complaint investigation included failure to obtain informed consent for psychotropic medication for resident #18, failure to timely report and respond to abuse allegations involving resident #39, failure to complete PASARR screening for resident #25, failure to follow insulin orders for resident #14, failure to maintain RN coverage, inaccurate nurse staffing postings, and failure to monitor refrigerator temperatures.
Findings
The facility failed to ensure informed consent for psychotropic medication, timely reporting and response to abuse allegations, completion of PASARR screening, adherence to insulin administration orders, RN coverage for at least 8 hours daily, accurate daily nurse staffing postings, and consistent monitoring and documentation of refrigerator temperatures.
Deficiencies (8)
Failed to ensure resident or representative was informed and consented to psychotropic medication use prior to administration.
Failed to timely report suspected abuse and report investigation results to proper authorities.
Failed to respond appropriately to alleged violations, allowing potential further abuse by staff.
Failed to complete PASARR Level 1 screening as required for one resident.
Failed to follow physician orders regarding insulin administration for one resident.
Failed to have a registered nurse on duty for at least 8 consecutive hours daily.
Failed to post accurate daily nurse staffing information reflecting actual hours worked.
Failed to consistently monitor, maintain, and document refrigerator temperatures.
Report Facts
Resident: 18
Resident: 39
Resident: 25
Resident: 14
Census: 57
Staff sample: 15
Dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator/Director of Nursing | Interviewed regarding psychotropic medication consent, abuse reporting, insulin administration, RN coverage, and staffing postings | |
| Licensed Practical Nurse (LPN) | Interviewed regarding psychotropic medication consent and abuse reporting | |
| Certified Nursing Assistant (CNA) | Involved in abuse allegation and reporting | |
| Registered Nurse (RN) | Interviewed regarding insulin administration and staffing | |
| Executive Chef | Interviewed regarding refrigerator temperature monitoring | |
| Staffing Coordinator | Interviewed regarding nurse staffing postings accuracy |
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