Inspection Report
Complaint Investigation
Capacity: 145
Deficiencies: 26
Oct 22, 2025
Visit Reason
State-compiled facility profile showing 15 inspections from 2023-04 to 2025-10 with deficiency history and complaint investigations.
Findings
Across multiple complaint and compliance inspections, deficiencies were found related to medical record safeguards, tuberculosis screening, resident dignity, medication administration, service plan documentation, emergency and safety standards, and environmental hazards. Several repeat deficiencies were noted, and some inspections found no deficiencies.
Complaint Details
Multiple complaint investigations conducted between 2023 and 2025 with findings of deficiencies related to resident care, documentation, medication administration, and safety standards. Some investigations found no deficiencies.
Deficiencies (26)
| Description |
|---|
| R9-10-811.B.1-2. Medical Records: Failed to ensure safeguards existed to prevent unauthorized access to resident medical records. |
| R9-10-803.J.1-6. Administration: Failed to report suspected abuse, neglect, or exploitation as required by A.R.S. § 46-454. |
| R9-10-806.A.8.a-b. Personnel: Failed to ensure caregivers provided evidence of freedom from infectious tuberculosis before providing services for six of ten personnel sampled. |
| R9-10-807.A.1-2. Residency and Residency Agreements: Failed to ensure residents provided evidence of freedom from infectious tuberculosis within required timeframe for six of ten residents sampled. |
| R9-10-810.B.1. Resident Rights: Failed to ensure a resident was treated with dignity, respect, and consideration. |
| R9-10-815.F.2.a-c. Directed Care Services: Failed to ensure means of exiting the facility controlled or alerted employees of resident egress. |
| R9-10-816.B.3.b. Medication Services: Failed to ensure medication was administered in compliance with medication order for one of ten residents sampled. |
| R9-10-816.F.1. Medication Services: Failed to ensure medication was stored in a separate locked area used only for medication storage. |
| R9-10-818.A.6.a-e. Emergency and Safety Standards: Failed to maintain documentation of evacuation drills including identification of residents needing assistance and those not evacuated. |
| R9-10-818.D.2.a-f. Emergency and Safety Standards: Failed to document actions taken, notifications, and prevention measures after resident accident requiring medical services. |
| R9-10-819.A.1.b. Environmental Standards: Failed to ensure premises and equipment were free from conditions that may cause physical injury. |
| B. Medication Administration: Failed to ensure medication was administered in compliance with medication order; medication given without order and improper administration documented. |
| A. Service Plan: Failed to ensure residents had written service plans including level of service expected for two of four residents sampled. |
| C. Documentation: Failed to ensure caregiver documented services provided in resident's medical record for three of four residents reviewed. |
| A. Service Plan: Failed to ensure six of ten residents' service plans were signed and dated by required parties when developed and updated. |
| C. Medical Record: Failed to document notification of availability of influenza and pneumonia vaccinations for residents as required. |
| B. Directed Care Services: Failed to obtain signed determinations from medical practitioners for residents unable to ambulate for one of two sampled residents. |
| E. Alert Systems: Failed to ensure call bell, intercom, or mechanical alert means were available in bedrooms of residents receiving directed care services. |
| A. Environmental Safety: Failed to ensure premises and equipment were free from conditions causing physical injury, including unsafe bedrails and pillows. |
| A. Service Plan: Failed to ensure three of seven residents receiving personal care services had service plans reviewed and updated at least every six months. |
| A. Service Plan: Failed to ensure two of three residents receiving directed care services had service plans reviewed and updated at least every three months. |
| A. Service Plan: Failed to ensure one of thirteen residents' service plans were signed and dated by required parties when developed and updated. |
| C. Medical Record: Failed to document notification of availability of influenza and pneumonia vaccinations for one of four residents reviewed. |
| B. Directed Care Services: Failed to obtain signed determinations from medical practitioners for three of seven residents unable to ambulate as required. |
| A. Cleaning and Infection Control: Failed to ensure premises and equipment were cleaned and disinfected according to policies to prevent illness or infection. |
| A. Environmental Safety: Failed to ensure premises were free from conditions causing physical injury, including pillows blocking bed exit for a resident. |
Report Facts
Inspections on page: 15
Total deficiencies: 30
Complaint inspections: 14
Total capacity: 145
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Named in multiple findings including failure to ensure safeguards for medical records, reporting abuse, tuberculosis screening, medication administration, and environmental safety. | |
| E2 | Named in findings related to service plan documentation, alert systems, and resident care. | |
| E3 | Named in tuberculosis screening deficiency. | |
| E4 | Named in tuberculosis screening deficiency. | |
| E6 | Named in tuberculosis screening deficiency. | |
| E7 | Named in tuberculosis screening deficiency. | |
| E9 | Named in fall prevention training deficiency. | |
| E10 | Named in tuberculosis screening deficiency. | |
| E11 | Named in medication administration deficiency. | |
| E12 | Named in resident dignity deficiency. | |
| E13 | Named in evacuation drill documentation deficiency. |
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