Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 23
Jun 24, 2025
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State-compiled facility profile showing 6 inspections from 2023-2025 with deficiency history and complaint investigations.
Findings
Multiple inspections revealed numerous deficiencies including failure to provide required emergency documentation, inadequate first aid and CPR training, incomplete tuberculosis screening, medication administration errors, environmental safety issues, and failure to ensure resident dignity and rights. Several deficiencies were repeat citations from prior inspections.
Complaint Details
Multiple complaint investigations were conducted including complaints 00133123, 00133789, 00106879, 00108187, 00104853, 00105305, 00105494, 00123150, 00125014, AZ00219040, AZ00204702, AZ00205138, AZ00206527, AZ00186901, AZ00191337, AZ00198770, AZ00200034, and AZ00200080.
Deficiencies (23)
| Description |
|---|
| A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to provide a written document with all required information to emergency responders on behalf of a resident. |
| A.R.S. § 36-420.B.2. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition: Failed to provide appropriate first aid before arrival of emergency medical services to a non-injured resident who had fallen. |
| R9-10-803.A.9. Administration: Governing authority failed to ensure compliance with A.R.S. § 36-411 regarding personnel background checks and references. |
| R9-10-803.C.1.e.i-iv. Administration: Failed to establish and document policies covering CPR training method and qualifications for trainers. |
| R9-10-806.A.10. Personnel: Failed to ensure caregiver provided current documentation of first aid and CPR training certification specific to adults before providing services. |
| R9-10-806.A.8.a-b. Personnel: Failed to ensure manager and caregiver provided evidence of freedom from infectious tuberculosis on or before date services began. |
| R9-10-808.C.1.g. Service Plans: Failed to ensure caregiver documented services provided in resident's medical record. |
| R9-10-810.B.1. Resident Rights: Failed to ensure resident was treated with dignity, respect, and consideration. |
| R9-10-816.B.3.b. Medication Services: Failed to ensure medication administered to residents was in compliance with medication orders. |
| R9-10-818.A.4. Emergency and Safety Standards: Failed to conduct and document disaster drills on each shift at least once every three months. |
| R9-10-819.A.1.b. Environmental Standards: Failed to ensure premises and equipment were free from conditions that may cause physical injury, including unlocked pool fence and unsecured medications. |
| R9-10-819.A.11. Environmental Standards: Failed to maintain poisonous or toxic materials in locked area inaccessible to residents. |
| R9-10-819.A.3.a-b. Environmental Standards: Failed to ensure garbage and refuse were stored in covered containers lined with plastic bags and removed weekly. |
| J. Reporting suspected abuse, neglect or exploitation: Manager failed to report suspected abuse, neglect, or exploitation immediately as required by A.R.S. § 46-454. |
| A. Governing authority shall ensure compliance with A.R.S. § 36-411: Failed to ensure compliance with fingerprint clearance and reference checks for personnel. |
| A. Manager shall verify caregiver skills and knowledge before providing services: Failed to verify and document skills and knowledge of caregivers before providing physical health services. |
| A. Manager shall ensure caregiver provides current documentation of CPR training certification specific to adults: Failed to ensure valid CPR training including demonstration of ability. |
| A. Manager shall ensure resident has written service plan including level of service expected: Failed to accurately include level of service in resident's service plan. |
| C. Manager shall ensure caregiver documents services provided in resident's medical record: Failed to document all instances of showering and bathing provided to residents. |
| D. Manager shall ensure caregiver documents actions taken to prevent future accidents or injuries: Failed to document preventive actions after resident injury requiring medical services. |
| A. Manager shall ensure food menu is posted at least one calendar day before first meal served: Failed to post current food menu. |
| A. Manager shall ensure evacuation drill for employees and residents conducted at least once every six months: Failed to conduct evacuation drill within required timeframe. |
| R9-10-113. Tuberculosis Screening: Failed to implement TB infection control activities including baseline screening for personnel and residents. |
Report Facts
Inspections on page: 6
Total deficiencies: 29
Complaint inspections: 5
Total capacity: 155
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cincy Perry | Health & Wellness Director | Named in multiple deficiency findings and responsible for implementing corrective actions |
| Brandy Cooper | District Director of Operations | Named as person responsible in emergency documentation deficiency |
| Penelope Watkins | Executive Director (former) | Named in multiple deficiency findings related to personnel and compliance |
| Andrea Henry | Executive Director | Named in personnel compliance deficiencies and district support |
| Gayle Lemenager | Business Office Manager | Named in personnel compliance and training deficiencies |
| Steve Mills | Maintenance Director, MD | Named in environmental safety deficiencies |
| E1 | Interviewed multiple times regarding findings | |
| E2 | Interviewed regarding medication and personnel findings | |
| E3 | Interviewed regarding resident dignity and documentation findings | |
| E5 | Caregiver/Medication Technician | Named in multiple deficiencies related to training and documentation |
| E6 | Assistant Caregiver | Named in personnel compliance deficiencies |
| E7 | Caregiver/Medication Technician | Named in abuse and CPR training deficiencies |
| E8 | Assistant Caregiver | Named in personnel compliance deficiencies |
| E9 | Assistant Caregiver | Named in personnel compliance deficiencies |
| E10 | Reported on medication administration documentation | |
| E11 | Not specifically named in findings | |
| Penelope Watkins | Executive Director (former) | Named in multiple deficiencies and retraining efforts |
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