Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 39
Sep 16, 2025
Visit Reason
State-compiled facility profile showing 11 inspections from 2023-08 to 2025-09 with deficiency history and complaint investigations.
Findings
Across multiple inspections, numerous deficiencies were found including failures in medication administration and documentation, resident rights violations, inadequate staff training and verification, failure to notify primary care providers timely, and environmental safety issues. Several complaints were investigated with some inspections citing no deficiencies.
Complaint Details
The page includes multiple complaint investigations, including complaints numbered 00143040, 00144184, 00144623, 00144713, 0000136637, 00135347, 00122654, AZ00221178, AZ00217685, AZ00216370, AZ00214769, AZ00214294, AZ00213809, AZ00213769, AZ00212955, AZ00212741, AZ00211631, AZ00210962, AZ00201232, AZ00201117, AZ00188259, AZ00190508, AZ00191312, AZ00192889, and AZ00193010 with various findings and investigations.
Deficiencies (39)
| Description |
|---|
| R9-10-803.K.2. Administration: Failed to provide written notification to the Department of a resident’s self-injury within two working days after the resident inflicted a self-injury requiring emergency intervention. |
| R9-10-811.C.13.a-d. Medical Records: Failed to ensure resident's medical record contained complete medication administration documentation including date, time, dosage, and signature. |
| R9-10-817.B.3.b. Medication Services: Medication administered was not in compliance with a medication order for two residents. |
| R9-10-819.D.1. Emergency and Safety Standards: Failed to immediately notify resident's primary care provider after an accident or injury requiring medical services. |
| R9-10-808.C.1.a. Service Plans: Failed to ensure a caregiver provided assisted living services as specified in the resident's service plan. |
| R9-10-810.B.1. Resident Rights: Failed to ensure a resident was treated with dignity, respect, and consideration. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan signed and dated by required parties. |
| C. A manager shall ensure that a caregiver documents the services provided in the resident's medical record. |
| B. A manager shall ensure that a resident is treated with dignity, respect, and consideration. |
| C. A manager shall ensure that a resident's medical record contains documentation of notification of the availability of pneumonia vaccination. |
| F. A manager shall ensure the service plan for a resident receiving personal care includes skin maintenance to prevent and treat injuries and infections. |
| B. A manager shall ensure the facility does not accept or retain residents confined to bed or chair without proper medical authorization. |
| C. A manager shall ensure service plans include coordination of communications with resident's representatives and family. |
| C. A manager shall ensure refrigerators used to store food or medication contain a working thermometer. |
| C. A manager shall ensure food-contact surfaces and equipment are clean and in good repair. |
| A. A manager shall ensure evacuation drills for employees and residents are conducted at least once every six months. |
| D. A manager shall ensure caregivers immediately notify resident's emergency contact and primary care provider after incidents requiring medical services. |
| D. A manager shall ensure caregivers document actions taken to prevent future incidents after accidents or emergencies. |
| A. A manager shall ensure premises and equipment are cleaned and disinfected to prevent infection. |
| A. A manager shall ensure garbage and refuse are stored in covered containers lined with plastic bags. |
| A. A manager shall ensure poisonous or toxic materials are stored in labeled containers in locked areas inaccessible to residents. |
| R9-10-113. Tuberculosis Screening: Failed to provide annual training and education on TB signs and symptoms to employees. |
| R9-10-120.F. Opioid Prescribing and Treatment: Failed to document resident's need for opioid and monitor effect before and after administration. |
| R9-10-808.A. A manager shall ensure a resident has a written service plan signed and dated by required parties. |
| J. A manager shall take immediate action, report, document, and investigate suspected abuse, neglect, or exploitation. |
| A. A manager shall ensure caregiver skills and knowledge are verified and documented before providing services. |
| A. A manager shall ensure caregivers have qualifications, experience, skills, and knowledge necessary to ensure resident health and safety. |
| A. A manager shall ensure documentation is maintained of caregivers working each day including hours worked. |
| A. A manager shall ensure caregivers receive orientation specific to duties before providing assisted living services. |
| A. A manager shall ensure residents provide evidence of freedom from infectious tuberculosis as specified. |
| A. A manager shall ensure a resident has a written service plan including description of medical or health problems. |
| A. A manager shall ensure a written service plan is reviewed and updated at least once every six months for residents receiving personal care. |
| A. A manager shall ensure a caregiver or assistant caregiver documents services provided in the resident's medical record. |
| A. A manager shall ensure disaster drills for employees are conducted on each shift at least once every three months and documented. |
| A. A manager shall ensure caregivers immediately notify resident's primary care provider after incidents requiring medical services. |
| A. A governing authority shall ensure compliance with fingerprint clearance and good faith efforts to verify employee fitness. |
| J. A manager shall take immediate action, report, document, and investigate suspected abuse, neglect, or exploitation. |
| A. A manager shall ensure caregiver skills and knowledge are verified and documented before providing services. |
| A. A manager shall ensure caregivers provide current documentation of first aid and CPR training specific to adults before providing services. |
Report Facts
Inspections on page: 11
Total deficiencies: 46
Complaint inspections: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sylvia Mulshine | Executive Director | Named as person responsible in multiple deficiency findings related to reporting, medication administration, and service plan compliance. |
| Rochelle Mayo | Health and Wellness Director | Named as person responsible in multiple deficiency findings related to medication documentation, service plan compliance, and staff training. |
| E1 | Manager | Interviewed and acknowledged multiple deficiencies and findings. |
| E2 | Caregiver/Staff | Interviewed and involved in medication administration and documentation findings. |
| E3 | Caregiver | Personnel record reviewed for TB documentation and medication administration. |
| E5 | Caregiver/Staff | Interviewed and acknowledged multiple deficiencies. |
| E6 | Caregiver | Personnel record reviewed for fingerprint clearance and skills documentation. |
| E7 | Medication Technician | Personnel record reviewed for fingerprint clearance and involved in environmental inspections. |
| E8 | Caregiver | Involved in resident care and documentation findings. |
| E9 | Medication Technician | Personnel record reviewed for first aid and CPR certification. |
| E10 | Caregiver | Named in abuse allegations and personnel record reviewed for qualifications and documentation. |
| E11 | Caregiver | Personnel record reviewed for TB training and skills documentation. |
| E12 | Caregiver | Personnel record reviewed for fingerprint clearance and TB training. |
| E13 | Caregiver | Personnel record reviewed for fall prevention training. |
| E14 | Caregiver | Personnel record reviewed for orientation and skills documentation. |
| E15 | Caregiver | Personnel record reviewed for fall prevention and TB training. |
| E16 | Caregiver | Personnel record reviewed for TB documentation. |
| E17 | Caregiver | Personnel record reviewed for TB training and documentation. |
| E18 | Caregiver | Personnel record reviewed for skills and TB documentation. |
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