Inspection Report
Capacity: 74
Deficiencies: 26
Oct 10, 2025
Visit Reason
State-compiled facility profile showing 12 inspections from 2023-01-04 to 2025-10-10 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies were found related to resident safety, staff qualifications, medication storage, environmental cleanliness, and documentation compliance. Several repeat deficiencies were noted, and some inspections found no deficiencies.
Complaint Details
Multiple complaint investigations are included, with deficiencies found during investigations of complaints numbered 00131852, 00130714, 00126264, 00124977, 00124970, 00124915, 00124916, 00123805, 00123713, 00123809, 00105482, 00105618, 00121659, AZ00217949, AZ00214454, AZ00213937, AZ00205713, AZ00205272, AZ00200626, AZ00201265, AZ00203168, AZ00203670, and AZ00183156.
Deficiencies (26)
| Description |
|---|
| R9-10-815.F.2.a-c. Directed Care Services: Failed to ensure a means of exiting the facility that controlled or alerted employees of resident egress. |
| R9-10-806.A.8.a-b. Personnel: Failed to ensure employees provided evidence of freedom from infectious tuberculosis before providing services. |
| R9-10-808.A.3.b. Service Plans: Failed to ensure written service plan included the level of service the resident was expected to receive. |
| R9-10-808.A.3.f. Service Plans: Failed to ensure service plan included how medication would be stored and controlled for residents self-administering medication. |
| R9-10-803.C.1.g. Administration: Failed to implement policies and procedures covering caregiver response to resident's sudden or out-of-control behavior to prevent harm. |
| R9-10-817.C.1. Food Services: Failed to ensure food stored was free from spoilage and safe for consumption. |
| R9-10-819.A.1.a. Environmental Standards: Failed to ensure premises and equipment were cleaned and disinfected properly. |
| R9-10-819.A.11. Environmental Standards: Failed to ensure poisonous or toxic materials were maintained in locked containers inaccessible to residents. |
| D. Documentation of accidents/emergencies: Failed to document required information after resident medical emergency. |
| A. Documentation provision: Failed to provide required documentation to Department within two hours after request. |
| A. Caregiver training documentation: Failed to provide documentation of completion of approved caregiver training program for multiple employees. |
| A. Assistant caregiver supervision: Failed to ensure assistant caregiver interacted with residents under supervision. |
| A. Caregiver skills verification: Failed to verify and document caregiver skills and knowledge before providing services. |
| A. CPR training documentation: Failed to ensure caregivers provided current CPR training documentation. |
| A. Service plan signatures: Failed to ensure written service plan was signed and dated by manager. |
| B. Resident dignity: Failed to ensure resident was treated with dignity, respect, and consideration. |
| F. Medication storage: Failed to ensure medication was stored in a separate locked area used only for medication storage. |
| A. Oxygen container security: Failed to ensure oxygen containers were secured in an upright position. |
| A. Toxic materials storage: Failed to maintain poisonous or toxic materials in locked containers inaccessible to residents. |
| A. Quality management plan: Failed to establish and document a quality management plan including frequency of reports to governing authority. |
| C. Vaccination notification: Failed to document notification of residents about availability of pneumonia vaccination. |
| B. Resident retention documentation: Failed to obtain required documentation for non-ambulatory residents to remain in facility. |
| A. Disaster drills: Failed to conduct and document disaster drills on each shift at least once every three months. |
| A. Evacuation drill documentation: Failed to document identification of residents needing assistance and those not evacuated. |
| A. Pet licensing: Failed to ensure pets allowed in facility were licensed consistent with local ordinances. |
| R9-10-806.A.8.a-b. Personnel: Failed to ensure evidence of freedom from infectious tuberculosis for three of four employees. |
Report Facts
Inspections on page: 12
Total deficiencies: 33
Complaint inspections: 10
Total capacity: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Haralambos Babaletskos | AL Manager/executive director | Named as person responsible for multiple deficiencies including directed care services, tuberculosis documentation, service plans, food safety, environmental standards, medication storage, and staff training. |
| E1 | Interviewed and acknowledged multiple deficiencies including food spoilage, environmental cleanliness, medication storage, oxygen container security, and documentation failures. | |
| E10 | Assisted Living Manager | Interviewed regarding caregiver training, skills verification, medication storage, oxygen container security, and other compliance issues. |
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