Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 8
Jul 18, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2023-03 to 2025-07 with deficiency history and complaint investigations.
Findings
Across all inspections, multiple deficiencies were found including failure to provide required emergency responder documentation, delayed reporting of suspected abuse, incomplete personnel orientation records, lack of staff training on fall prevention, and facility maintenance issues such as cleanliness and safety hazards. Some inspections found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted including complaints 0136651, 00136639, 00120744, 00131672, 00125985, 00124950, AZ00213432, AZ00217662, AZ00217699, AZ000198613, AZ00200070, AZ00200071, and AZ00207578 with findings of deficiencies in some and no deficiencies in others.
Deficiencies (8)
| Description |
|---|
| A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to provide emergency responders with all required written documentation including reasons for request and HIPAA release. |
| R9-10-803.J.1-6. Administration: Manager failed to report suspected abuse, neglect, or exploitation according to A.R.S. § 46-454 in a timely manner. |
| C. A manager shall ensure that a personnel record for each employee or volunteer includes documentation of completed orientation and in-service education: Failed to document orientation for six of nine personnel records sampled. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition: Manager failed to ensure training program for fall prevention and recovery was administered to all staff, affecting five of six sampled personnel. |
| A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and CPR certification: Failed to provide documentation for one of three sampled employees. |
| A. A manager shall ensure that: 1.a. The premises and equipment used at the assisted living facility are cleaned and disinfected according to policies to prevent illness or infection: Failed to maintain cleanliness in resident unit with urine odor. |
| A. A manager shall ensure that: 1.b. The premises are free from conditions that may cause physical injury: Failed to maintain repair of broken wall exposing bare frame in resident unit. |
| A. A manager shall ensure that: 9. Soiled linen and clothing are stored separate from clean linen in closed containers: Failed to store soiled linen and clothing in closed containers in laundry area. |
Report Facts
Inspections on page: 5
Total deficiencies: 8
Complaint Inspections: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Acknowledged failures in emergency responder documentation, abuse reporting, and personnel record documentation | |
| Health & Wellness Director | Person responsible for emergency responder documentation deficiency | |
| Executive Director | Person responsible for abuse reporting deficiency |
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