Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Modification
Capacity: 200
Deficiencies: 23
Oct 23, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2023-03-20 to 2025-10-23 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies were found related to emergency responder documentation, quality management reporting, resident documentation, medication administration, staff training, and supervision. Several complaint investigations revealed repeated and ongoing compliance issues.
Complaint Details
Multiple complaint investigations were conducted on dates including 2023-03-20, 2024-05-21, 2024-08-14, and 2025-03-31 with deficiencies cited related to resident care, documentation, staff training, and supervision.
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 emergency responders with all required written documentation for residents R2, R4, and R5. |
| A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes identification of concerns and actions taken: Failed to submit documented quality management reports to governing authority. |
| B. A manager shall ensure that before or at acceptance, documentation dated within 90 days signed by medical practitioner is submitted: Failed to ensure one of nine residents submitted required medical documentation. |
| F. A manager shall ensure means of exiting the facility for residents without keys or special knowledge: Failed to provide means of exiting that allowed residents to be at least 30 feet away and alerted employees. |
| B. A manager shall ensure medication administered is in compliance with medication order: Failed to ensure medication administered per order for one of nine residents. |
| D. A manager shall ensure a current drug reference guide is available: Failed to have current drug reference guide available. |
| D. A manager shall ensure a current toxicology reference guide is available: Failed to have current toxicology reference guide available. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to develop and administer fall prevention and recovery training for all staff. |
| A. A governing authority shall ensure compliance with A.R.S. § 36-411: Failed to ensure fingerprint clearance and work references for three of four personnel records. |
| A. A manager shall ensure caregiver skills and knowledge are verified and documented before providing services: Failed to verify and document skills for four caregivers. |
| A. Except as required, a manager shall ensure resident written service plans are reviewed and updated at least every six months: Failed to update service plans timely for two residents. |
| C. A manager shall ensure resident medical records contain signed residency agreements and amendments: Failed to have signed residency agreements for five residents. |
| C. A manager shall ensure resident medical records contain service plans and updates: Failed to have original service plans and updates for one resident. |
| C. A manager shall ensure resident medical records contain documentation of assisted living services provided: Failed to document services provided for five residents. |
| C. A manager shall ensure resident medical records contain documentation of medication administered including date, time, name, dosage, signature, and reactions: Failed to provide documentation for five residents after January 2024. |
| C. A manager shall ensure resident medical records contain documentation of notification of vaccination availability: Failed to document influenza and pneumonia vaccination offers for four residents. |
| A. A manager shall ensure assistant caregivers interact with residents under supervision: Failed to ensure supervision for two assistant caregivers. |
| A. A manager shall ensure at least one manager or caregiver is present and awake when residents are on premises: Failed to ensure presence during overnight shift. |
| 36-420. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition: Failed to provide appropriate first aid to a non-injured resident who had fallen. |
| C. A manager shall ensure personnel records include documentation of required licenses or certifications: Failed to provide caregiver certification documentation for one individual. |
| B. A manager shall ensure documentation dated within 90 days before acceptance is submitted including medical requirements: Failed to provide required documentation for one resident. |
| A. Except as required, a manager shall ensure resident written service plans are signed and dated by required parties: Failed to have signatures and dates on service plans for six residents. |
| A. A manager shall ensure evacuation drills for employees and residents are conducted at least once every six months: Failed to conduct evacuation drills as required. |
Report Facts
Inspections on page: 7
Total deficiencies: 23
Complaint inspections: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Halla | ED | Named as person responsible in emergency responder documentation deficiency |
| Donald Henney | HWD | Named as person responsible in emergency responder documentation deficiency |
| E1 | Manager | Acknowledged multiple deficiencies and lack of documentation in interviews |
| E2 | Compliance Officer / Staff | Interviewed regarding training and documentation deficiencies |
| E3 | Staff | Reported on evacuation drills and training deficiencies |
| E4 | Caregiver | Personnel record reviewed for skills verification deficiency |
| E5 | Assistant Caregiver | Personnel record reviewed and cited for supervision and fingerprint clearance deficiencies |
| E6 | Assistant Caregiver | Personnel record reviewed and cited for certification and supervision deficiencies |
| O1 | Facility Staff | Reported on 911 call and fall incident |
Report
File
6-4-2024-enforcement.html
Report
File
6-4-2024-enforcement_att-01.pdf
Report
File
nodate-enforcement-2.html
Report
File
nodate-enforcement-2_att-01.pdf
Report
File
nodate-enforcement-3.html
Report
File
nodate-enforcement-3_att-01.pdf
Report
File
nodate-enforcement.html
Report
File
nodate-enforcement_att-01.pdf
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