Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
103% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
31 residents
Based on a January 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Deficiencies: 2
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration, storage, resident safety, and accident prevention in the nursing home.
Findings
The facility failed to ensure proper self-administration of medications for one resident, resulting in medications being left at bedside without assessment. Additionally, a resident was mistakenly given Dakin's solution orally instead of water, posing a risk of adverse effects. The facility also failed to ensure adequate supervision to prevent accidents.
Deficiencies (2)
Allow residents to self-administer drugs if determined clinically appropriate; medications were left at bedside without proper assessment.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Residents affected: 1
Residents affected: 1
Sample size: 13
Medication dosage: 7.6
Medication dosage: 0.5
Medication dosage: 50
Dakin's solution ingested: 30
Elevated systolic pressure: 147
Elevated blood sugar: 386
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #100 | Licensed Practical Nurse (LPN) | Identified medications left at bedside and stated policy on medication administration |
| Staff #60 | Licensed Practical Nurse (LPN) | Interviewed about medication administration procedures |
| Staff #92 | Director of Nursing (DON) | Provided information on medication self-administration policy and incident awareness |
| Staff #61 | Licensed Practical Nurse (LPN) | Administered incorrect substance (Dakin's solution) to resident |
| Staff #91 | Assistant Director of Nursing (ADON) | Interviewed regarding wound care and medication administration |
| Staff #210 | Nurse Practitioner | Interviewed regarding wound care and medication administration |
| Staff #87 | Licensed Practical Nurse (LPN) | Interviewed about medication error reporting procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 12, 2025
Visit Reason
The inspection was conducted due to concerns about a Licensed Practical Nurse (Staff #29) who was found to have a revoked nursing license, potentially impacting resident care safety and quality.
Complaint Details
The investigation was complaint-related, focusing on the revocation of Staff #29's nursing license and the facility's failure to prevent her from working while unlicensed. The complaint was substantiated as the license revocation was confirmed and the staff worked 24 shifts during the period.
Findings
The facility failed to ensure that one Licensed Practical Nurse had a valid license to practice in Arizona. Staff #29's license was revoked, but she worked 24 shifts before being suspended. The facility's process for ongoing license verification was unclear, and the Human Resources department conducted random audits but was not fully aware of risks associated with invalid licenses.
Deficiencies (1)
Failure to ensure one Licensed Practical Nurse had a valid license to practice in the State of Arizona.
Report Facts
Shifts worked by unlicensed nurse: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #29 | Licensed Practical Nurse | Nurse with revoked license who worked 24 shifts. |
| Staff #22 | Director of Nursing | Interviewed regarding license verification processes and risks. |
| Staff #49 | Director of Human Resources | Interviewed about license verification and audits. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 24, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to develop a complete baseline care plan for a resident and failure to ensure appropriate monitoring of a resident post fall.
Complaint Details
The complaint investigation found that resident #3 was left unattended after a fall, and the baseline care plan lacked necessary interventions for bladder incontinence. The complaint was substantiated based on staff interviews, family statements, and policy review.
Findings
The facility failed to develop a complete baseline care plan including necessary interventions for bladder incontinence for resident #3, and failed to ensure the resident was appropriately monitored after a fall, resulting in potential harm. Multiple staff interviews and documentation reviews confirmed these deficiencies.
Deficiencies (2)
Failure to develop a complete baseline care plan including interventions for bladder incontinence for resident #3.
Failure to ensure appropriate monitoring of resident #3 post fall, leaving the resident unattended on the floor for a short time.
Report Facts
BIMS score: 11
Date baseline care plan initiated: Jun 17, 2024
Date of fall incident: Jun 19, 2024
Time resident left alone post fall: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #40 | Social Services Director | Interviewed regarding baseline care plan expectations and deficiencies |
| Staff #35 | Licensed Practical Nurse | Interviewed regarding baseline care plan and fall incident response |
| Staff #2 | Assistant Director of Nursing | Interviewed regarding care plan review and post fall monitoring expectations |
| Staff #12 | Registered Nurse | Entered interdisciplinary team note about fall incident |
| Staff #15 | Licensed Practical Nurse | Interviewed regarding fall protocol |
| Staff #28 | Licensed Practical Nurse | Interviewed regarding post fall monitoring and observations |
Inspection Report
Routine
Deficiencies: 5
Date: May 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notification of hospital transfers, bed-hold policies, baseline care plan provision, infection prevention and control, and equipment safety in the facility.
Findings
The facility was found deficient in timely written notification to residents and their representatives regarding hospital transfers, failure to provide bed-hold policy information upon transfer, failure to provide baseline care plan summaries to residents and representatives, lapses in infection control practices during medication administration, and failure to maintain kitchen equipment in proper working order.
Deficiencies (5)
Failure to provide timely written notification to residents and their representatives about hospital transfers.
Failure to notify resident and representative in writing about bed-hold policy before hospital transfer.
Failure to provide resident and representative with a summary of the baseline care plan within 48 hours of admission.
Failure to ensure infection control protocols were followed during medication administration, including lack of hand hygiene before and after medication administration.
Failure to ensure kitchen equipment (meat slicer) was in proper working order; cracked food contact plate not repaired timely.
Report Facts
BIMS score: 10
BIMS score: 8
BIMS score: 7
Medication dosage: 81
Medication dosage: 500
Medication dosage: 30
Medication dosage: 200
Medication dosage: 5
Medication dosage: 40
Medication dosage: 500
Medication dosage: 20
Medication dosage: 0.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #45 | Director of Social Services | Interviewed regarding resident transfer notifications and bed-hold policy |
| Staff #28 | Licensed Practical Nurse | Interviewed regarding transfer notifications and bed-hold policy |
| Staff #33 | Administrator | Interviewed regarding transfer notifications, bed-hold policy, and equipment maintenance |
| Staff #8 | RAI Coordinator | Interviewed regarding baseline care plan provision |
| Staff #12 | Director of Nursing | Interviewed regarding infection control expectations |
| Staff #35 | Licensed Practical Nurse | Observed and interviewed regarding hand hygiene during medication administration |
| Staff #46 | Head Chef | Interviewed regarding kitchen equipment maintenance |
| Staff #13 | Maintenance Director | Interviewed regarding equipment repair process and meat slicer work order |
Inspection Report
Routine
Census: 31
Deficiencies: 14
Date: Jan 5, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, infection control, medication management, staff competencies, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to complete advance directives timely, update care plans after falls, communicate discharge information properly, ensure staff competencies and training, monitor medication regimens especially psychotropic medications, maintain infection prevention and antibiotic stewardship programs, ensure infection preventionist training, provide vaccination education and documentation, maintain COVID-19 vaccination exemption documentation for staff, and provide abuse prevention training for staff.
Deficiencies (14)
Failed to ensure one resident's advance directives were completed upon admission.
Failed to update care plan to meet changing needs after resident falls.
Failed to convey discharge summary information and medication reconciliation to resident and/or representative.
Failed to ensure two CNAs demonstrated necessary competencies and skills.
Failed to complete yearly performance reviews and provide regular in-service education for one CNA.
Failed to ensure pharmacist recommendations were reviewed and acted upon for one resident's medication regimen.
Failed to monitor psychotropic medication use including duration and side effects for one resident.
Failed to implement an infection prevention and control program with adequate surveillance and follow-up.
Failed to implement an antibiotic stewardship program with ongoing review and monitoring.
Infection preventionist lacked completed infection control training prior to assuming role.
Failed to provide information and offer influenza and pneumococcal vaccinations according to policy for one resident.
Failed to maintain documentation related to COVID-19 vaccine exemption requirements for one staff member.
Failed to provide training for abuse, neglect, exploitation and misappropriation of resident property for one staff member.
Failed to ensure one CNA received the required minimum 12 hours per year of in-service training.
Report Facts
Census: 31
Deficiencies cited: 14
Medication review sample size: 5
Staff training sample size: 10
CNA training sample size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #82 | Licensed Practical Nurse | Named in advance directive deficiency and discharge summary documentation |
| Staff #81 | Regional Director of Clinical Operations | Interviewed regarding care plan updates, medication monitoring, infection control, and staff training |
| Staff #83 | Registered Nurse | Interviewed regarding care plan updates and medication monitoring |
| Staff #84 | Director of Human Resources | Interviewed regarding staff training and COVID-19 vaccination documentation |
| Staff #6 | Licensed Practical Nurse / Infection Preventionist | Named as infection preventionist lacking formal training and responsible for infection control and antibiotic stewardship |
| Staff #62 | Social Services Director | Interviewed regarding discharge process and infection control awareness |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 6
Date: Jan 14, 2022
Visit Reason
The inspection was conducted due to a complaint regarding a Certified Nursing Assistant drawing on a resident's arm and upper lip with a permanent marker, which raised concerns about respecting resident dignity.
Complaint Details
The complaint involved a CNA drawing on a resident (#133) with a permanent marker on her arm and upper lip. The incident was substantiated by the facility investigation, and the CNA was terminated.
Findings
The facility substantiated the complaint that a CNA drew on a resident with a permanent marker and terminated the staff member. The facility provided in-service training on resident rights and dignity. Additional deficiencies were found related to pressure ulcer care, urinary catheter care, weight monitoring, medication administration, and food safety practices.
Deficiencies (6)
Failed to ensure one resident was treated with dignity when a CNA drew on her arm and upper lip with a permanent marker.
Failed to provide appropriate pressure ulcer care and assessment for one resident, lacking thorough wound assessment and documentation.
Failed to provide appropriate urinary catheter care in accordance with physician's orders for one resident.
Failed to address significant weight loss for one resident, including lack of weekly weights and unsigned dietary recommendations.
Failed to administer opioid pain medication according to physician's ordered parameters, administering oxycodone for pain levels less than ordered.
Failed to ensure kitchen staff wore hairnets properly and failed to maintain clean equipment, dishware, and cookware, risking foodborne illness.
Report Facts
Facility census: 33
Weight loss percentage: 17.51
Number of occasions oxycodone administered inappropriately: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) staff #87 | Named in dignity violation for drawing on resident with permanent marker; terminated | |
| Licensed Practical Nurse (LPN) staff #86 | Observed catheter care and provided statements regarding documentation | |
| Director of Nursing (DON) staff #45 | Provided statements on dignity, wound care expectations, and medication administration | |
| Administrator staff #78 | Provided statements on resident dignity and observed hairnet violations | |
| Director of Dietary Services staff #44 | Provided statements on hairnet policy and dishwashing deficiencies | |
| Diet Technician staff #51 | Provided statements on nutritional supplement recommendations and weight monitoring |
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