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851 N. Harris Dr., Mesa, AZ 85203, AZ, 85203
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Inspection Report
Complaint Investigation
Census: 8
Capacity: 10
Deficiencies: 26
Apr 30, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-04-17 to 2025-04-30 with deficiency history and complaint investigations.
Findings
Across all inspections, multiple deficiencies were identified including failures in employee verification, training, resident rights, medication administration, environmental safety, and documentation compliance, posing various risks to resident safety and regulatory compliance.
Complaint Details
The inspections include complaint investigations for complaints 00127246, AZ00208281, AZ00179092, AZ00183728, and AZ00184345.
Deficiencies (26)
| Description |
|---|
| R9-10-803.A.9. Administration: Governing authority failed to ensure compliance with A.R.S. § 36-411 regarding employee registry verification. |
| R9-10-806.A.4.a-b. Personnel: Manager failed to verify and document caregiver skills and knowledge before providing health services. |
| R9-10-806.A.10. Personnel: Manager failed to ensure current documentation of first aid and CPR training for personnel. |
| R9-10-810.B.2.i. Resident Rights: Manager failed to ensure a resident was not subjected to restraint. |
| R9-10-819.A.6. Environmental Standards: Manager failed to maintain hot water temperatures between 95º F and 120º F in resident areas. |
| A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs: Failed to administer initial fall prevention training to staff. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to administer fall prevention training for staff. |
| A. Governing authority failed to notify Department of change in manager and provide new manager's qualifications. |
| A. Governing authority failed to ensure compliance with A.R.S. § 36-411 for employee background checks. |
| A. Manager failed to ensure assistant caregiver interacted with residents under supervision. |
| A. Manager failed to verify and document assistant caregiver skills and knowledge before providing services. |
| A. Manager failed to provide evidence of freedom from infectious tuberculosis as required. |
| C. Manager failed to ensure personnel records included correct employment start dates. |
| E. Manager failed to obtain required signatures on residency agreements. |
| A. Manager failed to protect resident medical records from loss, damage, or unauthorized use. |
| F. Manager failed to ensure means of exiting facility provided access and alerted employees of resident egress. |
| A. Manager failed to provide conspicuously posted food menu at least one day before meals. |
| A. Manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. |
| A. Manager failed to store poisonous or toxic materials in locked, labeled containers inaccessible to residents. |
| C. Manager failed to ensure resident bathroom contained slip-resistant surfaces in shower. |
| E. Manager failed to provide required documentation to Department within two hours after request. |
| B. Manager failed to ensure non-resident individuals complied with fingerprinting requirements or were supervised. |
| B. Manager failed to ensure acceptance documentation dated within 90 days and signed by authorized medical professional. |
| D. Manager failed to ensure documented residency agreements included required elements for residents. |
| B. Manager failed to ensure medication administered to residents was documented in medical records. |
| F. Manager failed to ensure medications were stored in a locked area. |
Report Facts
Inspections on page: 3
Total deficiencies: 28
Complaint inspections: 3
Facility capacity: 10
Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Manager | Named in multiple findings related to personnel records, training, and compliance |
| E2 | Compliance Officer / Manager | Interviewed and acknowledged multiple deficiencies |
| E3 | Caregiver | Named in findings related to skills verification and supervision |
| E4 | Assistant Caregiver | Named in findings related to skills verification, training, and supervision |
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