Inspection Report
Complaint Investigation
Census: 9
Capacity: 20
Deficiencies: 15
Jul 21, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2023-07 to 2025-07 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility had several deficiencies related to fire safety, staff compliance, medication management, food safety, and resident care. Some inspections found no deficiencies, while others cited issues including inadequate fire protection, incomplete narcotic log documentation, expired food items, and insufficient resident transfer assistance.
Complaint Details
The page includes multiple complaint investigations, including complaint numbers 00137000, 00136994, 00133163, AZ00214374, AZ00214561, and numerous others investigated in inspections dated 2023-07-17 to 2025-07-21. Some complaint inspections found no deficiencies, while others resulted in citations.
Deficiencies (15)
| Description |
|---|
| Multiple Occupancies - Construction Type: Failed to provide adequate fire protection and separation between the skilled nursing center and assisted living facility. |
| Spinkler System - Installation: Failed to provide automatic sprinkler protection for the roof overhang at the entrance to the Skilled Nursing Center. |
| Subdivision of Building Spaces - Smoke Barrier Construction: Failed to properly fill penetrations in multiple areas of the smoke barriers. |
| Maintenance, Inspection & Testing - Doors: Failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80. |
| Electrical Systems - Maintenance and Testing: Failed to conduct, maintain, and document electrical receptacle testing in patient care areas. |
| R9-10-406.F.3.c: Failed to ensure one staff member was compliant with fingerprint clearance requirements. |
| R9-10-423.A.3.b: Failed to ensure no expired food items were available for resident use in the dining room refrigerator. |
| §483.25 Quality of care: Failed to document treatment and care regarding implementation of compression stockings for one resident. |
| §483.25(d) Accidents: Failed to ensure resident environment was free of accident hazards and appropriate transfer assistance was provided, resulting in resident injury. |
| §483.45 Pharmacy Services: Failed to ensure accurate narcotic count logs with multiple missing signatures. |
| §483.60(i) Food safety requirements: Failed to ensure food was properly stored, labeled, and dated in sanitary conditions. |
| §483.75(c) Program feedback, data systems and monitoring: Failed to implement and review an appropriate plan of action to correct incomplete narcotic count documentation. |
| R9-10-421.D.3.d: Failed to establish policies and procedures to protect residents regarding storing, inventorying, and dispensing controlled substances. |
| R9-10-423.A.3.b: Failed to ensure the nursing care institution could store, refrigerate, and reheat food to meet dietary needs of residents. |
| R9-10-425.A.1.b: Failed to ensure premises and equipment were free from conditions causing physical injury related to shower chair safety and transfer assistance. |
Report Facts
Inspections on page: 7
Total deficiencies: 17
Complaint inspections: 4
Census: 9
Total capacity: 20
Missing narcotic log signatures: 139
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #7 | Housekeeping staff | Named in fingerprint clearance deficiency |
| HR Coordinator (staff #25) | Human Resource Coordinator | Interviewed regarding fingerprint clearance deficiency |
| Director of Nursing (DON/staff #20 and staff #2) | Director of Nursing | Interviewed regarding fingerprint clearance and narcotic log deficiencies |
| Administrator (staff #10 and staff #106) | Administrator | Interviewed regarding food storage and narcotic log deficiencies |
| Staff #17 | Licensed Practical Nurse (LPN) | Interviewed regarding compression stocking and transfer assistance deficiencies |
| Staff #41 | MDS Nurse | Interviewed regarding compression stocking deficiency |
| Certified Nursing Assistant (CNA/staff #11) | Certified Nursing Assistant | Interviewed regarding resident transfer and shower chair safety deficiency |
| Food Service Director (staff #7) | Food Service Director | Interviewed regarding food safety deficiencies |
| Executive Director (ED/staff #6) | Executive Director | Interviewed regarding shower chair safety deficiency |
| Licensed Practical Nurse (LPN/staff #105) | Licensed Practical Nurse | Observed medication storage and narcotic cart |
Loading inspection reports...
