Inspection Report
Complaint Investigation
Capacity: 128
Deficiencies: 8
May 20, 2025
Visit Reason
State-compiled facility profile showing 16 inspections from 2023-03-29 to 2025-05-20 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility had several complaint and annual compliance surveys with some deficiencies cited related to medication policies, infection control, abuse prevention, food safety, emergency preparedness, and life safety code compliance. Many complaint investigations found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, many resulting in no deficiencies cited. Investigations included intake numbers such as SF00131258, AZ00193297, 00128307, 00128547, and others.
Deficiencies (8)
| Description |
|---|
| R9-10-403.C.2.d. — Policies and procedures for physical health services covering storing, dispensing, administering, and disposing of medication were not properly implemented. |
| R9-10-403.C.2.e. — Policies and procedures covering infection control were not properly implemented. |
| R9-10-410.B.3.a. — Facility failed to ensure residents were free from abuse by other residents, including incidents involving residents #192, #3, #200, and #197. |
| §483.60(i) Food safety requirements — Facility failed to maintain a clean and sanitary kitchen and ensure expired food items were not available for resident use, risking food borne illness. |
| R9-10-423.A.1. — Facility failed to maintain a license or permit as a food establishment under 9 A.A.C. 8, Article 1, related to kitchen sanitation and expired food items. |
| [The facility must comply with all applicable Federal, State and local emergency preparedness requirements.] — Facility failed to review and update the Emergency Preparedness Plan annually. |
| Corridor - Doors — Facility failed to maintain two doors properly to resist passage of smoke, risking patient and staff safety. |
| Utilities - Gas and Electric — Facility allowed an electrical power cord to be run through a wall improperly, risking fire hazard. |
Report Facts
Inspections on page: 16
Total deficiencies: 8
Complaint inspections: 14
Total capacity: 128
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