Inspection Report Summary
Most inspections found no deficiencies, including the most recent report dated June 5, 2025, which was clean. Earlier reports identified several deficiencies primarily related to maintaining safe room temperatures, medication administration, nutrition and hydration, medical record documentation, and equipment maintenance. Several complaint investigations were unsubstantiated, while others noted minor or isolated issues in these same areas. There were no fines, enforcement actions, or severe harm-level findings listed in the available reports. The trend suggests improvement over time, with recent inspections showing no deficiencies after earlier citations.
Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 81
Capacity: 106
Deficiencies: 15
Jun 5, 2025
Visit Reason
State-compiled facility profile showing 20 inspections from 2023-01 to 2025-06 with deficiency history and complaint investigations.
Findings
Across all inspections, multiple complaint investigations and compliance surveys were conducted with a total of 15 deficiencies cited in several inspections. Most recent inspections found no deficiencies. Deficiencies included failures in maintaining safe environment temperatures, medication administration, nutrition and hydration, medical record documentation, and equipment maintenance.
Complaint Details
Multiple complaint investigations were conducted throughout 2023-2025 with intakes referenced by number. Several complaint inspections found no deficiencies, while others cited deficiencies related to nutrition, medication, documentation, and environment.
Deficiencies (15)
| Description |
|---|
| §483.10(i) Safe Environment. Failed to ensure comfortable and safe temperatures were maintained in one resident room (Resident #274). |
| §483.21(b)(3) Comprehensive Care Plans. Failed to ensure medication services are provided according to accepted standards of clinical practice for one resident (#177). |
| §483.25(g) Assisted nutrition and hydration. Failed to ensure staff provided meals according to regulations to one resident (#76). |
| §483.20(f)(5) Resident-identifiable information and §483.70(i) Medical records. Failed to ensure nursing documentation reflected care and medical services provided for Resident #36 according to professional standards. |
| R9-10-411.A. Administrator shall ensure medical records are established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1; failed to ensure nursing documentation reflected care for Resident #36. |
| R9-10-421.B. Policies and procedures for medication administration: Ensure medication is administered only as prescribed; failed to ensure medication services provided according to accepted standards for Resident #177. |
| R9-10-423.B. Registered dietitian or director of food services shall ensure resident is provided a diet meeting nutritional needs; failed to ensure meals provided according to regulations to Resident #76. |
| R9-10-425.A. Heating and cooling systems maintain temperature between 70° F and 84° F; failed to maintain comfortable and safe temperatures in Resident #274's room. |
| §483.25(g) Assisted nutrition and hydration. Failed to identify and address risk factors for nutritional status for one resident (#1). |
| R9-10-414.B. Care plan ensures resident is provided nursing care to maintain highest practicable well-being; failed to address nutritional risk factors for Resident #1. |
| R9-10-403.C. Policies and procedures for physical and behavioral health services including medication handling; failed to ensure medications were available as ordered for Resident #261. |
| §483.45 Pharmacy Services. Failed to ensure medications were available as ordered for Resident #261. |
| §483.70(i) Medical records. Failed to ensure continence care was adequately documented for Resident #266. |
| R9-10-411.A. Entry in resident's medical record must be dated, legible, and authenticated; failed to ensure continence care documentation for Resident #266. |
| Electrical Equipment - Testing and Maintenance Requirements. Failed to provide record of electrical equipment tests, repairs, and modifications; preventive maintenance stickers expired on blood pressure monitors. |
Report Facts
Inspections on page: 20
Total deficiencies: 15
Complaint inspections: 18
Facility capacity: 106
Facility census: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #115 | Maintenance Director | Named in temperature environment deficiency findings |
| Staff #200 | Licensed Practical Nurse (LPN) | Named in medication administration deficiency findings |
| Staff #14 | Director of Nursing (DON) | Named in multiple deficiencies related to medication, documentation, and fall incident reporting |
| Staff #64 | Assistant Director of Nursing (ADON) | Named in fall incident documentation deficiency findings |
| Staff #40 | Certified Nursing Assistant (CNA) | Named in nutrition and meal documentation deficiency findings |
| Staff #24 | Certified Nursing Assistant (CNA) | Named in nutrition and meal documentation deficiency findings |
| Staff #11 | Registered Nurse (RN) | Named in medication administration deficiency findings |
| Staff #72 | Administrator | Present during maintenance temperature interview |
| Staff #7 | Director of Nursing (DON) | Named in medication availability deficiency findings |
| Staff #2 | Registered Nurse (RN) | Named in medication availability deficiency findings |
| Staff #129 | Consultant Pharmacist | Named in medication availability deficiency findings |
| Staff #34 | Certified Nursing Assistant (CNA) | Named in continence care documentation deficiency findings |
| Staff #57 | Director of Nursing (DON) | Named in continence care documentation deficiency findings |
| Kevin Whitlock Sr | Compliance Officer LSC | Named in Life Safety Code recertification survey |
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