Inspection Report
Annual Inspection
Capacity: 10
Deficiencies: 7
Aug 27, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2024-04 to 2025-08 with deficiency history
Findings
Across three inspections, two annual compliance inspections and one other inspection, the facility had seven deficiencies identified in the April 8, 2024 annual compliance inspection, with no deficiencies found in the May 1, 2024 and August 27, 2025 inspections.
Deficiencies (7)
| Description |
|---|
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition: Failed to ensure employees had competency and continued competency in fall prevention and fall recovery training. |
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411: Failed to verify fingerprint clearance cards with DPS for two of three employees. |
| A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: Failed to verify and document skills and knowledge for two of three employees. |
| A. A manager shall ensure that: 7. Documentation is maintained for at least 12 months after the last date on the documentation of caregivers and assistant caregivers working each day, including hours worked: Failed to maintain documentation for three of three employees. |
| C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: b. The individual's starting date of employment or volunteer service: Failed to include starting dates for two of three employees. |
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record: Failed to document services provided to two of three residents, including prefilled documentation for services not yet provided. |
| R9-10-113. Tuberculosis Screening: Failed to implement tuberculosis infection control activities including annual TB screening for one of three employees. |
Report Facts
Inspections on page: 3
Total deficiencies: 7
Complaint inspections: 0
Total capacity: 10
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