Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 5
Jun 25, 2025
Visit Reason
State-compiled facility profile showing 15 inspections from 2023-01 to 2025-06 with deficiency history and complaint investigations.
Findings
Across 15 inspections, most were complaint investigations with no deficiencies cited. Two inspections with deficiencies found issues related to emergency preparedness policies, fire protection, and personnel record documentation.
Complaint Details
A complaint survey was conducted on June 25, 2025 for the investigation of intakes #'s: AZ00171677 and AZ00190992. There were no deficiencies cited.
Deficiencies (5)
| Description |
|---|
| [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. |
| Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 |
| Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 |
| Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. |
| R9-10-406.F. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: R9-10-406.F.3. Documentation of: R9-10-406.F.3.c. The individual's compliance with the requirements in A.R.S. § 36-411; |
Report Facts
Inspections on page: 15
Total deficiencies: 5
Complaint Inspections: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #33 | Housekeeper | Named in personnel record deficiency regarding fingerprint clearance |
| Staff #135 | Human Resources Generalist | Interviewed regarding fingerprint clearance documentation |
| Staff #48 | Auxiliary staff (underage) | Mentioned in fingerprint clearance deficiency |
| Staff #40 | Dietary Manager | Interviewed about underage staff roles |
| Staff #18 | Director of Nursing | Interviewed regarding fingerprint clearance policy |
Loading inspection reports...
