Inspection Report
Census: 86
Capacity: 112
Deficiencies: 14
May 27, 2025
Visit Reason
State-compiled facility profile showing 13 inspections from 2023-03 to 2025-05 with deficiency history including complaint investigations and other survey types.
Findings
Across multiple inspections, deficiencies were found related to infection control, abuse prevention, notification of changes, accident prevention, medication management, and life safety code compliance. Several complaint investigations cited deficiencies, while some complaint inspections found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted, including intakes AZ00212850, SF00115515, AZ00221683, AZ00221765, AZ00219762, AZ00212917, AZ00212898, AZ00215652, AZ00211933, AZ00211807, AZ00206737, AZ00206552, AZ00199598, AZ00202192, AZ00202650, AZ00202642, AZ00201796, AZ00195578, AZ00195723, AZ00195862, AZ00195918, AZ00197633, AZ00198821, AZ00199575, AZ00201331, AZ00201362, AZ00192311, AZ00192310, AZ00200588, AZ00198475, and others. Some complaint inspections cited deficiencies while others found no deficiencies.
Deficiencies (14)
| Description |
|---|
| Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3. A resident is not subjected to: R9-10-410.B.3.a. Abuse; |
| §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. |
| §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9). |
| §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. |
| §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: R9-10-414.B.3. Ensures that a resident is provided nursing care institution services that: R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. |
| §483.35(b) Registered nurse §483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. §483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. §483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. |
| §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- §483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. |
| §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. |
| R9-10-421.D. When medication is stored at a nursing care institution, an administrator shall ensure that: R9-10-421.D.3. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident for: R9-10-421.D.3.a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication; |
| R9-10-425.A. An administrator shall ensure that: R9-10-425.A.1. A nursing care institution's premises and equipment are: R9-10-425.A.1.b. Free from a condition or situation that may cause a resident or an individual to suffer physical injury; |
| Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. |
| Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 |
Report Facts
Inspections on page: 13
Total deficiencies: 20
Complaint inspections: 11
Census: 86
Total capacity: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ANDREW MILES | Administrator | Named as facility administrator in facility information |
| Director of Nursing | Director of Nursing | Named in multiple findings and interviews related to deficiencies and policy enforcement |
| CNA (staff #60) | Certified Nurse Assistant | Named in abuse and infection control findings |
| LPN (staff #91) | Licensed Practical Nurse | Named in infection control deficiency observation |
| LPN (staff #84) | Licensed Practical Nurse | Interviewed regarding hand hygiene training |
| EVS (staff #41) | Environmental Services Director | Named in abuse incident intervention |
| RN (staff #12) | Registered Nurse | Interviewed regarding notification of family/POA |
| LPN (staff #80) | Licensed Practical Nurse | Interviewed regarding fall notification and medication room observations |
| LPN (staff #73) | Licensed Practical Nurse | Interviewed regarding fall incident |
| CNA (staff #105) | Certified Nurse Assistant | Named in fall incident and assistance deficiencies |
| Director of Rehabilitation (DOR/staff #98) | Director of Rehabilitation | Interviewed regarding resident assistance needs |
| Staff #50 | Certified Nurse Assistant | Interviewed regarding pericare and fall assistance |
| Staff #110 | Licensed Practical Nurse | Interviewed regarding pain medication administration |
| Staff #32 | Director of Nursing | Interviewed regarding multiple deficiencies and policy enforcement |
| Staff #111 | Staffing Coordinator | Interviewed regarding RN coverage |
| Staff #96 | Director of Nursing | Interviewed regarding wound care and prevention |
| Staff #40 | Wound Nurse | Interviewed regarding wound assessment and care |
| Staff #90 | Licensed Practical Nurse | Interviewed regarding wound observation and notification |
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