Inspection Report
Capacity: 38
Deficiencies: 9
May 7, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-01-30 to 2025-05-07 with deficiency history and complaint investigations.
Findings
Across four inspections, multiple deficiencies were identified including failures in tuberculosis screening and infection control, personnel record compliance, medication administration, emergency drills, and exit door alarms. Some inspections found no deficiencies, while others revealed risks to resident safety and regulatory noncompliance.
Complaint Details
Complaint investigations AZ00218652 and AZ00203368 were conducted during inspections on April 14, 2025 and January 3, 2024 respectively, revealing multiple deficiencies related to compliance and resident care.
Deficiencies (9)
| Description |
|---|
| R9-10-113.A.2.a-f. Tuberculosis Screening: Failed to ensure documentation and implementation of tuberculosis infection control activities including baseline screening, annual training, and reporting. |
| R9-10-803.A.9. Administration: Governing authority failed to ensure compliance with A.R.S. § 36-411 regarding fingerprint clearance cards and adult protective services registry checks for personnel. |
| R9-10-815.F.2.a-c. Directed Care Services: Failed to ensure means of exiting the facility that controlled or alerted employees of resident egress on all exits. |
| R9-10-816.B.3.b. Medication Services: Medication administered to a resident was not administered in compliance with a medication order due to medication unavailability and lack of proper orders or termination notices. |
| A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs: Failed to administer initial and continued competency training on fall prevention and recovery for staff. |
| C. A manager shall ensure that a caregiver or assistant caregiver documents the services provided in the resident's medical record; and: Failed to document bowel movements as required by resident's service plan. |
| B. If an assisted living facility provides medication administration, a manager shall ensure medication is administered in compliance with a medication order: Failed to properly document medication availability and administration for multiple medications. |
| A. A manager shall ensure that a disaster drill for employees is conducted on each shift at least once every three months and documented; Failed to conduct and document disaster drills on all shifts as required. |
| A. A manager shall ensure that an evacuation drill for employees and residents is conducted at least once every six months; Failed to conduct evacuation drills at required frequency. |
Report Facts
Inspections on page: 4
Total deficiencies: 9
Complaint Inspections: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Reid Reilly | Manager | Named as person responsible for multiple deficiency findings and corrective actions |
| E1 | Named in findings related to tuberculosis screening, medication administration, and personnel record deficiencies | |
| E2 | Named in findings related to tuberculosis screening and personnel record deficiencies | |
| E3 | Assistant Caregiver | Named in personnel record and training deficiencies |
| E4 | Caregiver | Named in personnel record deficiencies |
| E5 | Caregiver | Named in personnel record deficiencies |
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