Deficiencies per Year
24
18
12
6
0
Unclassified
Inspection Report
Complaint Investigation
Census: 159
Capacity: 228
Deficiencies: 22
Sep 18, 2025
Visit Reason
State-compiled facility profile showing multiple complaint investigations from 2023 to 2025 with deficiency history and compliance findings.
Findings
Across multiple complaint investigations, the facility was cited for deficiencies primarily related to resident abuse prevention, resident rights, safety and supervision, and life safety code violations. Several inspections found no deficiencies, while others cited multiple violations including failure to protect residents from abuse, inadequate supervision, and fire safety issues.
Complaint Details
The page includes multiple complaint investigations with detailed intake numbers and findings. Several complaint surveys were conducted from 2023 through 2025, investigating numerous intake complaints, with some resulting in deficiencies and others with no deficiencies cited.
Deficiencies (22)
| Description |
|---|
| 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; |
| R9-10-403.F. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe that abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from a nursing care institution's employee or personnel member, an administrator shall: R9-10-403.F.2. Report the suspected abuse, neglect, or exploitation of the resident as follows: R9-10-403.F.2.a. For a resident 18 years of age or older, according to A.R.S. § 46-454; or |
| R9-10-403.F. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe that abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from a nursing care institution's employee or personnel member, an administrator shall: R9-10-403.F.4. Maintain the documentation in subsection (F)(3) for at least 12 months after the date of the report in subsection (F)(2); |
| §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; |
| §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. |
| §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. |
| 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; |
| R9-10-410.B. An administrator shall ensure that:<br> <br> R9-10-410.B.3. A resident is not subjected to:<br> <br> R9-10-410.B.3.a. Abuse; |
| R9-10-410.C. A resident has the following rights:<br> <br> R9-10-410.C.5. To retain personal possessions including furnishings and clothing as space permits unless use of the personal possession infringes on the rights or health and safety of other residents; |
| R9-10-412.B. A director of nursing shall ensure that: <br> <br> R9-10-412.B.7. An unnecessary drug is not administered to a resident. |
| R9-10-425.A. An administrator shall ensure that: <br> <br> R9-10-425.A.1. A nursing care institution's premises and equipment are: <br> <br> R9-10-425.A.1.b. Free from a condition or situation that may cause a resident or an individual to suffer physical injury; |
| Portable Fire Extinguishers<br> Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.<br> 18.3.5.12, 19.3.5.12, NFPA 10 |
| Corridor - Doors <br> 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.<br> 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.<br> <br> 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 <br> Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. |
| Subdivision of Building Spaces - Smoke Barrier Construction<br> 2012 EXISTING<br> 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. <br> 19.3.7.3, 8.6.7.1(1) <br> Describe any mechanical smoke control system in REMARKS. |
| Electrical Systems - Other<br> List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.<br> Chapter 6 (NFPA 99) |
| Electrical Systems - Essential Electric System Maintenance and Testing<br> The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. <br> Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. <br> 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) |
| R9-10-403.H. An administrator shall provide written notification to the Department of a resident's: <br> <br> R9-10-403.H.2. Self-injury, within two working days after a the resident inflicts a self-injury that requires immediate intervention by an emergency medical services provider. |
| R9-10-410.B. An administrator shall ensure that:<br> <br> R9-10-410.B.3. A resident is not subjected to:<br> <br> R9-10-410.B.3.a. Abuse; |
| R9-10-410.B. An administrator shall ensure that:<br> <br> R9-10-410.B.3. A resident is not subjected to:<br> <br> R9-10-410.B.3.a. Abuse; |
| R9-10-410.B. An administrator shall ensure that:<br> <br> R9-10-410.B.2. A resident is treated with dignity, respect, and consideration; |
| R9-10-410.C. A resident has the following rights:<br> <br> R9-10-410.C.3. To choose activities and schedules consistent with the resident's interests that do not interfere with other residents; |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: <br> <br> R9-10-414.B.3. Ensures that a resident is provided nursing care institution services that: <br> <br> 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. |
Report Facts
Inspections on page: 47
Total deficiencies: 24
Complaint inspections: 45
Total capacity: 228
Census: 159
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SUSAN MCCARTHY-ROBINSON | Administrator | Named as Administrator in facility information |
| Staff #6 | Certified Nursing Assistant (CNA) | Named in deficiency related to resident confinement and dignity |
| Staff #17 | Nursing Administrator Staff (LPN) | Named in deficiency related to COVID-19 quarantine and resident rights |
| Staff #20 | Quality Assurance and Performance Improvement (QAPI) nurse / Infection Control Preventionist | Named in deficiency related to COVID-19 quarantine and resident rights |
| Staff #14 | Licensed Practical Nurse (LPN) | Named in deficiency related to COVID-19 quarantine and resident rights |
| Staff #1 | Director of Nursing (DON) | Named in deficiency related to resident supervision and safety |
| Staff #12 | Licensed Practical Nurse (LPN) | Named in deficiency related to resident supervision and safety |
| Staff #18 | Unit Manager (UM/LPN) | Named in deficiency related to self-injury notification and suicide prevention |
| Staff #10 | Certified Nursing Assistant (CNA) | Named in deficiency related to self-injury notification and suicide prevention |
| Staff #23 | Director of Nursing (DON) | Named in deficiency related to self-injury notification and suicide prevention |
| Staff #26 | Activity Assistant / Life Enrichment Associate | Named in deficiency related to activity provision during COVID-19 outbreak |
| Staff #35 | Life Enrichment Director | Named in deficiency related to activity provision during COVID-19 outbreak |
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