The most recent inspection on February 25, 2025, found no deficiencies during the complaint investigation. Earlier inspections showed a pattern of deficiencies primarily related to written service plans, medication administration, caregiver qualifications, and documentation of emergency responses. Enforcement actions included several fines totaling at least $7,000, all of which have been paid in full, with no license suspensions or immediate jeopardy findings listed in the available reports. Most complaint investigations were unsubstantiated, and no substantiated complaints with notable events were reported. The facility’s record suggests some improvement over time, culminating in a clean inspection at the most recent visit.
Deficiencies (last 2 years)
Deficiencies (over 2 years)14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The facility was found to have repeated deficiencies related to service plan documentation and medication administration, resulting in a total civil fine of $2000.00.
Fines & Penalties (3)
Amount
Reason
Status
$250.00
Failure to ensure a written service plan included the signature and date from the resident or representative for two residents.
—
$1,500.00
Failure to ensure a written service plan was available for three residents.
—
$250.00
Failure to ensure medication was administered in compliance with a medication order for one resident.
Investigation of multiple complaints found eight deficiencies related to resident tuberculosis documentation, residency agreements, service plans, and medication administration.
Findings
Investigation of multiple complaints found eight deficiencies related to resident tuberculosis documentation, residency agreements, service plans, and medication administration.
The enforcement resulted in a civil fine of $250 for failure to document names of individuals who observed the incident, which was a repeat citation from a prior inspection.
Fines & Penalties (1)
Amount
Reason
Status
$250.00
Failure to ensure documentation of names of individuals who observed a resident incident requiring medical services.
The facility was found to have multiple violations including non-compliance with employee certification requirements and falsification of information, resulting in civil fines totaling $1500.
Fines & Penalties (3)
Amount
Reason
Status
$500.00
Failure to ensure compliance with A.R.S. § 36-411(A) for one of four sampled employees.
Pending
$500.00
Manager failed to ensure caregiver had current first aid and CPR training certification; caregiver worked with expired certifications.
Pending
$500.00
Caregiver documented services while resident was not at the facility and provided false and misleading information to the Department.
The enforcement resulted in multiple citations for management failures and staff compliance issues, leading to a total civil fine of $2,500.00.
Fines & Penalties (5)
Amount
Reason
Status
$1,000.00
Failure to designate, in writing, a certified manager between September 15-25, 2023.
—
$250.00
Failure to ensure compliance with A.R.S. § 36-411(C) for two of five sampled employees.
—
$250.00
Failure to ensure the skills and knowledge of two of five sampled caregivers and assistant caregivers were verified and documented before providing physical health services.
—
$500.00
Failure to ensure the facility had sufficient qualified staff to meet the needs of residents.
—
$250.00
Failure to ensure when a resident had an emergency requiring medical services, a caregiver immediately notified the resident's emergency contact.
Investigation of multiple complaints found seven deficiencies related to emergency responder documentation, governing authority compliance, caregiver training and documentation, meal service, and emergency notifications.
Findings
Investigation of multiple complaints found seven deficiencies related to emergency responder documentation, governing authority compliance, caregiver training and documentation, meal service, and emergency notifications.
Compliance inspection and investigation of multiple complaints found eleven deficiencies related to fall prevention training, manager designation, governing authority compliance, policies and procedures, caregiver skills and orientation, medication administration, and emergency notifications.
Findings
Compliance inspection and investigation of multiple complaints found eleven deficiencies related to fall prevention training, manager designation, governing authority compliance, policies and procedures, caregiver skills and orientation, medication administration, and emergency notifications.
Deficiencies (11)
Description
36-420.01 Fall prevention and recovery training programs
Manager designation in writing
Governing authority compliance with A.R.S. § 36-411
Policies and procedures to protect resident health and safety
Caregiver skills and knowledge verification
Caregiver qualifications and experience
Employee evidence of freedom from infectious tuberculosis
Caregiver orientation specific to duties
Medication administered in compliance with orders
Caregiver notification of primary care provider after emergencies
Caregiver response to resident accidents or emergencies