Inspection Report
Complaint Investigation
Capacity: 235
Deficiencies: 21
Oct 28, 2025
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State-compiled facility profile showing 5 inspections from 2023-06-02 to 2025-10-28 with deficiency history and complaint investigations.
Findings
Across all inspections, multiple deficiencies were cited including failures in food safety, chemical storage, caregiver training and documentation, medication administration, incident reporting, abuse reporting, and quality management. Several repeat deficiencies were noted, posing risks to resident health and safety.
Complaint Details
Multiple complaint investigations were conducted including complaints 00148872, 00141373, 00139080, 00105383, 00105227, 00106422, 00106295, AZ00208701, AZ00208932, AZ00209252, AZ00205917, AZ00196761, AZ00205228, AZ00202031, AZ00200921, AZ00205559, AZ00187866, AZ00191533, AZ00191755, AZ00192522, and AZ00192999.
Deficiencies (21)
| Description |
|---|
| R9-10-818.C.4.a. Food Services: Failed to ensure foods requiring refrigeration were maintained at 41° F or below. |
| R9-10-820.A.11. Environmental Standards: Failed to ensure poisonous or toxic materials were stored in locked, inaccessible containers. |
| C. A manager shall ensure that policies and procedures are established to protect resident health and safety including response to sudden, intense, or out-of-control behavior. |
| J. Manager failed to report suspected abuse, neglect or exploitation according to A.R.S. § 46-454. |
| A. A manager shall ensure caregiver skills and knowledge are verified and documented before providing services. |
| A. A manager shall ensure caregivers provide evidence of freedom from infectious tuberculosis as required by R9-10-113. |
| A. A manager shall ensure caregivers receive orientation specific to duties before providing services. |
| A. A manager shall ensure caregivers provide documentation of current first aid and CPR training specific to adults. |
| A. A manager shall ensure residents have written service plans including level of service expected. |
| A. A manager shall ensure service plans are signed and dated by resident/representative, manager, and medical practitioner as required. |
| A. A manager shall ensure medication service policies include procedures for assisting residents in procuring medication. |
| B. Manager failed to ensure medications were administered in compliance with medication orders. |
| 36-420.01. Health care institutions failed to develop and administer fall prevention and fall recovery training program for all staff. |
| E. Manager failed to provide documentation required by Article within two hours after Department request. |
| C. Manager failed to ensure personnel records included documentation of completed orientation for employees. |
| C. Manager failed to ensure personnel records included documentation of CPR and first aid training for assistant caregivers. |
| C. Manager failed to ensure caregivers documented services provided in resident medical records. |
| F. Manager failed to ensure means of exiting facility controlled or alerted employees of resident egress to outside area. |
| B. Manager failed to implement medication administration policies covering documentation of resident refusal to take medication. |
| D. Manager failed to ensure immediate notification of resident's primary care provider after accident, emergency, or injury. |
| D. Manager failed to ensure documentation of actions taken to prevent recurrence of accidents, emergencies, or injuries. |
Report Facts
Inspections on page: 5
Total deficiencies: 36
Complaint inspections: 5
Total capacity: 235
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lara Bowles | Executive Director | Named as person responsible for food services and chemical storage deficiencies |
| E1 | Interviewed regarding multiple deficiencies including training, documentation, and medication administration | |
| E2 | Interviewed regarding multiple deficiencies including training, documentation, and medication administration | |
| E3 | Interviewed and personnel record reviewed for training and documentation deficiencies | |
| E4 | Interviewed and personnel record reviewed for training and documentation deficiencies | |
| E5 | Interviewed and personnel record reviewed for training and documentation deficiencies | |
| E6 | Interviewed regarding abuse reporting and caregiver orientation | |
| E7 | Personnel record reviewed for training and documentation deficiencies | |
| E8 | Interviewed and personnel record reviewed for medication administration and training deficiencies | |
| E9 | Personnel record reviewed for training and documentation deficiencies | |
| E10 | Personnel record reviewed for training deficiencies | |
| E11 | Personnel record reviewed for training deficiencies | |
| O1 | Regional Director of Operations | Named in abuse investigation and suspension of caregiver |
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