Inspection Report Summary
Most inspections found multiple deficiencies related to caregiver training and documentation, medication administration, food safety, and incident reporting, with several repeat issues posing risks to resident health and safety. The facility faced enforcement actions resulting in civil fines totaling $4,250 between June 2023 and April 2024. Several complaint investigations were conducted, many with substantiated findings, while some complaints were unsubstantiated. The most recent inspection on October 28, 2025, continued to identify deficiencies similar to prior reports, indicating ongoing challenges in compliance. There is no clear improvement trend, as issues with caregiver training, documentation, and medication management have persisted over time.
Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Complaint Investigation
Capacity: 235
Deficiencies: 0
Oct 28, 2025
Visit Reason
No deficiencies were found during the on-site investigation of complaint 00148872.
Findings
No deficiencies were found during the on-site investigation of complaint 00148872.
Inspection Report
Complaint Investigation
Capacity: 235
Deficiencies: 2
Aug 19, 2025
Visit Reason
Two deficiencies were found related to food services refrigeration and environmental standards involving poisonous materials.
Findings
Two deficiencies were found related to food services refrigeration and environmental standards involving poisonous materials.
Complaint Details
Complaints 00141373, 00139080, 00105383, 00105227, 00106422, 00106295
Deficiencies (2)
| Description |
|---|
| R9-10-818.C.4.a. Food Services — Failure to maintain refrigeration temperature |
| R9-10-820.A.11. Environmental Standards — Poisonous or toxic materials accessible to residents |
Enforcement Action
Enforcement
Fines: 1
Total: $1,750.00
May 28, 2024
Summary
The enforcement resulted in a fine of $1,750.00 which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,750.00 | Enforcement fine against the facility | Paid |
Enforcement Action
Enforcement
Fines: 4
Total: $1,750.00
Apr 18, 2024
Summary
The facility was found to have multiple repeat deficiencies related to caregiver training and medication administration, resulting in civil fines totaling $1,750.00.
Fines & Penalties (4)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Three caregivers' skills and knowledge were not verified and documented before providing physical health services. | — |
| $250.00 | Two caregivers did not have documentation of orientation. | — |
| $500.00 | One employee had no documentation of CPR and first aid training. | — |
| $500.00 | One resident's medication was not administered in compliance with a medication order. | — |
Inspection Report
Complaint Investigation
Capacity: 235
Deficiencies: 9
Apr 18, 2024
Visit Reason
Ten deficiencies were cited involving policy documentation, abuse reporting, caregiver verification, orientation, medication administration, and service plans.
Findings
Ten deficiencies were cited involving policy documentation, abuse reporting, caregiver verification, orientation, medication administration, and service plans.
Complaint Details
Complaints #AZ00208701, AZ00208932, AZ00209252
Deficiencies (9)
| Description |
|---|
| C. A manager shall ensure that policies and procedures are established, documented, and implemented to protect resident health and safety |
| J. Abuse reporting — Failure to report alleged abuse as required by A.R.S. § 46-454 |
| A. Caregiver skills and knowledge verification and documentation — Not verified or documented before providing care |
| A. Caregiver freedom from infectious tuberculosis evidence — Not provided |
| A. Caregiver orientation — Failed to provide orientation specific to duties |
| A. Documentation of first aid and CPR training — Not provided |
| A. Resident written service plan — Missing level of service and signatures |
| A. Medication services policies and procedures — Incomplete or missing procedures |
| B. Medication administration — Medications not administered in compliance with orders |
Enforcement Action
Enforcement
Fines: 1
Total: $1,250.00
Feb 20, 2024
Summary
The enforcement resulted in a fine of $1,250.00 which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,250.00 | Fine associated with enforcement action #00111670 | Paid |
Inspection Report
Complaint Investigation
Capacity: 235
Deficiencies: 13
Feb 5, 2024
Visit Reason
Thirteen deficiencies were cited including fall prevention training, incident reporting, abuse reporting, notification of deaths, quality management, caregiver verification and orientation, medication administration, and documentation.
Findings
Thirteen deficiencies were cited including fall prevention training, incident reporting, abuse reporting, notification of deaths, quality management, caregiver verification and orientation, medication administration, and documentation.
Complaint Details
Complaints #AZ00205917, #AZ00196761, #AZ00205228, #AZ00202031, #AZ00200921, #AZ00205559
Deficiencies (13)
| Description |
|---|
| 36-420.01. Fall prevention and recovery training program — Not administered to all staff |
| C. A manager shall ensure that policies and procedures are established, documented, and implemented to protect resident health and safety |
| J. Abuse reporting — Failure to report alleged abuse as required by A.R.S. § 46-454 |
| K. Notification to Department of resident deaths — Failed to provide written notification |
| A. Quality management program — Policies and procedures not documented or implemented |
| A. Caregiver skills and knowledge verification and documentation — Not verified or documented before providing care |
| A. Caregiver orientation — Failed to provide orientation specific to duties |
| B. Documentation dated within 90 days — Not submitted before or at acceptance |
| A. Resident written service plan — Not reviewed and updated based on condition changes |
| A. Medical record maintenance — Not ensured for each resident |
| C. Documentation of vaccination notification — Not ensured |
| C. Service plan for directed care — Missing strategies for personal safety |
| B. Medication administration — Medications not administered in compliance with orders |
Enforcement Action
Enforcement
Fines: 1
Total: $1,250.00
Jul 12, 2023
Summary
The facility was found non-compliant with multiple regulations including documentation timeliness, employee training verification, and caregiver service documentation, resulting in repeat citations and civil fines.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,250.00 | Civil fines for violations including failure to ensure requested documentation within two hours, failure to verify skills and knowledge of six employees, failure to ensure CPR and first aid training for two employees, and failure to document caregiver services in resident medical records. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $1,250.00
Jun 27, 2023
Summary
The enforcement resulted in a fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,250.00 | Fine related to enforcement action against the facility | Paid |
Inspection Report
Complaint Investigation
Capacity: 235
Deficiencies: 10
Jun 2, 2023
Visit Reason
Eleven deficiencies were cited including fall prevention training, documentation submission, caregiver verification and orientation, personnel records, medication administration, means of exit, and accident response.
Findings
Eleven deficiencies were cited including fall prevention training, documentation submission, caregiver verification and orientation, personnel records, medication administration, means of exit, and accident response.
Complaint Details
Complaints AZ00187866, AZ00191533, AZ00191755, AZ00192522, AZ00192999
Deficiencies (10)
| Description |
|---|
| 36-420.01. Fall prevention and recovery training program — Not administered to all staff |
| E. Documentation required by Article — Not provided within required timeframe |
| A. Caregiver skills and knowledge verification and documentation — Not verified or documented before providing care |
| C. Personnel records — Missing documentation of orientation and CPR training |
| C. Documentation of services provided in medical records — Not ensured |
| F. Means of exiting facility — Not ensured for residents without keys or special knowledge |
| B. Medication administration policies — Missing documentation of resident refusal |
| B. Medication administration — Medications not administered in compliance with orders |
| D. Caregiver response to resident accidents or emergencies — Not ensured |
| D. Caregiver response to resident accidents or emergencies — Not ensured |
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