Deficiencies per Year
24
18
12
6
0
Unclassified
Inspection Report
Complaint Investigation
Census: 57
Capacity: 132
Deficiencies: 22
May 14, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2023-2025 with deficiency history and complaint investigations.
Findings
Across multiple inspections from 2023 to 2025, the facility was found to have numerous deficiencies including failure to maintain personnel records, inconsistent code status documentation, inadequate wound care and pressure ulcer prevention, expired food storage, lack of physician orders for oxygen use, incomplete transfer notifications, and failure to ensure staff COVID-19 vaccination compliance. Some inspections found no deficiencies.
Complaint Details
An onsite complaint survey was conducted on May 14, 2025 for the investigation of intake #00129123, 00129741, 00126292, AZ00223413. Multiple complaint investigations were conducted on various dates including January 2, 2025; June 3-4, 2024; and January 17-19, 2023, with deficiencies cited in some and none in others.
Deficiencies (22)
| Description |
|---|
| R9-10-403.C. An administrator shall ensure that: R9-10-403.C.1.k. Cover medical records, including electronic medical records; |
| §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(h) Medical records. §483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(h)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(h)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(h)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. |
| R9-10-406.F. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: R9-10-406.F.3. Documentation of: R9-10-406.F.3.c. The individual's compliance with the requirements in A.R.S. § 36-411; |
| R9-10-410.C. A resident has the following rights: R9-10-410.C.8. To participate or have the resident's representative participate in the development of, or decisions concerning, treatment; |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: 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. |
| R9-10-423.A. An administrator shall ensure that: R9-10-423.A.3.b. The nursing care institution is able to store, refrigerate, and reheat food to meet the dietary needs of a resident; |
| § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. |
| §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. |
| R9-10-406.F. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: R9-10-406.F.3. Documentation of: R9-10-406.F.3.i. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (E); and |
| §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. |
| §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. |
| §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. |
| §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. |
| §483.80(i) COVID-19 Vaccination of facility staff. The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: 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. |
| R9-10-419. If respiratory care services are provided on a nursing care institution's premises, an administrator shall ensure that: R9-10-419.2. Respiratory care services are provided according to an order that includes: R9-10-419.2.e. The oxygen concentration or oxygen liter flow and method of administration; |
| R9-10-425.A. An administrator shall ensure that: R9-10-425.A.1.b. Free from a condition or situation that may cause a resident or an individual to suffer physical injury; |
| Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 |
| Corridor - Doors 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. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 |
| Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING 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. 19.3.7.3, 8.6.7.1(1) |
| Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. |
| Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. |
Report Facts
Inspections on page: 8
Total deficiencies: 30
Complaint Inspections: 6
Facility capacity: 132
Facility census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #33 | Registered Nurse | Named in fingerprint clearance card deficiency and resident interview |
| Liviu Iliescu | Administrator | Named as facility administrator |
| Staff #29 | Named in CPR training and TB screening deficiencies and COVID-19 vaccination deficiency | |
| Staff #12 | Named in fingerprint clearance deficiency | |
| Staff #45 | Interviewed regarding personnel file reviews | |
| Staff #52 | Licensed Practical Nurse, Case Manager | Interviewed regarding resident representative communication deficiency |
| Staff #63 | Health Information Management Director | Interviewed regarding resident representative communication deficiency |
| Staff #51 | Director of Nursing | Interviewed regarding resident representative communication and wound care deficiencies |
| Staff #9 | Dietary Manager | Interviewed regarding expired food deficiency |
| Staff #185 | Consultant Dietitian | Interviewed regarding expired food deficiency |
| Staff #7 | Registered Nurse | Interviewed regarding wound care deficiencies |
| Staff #59 | Registered Nurse | Interviewed regarding wound care deficiencies |
| Staff #102 | Executive Director | Interviewed regarding fingerprint clearance deficiency |
| Staff #11 | Licensed Practical Nurse | Interviewed regarding code status and oxygen order deficiencies |
| Staff #19 | Licensed Practical Nurse | Interviewed regarding transfer notification deficiency |
| Staff #87 | Certified Nursing Assistant | Interviewed regarding ostomy care deficiency |
| Staff #78 | Registered Nurse | Interviewed regarding wound care and medication safety deficiencies |
| Staff #48 | Licensed Practical Nurse | Interviewed regarding ostomy care and medication safety deficiencies |
| Staff #8 | Director of Nursing | Interviewed regarding wound care and pressure ulcer deficiencies |
| Staff #27 | Infection Preventionist | Interviewed regarding COVID-19 vaccination deficiency |
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