Inspection Report Summary
The most recent inspection on March 26, 2025, found no deficiencies. Earlier inspections show a mixed history with several citations related to resident care, abuse and neglect, infection control, emergency preparedness, and safety issues, particularly around mid-2024 and early 2024. Complaint investigations occasionally substantiated abuse and neglect concerns, with some deficiencies cited in those areas, but many complaint surveys found no deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection record shows improvement in recent months, with no deficiencies noted in the latest several complaint investigations and surveys.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
503% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Mar 26, 2025
Visit Reason
The onsite investigation of intake SF00123855 was conducted. No deficiencies were cited.
Findings
The onsite investigation of intake SF00123855 was conducted. No deficiencies were cited.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Mar 10, 2025
Visit Reason
An onsite complaint survey was conducted for the investigation of intake # 00121671, 00121127. No deficiencies were cited.
Findings
An onsite complaint survey was conducted for the investigation of intake # 00121671, 00121127. No deficiencies were cited.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Jan 28, 2025
Visit Reason
An onsite complaint survey was conducted for the investigation of intakes AZ00221923 and AZ00222024. No deficiencies were cited.
Findings
An onsite complaint survey was conducted for the investigation of intakes AZ00221923 and AZ00222024. No deficiencies were cited.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Sep 20, 2024
Visit Reason
An onsite complaint survey was conducted for the investigation of complaint #AZ00216188 and AZ00216064. No deficiencies were cited.
Findings
An onsite complaint survey was conducted for the investigation of complaint #AZ00216188 and AZ00216064. No deficiencies were cited.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 18
Jul 14, 2024
Visit Reason
A recertification survey conducted with complaint investigations cited 20 deficiencies including failure in Medicaid resident notification, safe environment, personnel records, care plans, food safety, infection control, emergency power, and training.
Findings
A recertification survey conducted with complaint investigations cited 20 deficiencies including failure in Medicaid resident notification, safe environment, personnel records, care plans, food safety, infection control, emergency power, and training.
Deficiencies (18)
| Description |
|---|
| §483.10(g)(17) — Medicaid-eligible resident notification |
| §483.10(i) — Safe Environment |
| R9-10-406.B — Personnel qualifications |
| R9-10-406.F — Personnel records |
| §483.21(b)(3) — Comprehensive Care Plans |
| §483.24(a)(2) — Assistance with activities of daily living |
| R9-10-407 — Admission documentation |
| §483.35(g) — Nurse Staffing Information |
| §483.60(i) — Food safety requirements |
| §483.80 — Infection Control |
| §483.90(c) — Emergency Power |
| §483.90(i) — Environmental Conditions |
| §483.95 — Training Requirements |
| R9-10-412.B — Nursing personnel documentation |
| R9-10-414.B — Care plan nursing care |
| R9-10-423.A — Food establishment contracts |
| R9-10-425.A — Premises and equipment safety |
| R9-10-426 — Physical Plant Standards |
Inspection Report
Life Safety
Capacity: 162
Deficiencies: 13
Jul 14, 2024
Visit Reason
Recertification survey for Medicare under Life Safety Code 2012 found 18 deficiencies related to emergency preparedness, fire safety, electrical systems, and hazardous area protections. Facility meets standards based on acceptance of plan of correction.
Findings
Recertification survey for Medicare under Life Safety Code 2012 found 18 deficiencies related to emergency preparedness, fire safety, electrical systems, and hazardous area protections. Facility meets standards based on acceptance of plan of correction.
Deficiencies (13)
| Description |
|---|
| Emergency Preparedness Plan development and maintenance |
| Emergency Preparedness policies and procedures |
| Training and testing for emergency preparedness |
| Emergency and standby power systems |
| Means of Egress safety |
| Hazardous Areas protection |
| Cooking Facilities protection per NFPA 96 |
| Sprinkler System maintenance and testing |
| Utilities - Gas and Electric Equipment safety |
| Fire Drills documentation |
| Electrical Systems maintenance and testing |
| Electrical Equipment - Power Cords and Extension Cords |
| Gas Equipment - Cylinder and Container Storage |
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Jun 14, 2024
Visit Reason
An onsite complaint survey was conducted for investigation of intakes AZ00211742 and AZ00195804. No deficiencies were cited.
Findings
An onsite complaint survey was conducted for investigation of intakes AZ00211742 and AZ00195804. No deficiencies were cited.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Mar 4, 2024
Visit Reason
An onsite complaint survey was conducted for investigation of intakes AZ00206984 and AZ00207061. No deficiencies were cited.
Findings
An onsite complaint survey was conducted for investigation of intakes AZ00206984 and AZ00207061. No deficiencies were cited.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Feb 15, 2024
Visit Reason
A complaint survey was conducted for investigation of intake AZ00206227 and AZ00206228. No deficiencies were cited.
Findings
A complaint survey was conducted for investigation of intake AZ00206227 and AZ00206228. No deficiencies were cited.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 2
Feb 5, 2024
Visit Reason
Investigation of multiple complaints found 2 deficiencies related to freedom from abuse, neglect, and exploitation.
Findings
Investigation of multiple complaints found 2 deficiencies related to freedom from abuse, neglect, and exploitation.
Complaint Details
Resident #48 was admitted with multiple diagnoses and was found neglected.
Deficiencies (2)
| Description |
|---|
| §483.12 — Freedom from Abuse, Neglect, and Exploitation |
| R9-10-410.B — Resident neglect |
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Jan 17, 2024
Visit Reason
Investigation of complaint AZ00204952 via closed record review and interviews. No deficiencies were cited.
Findings
Investigation of complaint AZ00204952 via closed record review and interviews. No deficiencies were cited.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 8
Jan 3, 2024
Visit Reason
Investigation of complaints AZ00204625 and AZ00204761 found 8 deficiencies related to abuse reporting, neglect, care plans, and resident rights.
Findings
Investigation of complaints AZ00204625 and AZ00204761 found 8 deficiencies related to abuse reporting, neglect, care plans, and resident rights.
Deficiencies (8)
| Description |
|---|
| R9-10-403.F — Abuse reporting |
| §483.10(b)(3) — Resident representative rights |
| §483.12 — Freedom from Abuse, Neglect, and Exploitation |
| §483.12(c) — Alleged violation investigations |
| §483.21(b)(3) — Comprehensive Care Plans |
| R9-10-410.B — Resident neglect |
| R9-10-410.C — Resident rights participation |
| R9-10-414.B — Care plan nursing care |
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 2
Dec 6, 2023
Visit Reason
Investigation of complaints AZ00209302 and AZ00203909 substantiated abuse allegations with 2 deficiencies cited.
Findings
Investigation of complaints AZ00209302 and AZ00203909 substantiated abuse allegations with 2 deficiencies cited.
Complaint Details
One resident (#10) was found to be physically abused by staff.
Deficiencies (2)
| Description |
|---|
| §483.12 — Freedom from Abuse, Neglect, and Exploitation |
| R9-10-410.B — Abuse |
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Sep 15, 2023
Visit Reason
Investigation of complaints AZ00200361 and AZ00200466 found no deficiencies.
Findings
Investigation of complaints AZ00200361 and AZ00200466 found no deficiencies.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Aug 17, 2023
Visit Reason
Complaint survey for intake AZ00198901 found no deficiencies.
Findings
Complaint survey for intake AZ00198901 found no deficiencies.
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 2
Apr 18, 2023
Visit Reason
Investigation of intakes AZ00193674 and AZ00193849 cited 2 deficiencies related to assisted nutrition and care plans.
Findings
Investigation of intakes AZ00193674 and AZ00193849 cited 2 deficiencies related to assisted nutrition and care plans.
Deficiencies (2)
| Description |
|---|
| §483.25(g) — Assisted nutrition and hydration |
| R9-10-414.B — Care plan nursing care |
Inspection Report
Annual Inspection
Capacity: 162
Deficiencies: 12
Mar 9, 2023
Visit Reason
State compliance survey conducted with 12 deficiencies cited including medication management, safe environment, care quality, incontinence care, pharmacy services, medication errors, and premises maintenance.
Findings
State compliance survey conducted with 12 deficiencies cited including medication management, safe environment, care quality, incontinence care, pharmacy services, medication errors, and premises maintenance.
Deficiencies (12)
| Description |
|---|
| R9-10-403.C — Policies and procedures for health services |
| §483.10(g)(17) — Medicaid-eligible resident notification |
| §483.10(i) — Safe Environment |
| §483.24(a)(2) — Assistance with activities of daily living |
| §483.25 — Quality of care |
| §483.25(e) — Incontinence care |
| §483.45 — Pharmacy Services |
| §483.45(f) — Medication Errors |
| §483.45(g) — Labeling of Drugs and Biologicals |
| R9-10-414.B — Care plan nursing care |
| R9-10-421.B — Medication administration compliance |
| R9-10-425.A — Premises and equipment cleanliness |
Inspection Report
Life Safety
Capacity: 162
Deficiencies: 10
Mar 9, 2023
Visit Reason
Recertification survey for Medicare under Life Safety Code 2012 found 10 deficiencies related to emergency preparedness, means of egress, fire extinguishers, corridor doors, fire drills, electrical systems, and power cords. Facility meets standards based on acceptance of plan of correction.
Findings
Recertification survey for Medicare under Life Safety Code 2012 found 10 deficiencies related to emergency preparedness, means of egress, fire extinguishers, corridor doors, fire drills, electrical systems, and power cords. Facility meets standards based on acceptance of plan of correction.
Deficiencies (10)
| Description |
|---|
| Emergency Preparedness Plan maintenance |
| Means of Egress requirements |
| Egress Doors safety |
| Portable Fire Extinguishers inspection |
| Corridor Doors maintenance |
| Fire Drills documentation |
| Electrical Systems maintenance and testing |
| Electrical Systems - Essential Electric System Categories |
| Electrical Systems - Essential Electric System Maintenance and Testing |
| Electrical Equipment - Power Cords and Extension Cords |
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Mar 1, 2023
Visit Reason
Complaint investigation survey conducted with complaints AZ00192049 and AZ00192087. No deficiencies were cited.
Findings
Complaint investigation survey conducted with complaints AZ00192049 and AZ00192087. No deficiencies were cited.
Report
File
complaint-inspection_2023-04-20.pdf
Report
File
complaint-inspection_2023-12-07.pdf
Report
File
complaint-inspection_2024-01-05.pdf
Report
File
complaint-inspection_2024-02-07.pdf
Report
File
complaint-inspection_2024-07-17.pdf
Report
File
complaint-inspection_2025-08-15.pdf
Report
File
complaint-inspection_2025-09-18.pdf
Report
File
health-inspection_2022-03-08.pdf
Report
File
health-inspection_2023-03-14.pdf
Report
File
health-inspection_2024-07-17.pdf
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