Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Complaint Investigation
Capacity: 50
Deficiencies: 13
Apr 17, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2025 with deficiency history and compliance findings.
Findings
Across multiple inspections, the facility demonstrated several deficiencies including failure to maintain adequate staffing per acuity-based staffing tool, kitchen sanitation issues, failure to comply with licensing rules, and incomplete staff training and monitoring. Some deficiencies were corrected on follow-up visits, while others remained uncorrected as of the latest inspections.
Complaint Details
Inspection PHX6 dated 2025-04-17 was a Complaint Investigation related to licensure complaint with 2 deficiencies noted.
Deficiencies (13)
| Description |
|---|
| C0360 - Staffing Requirements and Training: Staffing - Failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) and failure to staff per ABST requirements. |
| C0363 - Acuity Based Staffing Tool - Updates & Plan - Failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) and failure to staff per ABST requirements. |
| C0240 - Resident Services Meals, Food Sanitation Rule - Failure to maintain kitchen in good repair and sanitary manner including food spills, debris, improper glove use, dish machine temperature issues, and expired food storage. |
| Z0142 - Administration Compliance - Failure to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0000 - Comment - Findings documented for kitchen inspection with substantial compliance noted. |
| C0000 - Comment - Findings documented for kitchen inspection and revisit with substantial compliance noted. |
| C0240 - Resident Services Meals, Food Sanitation Rule - Failure to maintain kitchen in good repair and sanitary manner, improper food storage, lack of temperature checks, and contamination risks. |
| Z0142 - Administration Compliance - Failure to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0000 - Comment - Findings documented for re-licensure survey and revisit with substantial compliance noted. |
| C0270 - Change of Condition and Monitoring - Failure to ensure actions and interventions were documented, communicated, and monitored for resident short-term changes of condition. |
| C0302 - Systems: Tracking Control Substances - Failure to have accurate system for tracking controlled substances administered. |
| Z0155 - Staff Training Requirements - Failure to ensure newly hired staff demonstrated competency in required areas within 30 days of hire. |
| Z0162 - Compliance With Rules Health Care - Failure to provide health care services in accordance with licensing rules. |
Report Facts
Inspections on page: 5
Total deficiencies: 10
Total surveys: 5
Licensed beds: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in staffing deficiencies and kitchen inspection findings |
| Staff 2 | Dietary Manager | Named in kitchen inspection findings and education |
| Staff 3 | Memory Care Administrator | Named in kitchen inspection findings |
| Staff 11 | Health Services Director/RN | Named in change of condition and staff training deficiencies |
| Staff 17 | Memory Care Administrator | Named in multiple deficiencies including medication tracking and staff training |
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