Inspection Report
Complaint Investigation
Census: 180
Capacity: 180
Deficiencies: 23
Apr 4, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2023 to 2025 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility was found to have numerous deficiencies including failure to maintain adequate staffing, issues with resident dignity and abuse, inadequate care planning and treatment, medication cart security lapses, and life safety code violations related to door locking mechanisms and electrical safety.
Complaint Details
Multiple complaint investigations were conducted including intake numbers AZ00221707, AZ00222216, AZ00222097, AZ00221163, AZ00221161, AZ00217903, AZ00217901, AZ00208079, AZ00208077, AZ00206380, AZ00203229, AZ00203228, AZ00203125, AZ00201139, AZ00201138, AZ00201048, AZ00201046, AZ00199526, AZ00199223, AZ00193401, AZ00193302, AZ00192901, AZ00192900, AZ00191198, AZ00190350, AZ00190349, AZ00189731, AZ00189617, AZ00189619, AZ00204307, AZ00210852, AZ00189805, AZ00198856, AZ00198886, AZ00182440, AZ00184022, AZ00184532, AZ00184990, AZ00185922, AZ00187044, AZ0018752, AZ00196187, AZ00182438, AZ00184531, AZ00184987, AZ00187043, AZ00187526, AZ00195535, AZ00195534, AZ00198206, AZ00198535, AZ00220609, AZ00220610, AZ00220316, AZ00220322, AZ00219790. Deficiencies were cited in many of these investigations.
Deficiencies (23)
| Description |
|---|
| R9-10-403.C. An administrator shall ensure that: R9-10-403.C.1.j. Cover health care directives; |
| R9-10-403.C. An administrator shall ensure that: R9-10-403.C.2.e. Cover infection control; |
| §483.10(f) Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. |
| §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. |
| §483.25(e) Incontinence. The facility must ensure appropriate treatment and services for residents with urinary and fecal incontinence. |
| §483.60(i) Food safety requirements. The facility must procure, store, prepare, distribute and serve food in accordance with professional standards. |
| §483.65 Specialized rehabilitative services. The facility must provide or obtain required specialized rehabilitative services. |
| §483.80 Infection Control The facility must establish and maintain an infection prevention and control program. |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.4.m. May select a pharmacy of choice if the pharmacy complies with policies and procedures and does not pose a risk to the resident; |
| R9-10-413.B. A medical director shall ensure that: R9-10-413.B.6.f. Physical therapy; |
| 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; |
| R9-10-412.B. A director of nursing shall ensure that: R9-10-412.B.2. Sufficient nursing personnel are on premises to meet resident needs; |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.2. A resident is treated with dignity, respect, and consideration; |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3.a. A resident is not subjected to abuse; |
| §483.12 Freedom from Abuse, Neglect, and Exploitation: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. |
| § 483.25 Quality of care: The facility must ensure residents receive treatment and care in accordance with professional standards and care plans. |
| Egress Doors: Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless special locking arrangements are met. |
| Corridor - Doors: Doors protecting corridor openings must resist passage of smoke and have positive latching hardware. |
| Electrical Systems - Essential Electric System Maintenance and Testing: Facility failed to ensure a remote stop or kill switch for the generator was installed. |
| Electrical Equipment - Power Cords and Extension Cords: Facility failed to ensure staff did not use multiplug adapters which could create electrical hazards. |
| R9-10-403.C.2.d. Cover storing, dispensing, administering, and disposing of medication; Facility failed to ensure medication carts were secured while unattended. |
| §483.45(g) Labeling of Drugs and Biologicals and §483.45(h) Storage of Drugs and Biologicals: Facility failed to ensure medication carts were secured while unattended. |
Report Facts
Inspections on page: 9
Total deficiencies: 27
Complaint inspections: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA staff #313 | Certified Nursing Assistant | Named in dignity and respect deficiency involving resident #33 |
| CNA staff #507 | Certified Nursing Assistant | Witness in dignity and respect deficiency involving resident #33 |
| DON (Director of Nursing) staff #122 | Director of Nursing | Named in multiple deficiencies including staffing and abuse investigations |
| LPN staff #100 | Licensed Practical Nurse | Named in abuse investigation involving resident #30 |
| LPN staff #184 | Licensed Practical Nurse | Witness in abuse investigation involving resident #30 |
| RN staff #55 | Registered Nurse | Named in medication cart security deficiency |
| RN staff #145 | Registered Nurse | Named in medication cart security deficiency |
| Executive Director (ED) staff #505 | Executive Director | Named in staffing and shower schedule concerns |
| Ombudsman staff #515 | Ombudsman | Interviewed regarding shower issues and resident concerns |
| Assistant Director of Nursing (ADON)/Wound Nurse staff #117 | Assistant Director of Nursing / Wound Nurse | Named in wound care deficiency |
| Staff #180 | Staffing Coordinator | Interviewed regarding staffing data |
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