Inspection Report
Modification
Capacity: 124
Deficiencies: 16
Jul 16, 2025
Visit Reason
State-compiled facility profile showing 12 inspections from 2023-02-01 to 2025-07-16 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies primarily involved failure to comply with medication administration orders, inadequate verification of caregiver skills, lack of certified management, improper documentation, and failure to conduct required disaster drills. Some deficiencies were repeat citations and posed risks to resident health and safety.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, with deficiencies found related to medication administration, caregiver qualifications, management certification, and documentation compliance.
Deficiencies (16)
| Description |
|---|
| A.R.S. § 36-420.B.1. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition - Failed to initiate CPR in accordance with certification training and resident advance directives. |
| R9-10-806.A.4.a-b. Personnel - Manager failed to ensure caregiver skills and knowledge were verified and documented before providing physical health services. |
| R9-10-816.B.3.b. Medication Services - Medication administered was not in compliance with medication orders for multiple residents. |
| A. A governing authority shall: 3.b. Designate, in writing, a manager with a valid assisted living facility manager certificate - Facility failed to designate a certified manager in writing. |
| B. Medication administration compliance - Manager failed to ensure medication was administered in compliance with orders for multiple residents. |
| A. Manager shall ensure garbage and refuse are stored in covered containers lined with plastic bags - Garbage containers were uncovered posing infection risk. |
| A. Manager shall ensure caregiver skills and knowledge are verified and documented before providing services - Failed for one caregiver. |
| A. Manager shall ensure caregiver provides current documentation of first aid and CPR training specific to adults - Failed for one caregiver. |
| F. Medication storage - Medication was not stored in a separate locked room, closet, cabinet, or self-contained unit. |
| A. Governing authority shall ensure compliance with A.R.S. § 36-411 - Failed to make documented good faith efforts to contact previous employers for personnel. |
| E. Manager shall ensure documentation required is provided to Department within two hours after request - Failed to provide documentation timely. |
| A. Manager shall ensure caregiver has current documentation of first aid and CPR training specific to adults - One caregiver had altered CPR/FA card and false information was provided. |
| C. Manager shall ensure personnel record includes documentation of education and experience applicable to job duties - Missing for some personnel. |
| C. Manager shall ensure personnel record includes evidence of freedom from infectious tuberculosis - Missing or falsified documentation for one personnel. |
| A. Manager shall ensure resident's service plan is completed no later than 14 calendar days after acceptance - One resident's plan was completed late. |
| A. Manager shall ensure disaster drills for employees are conducted on each shift at least once every three months and documented - Drills were not conducted quarterly on all shifts. |
Report Facts
Inspections on page: 12
Total deficiencies: 19
Complaint inspections: 11
Total capacity: 124
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly VanderMate | Manager | Named as person responsible in multiple deficiency findings related to caregiver verification and medication administration |
| E1 | Interviewed and acknowledged multiple deficiencies including medication administration and documentation issues | |
| E2 | Interviewed and involved in findings related to documentation and medication administration | |
| E3 | Interviewed and involved in findings related to caregiver skills verification and medication administration | |
| E4 | Personnel record reviewed with deficiencies in education and verification | |
| E5 | Personnel record reviewed with deficiencies in education and verification | |
| E6 | Personnel record reviewed with deficiencies in caregiver skills verification | |
| E8 | Personnel record reviewed with missing first aid training documentation | |
| E9 | Personnel record reviewed with delayed skills verification | |
| E10 | Provided personnel records during exit interviews | |
| VanderMate, Holly | Manager | Named as person responsible in deficiency related to CPR initiation |
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