Inspection Report
Complaint Investigation
Capacity: 86
Deficiencies: 14
Oct 8, 2025
Visit Reason
State-compiled facility profile showing 20 inspections from 2022-12 to 2025-10 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility had 14 deficiencies primarily related to incomplete or unsigned service plans, lack of required training documentation for staff, failure to update service plans timely, and medication administration errors. Several complaint investigations found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted, including complaints 00147046, 00147030, 00128002, 00128016, 00126965, 00126982, 00126105, 00125723, 122048, 122052, AZ0000223214, AZ00222666, AZ00221254, AZ00221335, AZ00220830, AZ00220470, AZ00220529, AZ00218773, AZ00218980, AZ00218286, AZ00218210, AZ00217763, AZ00217978, AZ00215052, AZ00215326, AZ00215384, AZ00213178, AZ00203890, AZ00205699, AZ00200128. Some complaint investigations found no deficiencies, while others resulted in cited deficiencies.
Deficiencies (14)
| Description |
|---|
| R9-10-808.A.1-5. Service Plans: Failed to ensure service plans were signed and dated by resident or representative for two of six residents reviewed. |
| R9-10-808.B.1.a-b. Service Plans: Failed to develop a written service plan within three days of acceptance for one resident receiving respite care services. |
| R9-10-806.A.10. Personnel: Failed to ensure caregiver provided current documentation of valid CPR training including hands-on demonstration. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to develop and administer fall prevention and recovery training for all staff. |
| C. A manager shall ensure that policies and procedures are established, documented, and implemented to protect health and safety covering CPR training including demonstration of ability. |
| C. A manager shall ensure that policies and procedures are established, documented, and implemented to protect health and safety covering first aid training. |
| A. A manager shall ensure current documentation of first aid and CPR training certification before providing assisted living services for one employee. |
| A. Except as required in subsection (B), a manager shall ensure a written service plan includes a description of resident's medical or health problems for three of four residents reviewed. |
| A. Except as required in subsection (B), a manager shall ensure a written service plan includes the level of service the resident is expected to receive for four of four residents reviewed. |
| A. Except as required in subsection (B), a manager shall ensure a written service plan is updated at least once every three months for residents receiving directed care services; failed for one of four residents. |
| C. A manager shall ensure caregiver documents services provided in resident's medical record; failed for four of four residents reviewed. |
| B. A manager shall not accept or retain a resident confined to bed or chair without written determination from medical practitioner; failed for two residents. |
| C. A manager shall ensure service plan for directed care residents includes cognitive stimulation, safety strategies, encouragement to eat, weight documentation, and communication coordination; failed for four residents. |
| B. If medication administration is provided, manager shall ensure medication is administered in compliance with medication order; failed for one resident. |
Report Facts
Inspections on page: 20
Total deficiencies: 14
Complaint inspections: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Billet | Executive Director | Named as person responsible for multiple deficiencies including service plan and training issues |
| E1 | Acknowledged deficiencies related to service plans, CPR training, and documentation | |
| E2 | Acknowledged deficiencies related to service plans and training | |
| E3 | Caregiver | Personnel record reviewed for CPR training deficiency |
| E4 | Caregiver | Personnel record reviewed for fall prevention training deficiency |
| E6 | Reported medication administration and resident ambulation status |
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