Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Aug 7, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2023-01-24 to 2025-08-07 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies primarily involved failure to properly document abuse prevention actions, improper storage of toxic and flammable materials, failure to maintain equipment, incomplete or missing service plan updates, medication administration documentation errors, and inadequate staff training on fall prevention. Several deficiencies were repeats from prior inspections.
Complaint Details
Multiple complaint investigations were conducted, including complaints 00138704, 00138689, 00124980, 00123407, 00123410, 00120958, 00121530, AZ00221842, AZ00220474, AZ00220401, AZ00216352, AZ00220259, AZ00215312, AZ00216179, AZ00192664, AZ00184652, AZ00183643, AZ00181189, and AZ00178512 with substantiated and unsubstantiated allegations.
Deficiencies (9)
| Description |
|---|
| R9-10-803.J.1-6. Administration: Failed to document actions taken to prevent suspected abuse from occurring in the future. |
| A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents; |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: iii. At least once every three months for a resident receiving directed care services; |
| A. A manager shall ensure that: 13. Equipment used at the assisted living facility is: a. Maintained in working order; |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident's medical record. |
| A. A manager shall ensure that: 12. Combustible or flammable liquids and hazardous materials stored by the assisted living facility are stored in the original labeled containers or safety containers in a locked area inaccessible to residents; |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition: Failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. |
| E. A manager shall ensure that, unless otherwise stated: 1. Documentation required by this Article is provided to the Department within two hours after a Department request; |
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: c. Provides assistance with activities of daily living according to the resident's service plan; |
Report Facts
Inspections on page: 9
Total deficiencies: 11
Complaint inspections: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Bearg | General Manager | Named in deficiency related to failure to document actions to prevent suspected abuse |
| E1 | Acknowledged multiple deficiencies during interviews including documentation and storage issues | |
| E2 | Interviewed regarding medication administration documentation | |
| E7 | Acknowledged unlocked toxic and flammable materials during interviews |
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