Inspection Report
Annual Inspection
Capacity: 5
Deficiencies: 15
May 12, 2025
Visit Reason
State-compiled facility profile showing 2 annual compliance inspections from 2023-07-19 to 2025-05-12 with deficiency history
Findings
Across two annual compliance inspections, multiple deficiencies were identified including failures in staff training, documentation, medication administration, resident rights, food safety, disaster preparedness, and environmental safety.
Deficiencies (15)
| Description |
|---|
| A.R.S. § 36-420.01.A. 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 including continued competency training. |
| R9-10-113.A.2.a-f. Tuberculosis Screening: Failed to provide annual training and education related to recognizing the signs and symptoms of tuberculosis to all personnel. |
| R9-10-806.A.10. Personnel: Failed to ensure caregiver provided current documentation of first aid training before providing assisted living services. |
| R9-10-810.B.3.b. Resident Rights: Failed to obtain resident or representative consent to photographing the resident. |
| R9-10-811.A.5. Medical Records: Failed to protect resident medical records from loss, damage, or unauthorized use. |
| R9-10-816.B.3.a-c. Medication Services: Medication administration was not in compliance with medication orders. |
| R9-10-817.C.1. Food Services: Failed to ensure food stored was free from spoilage, filth, or contamination and safe for consumption. |
| R9-10-819.A.1.b. Environmental Standards: Failed to ensure premises and equipment were free from conditions that may cause physical injury. |
| B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation dated within 90 days including medical service needs and restraints: Failed to ensure required pre-admission determination documentation was completed. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan signed and dated by required parties: Failed to ensure service plans were signed and dated by resident or representative and manager. |
| C. A manager shall ensure that a resident's medical record contains documentation of notification of vaccination availability: Failed to document pneumonia vaccination notification or administration. |
| C. A manager shall ensure potentially hazardous foods requiring refrigeration are maintained at 41° F or below: Failed to maintain refrigerator temperature at or below 41° F. |
| A. A manager shall ensure the disaster plan is reviewed at least once every 12 months: Failed to document disaster plan review within past 12 months. |
| A. A manager shall ensure disaster drills are conducted on each shift at least once every three months and documented: Failed to conduct and document disaster drills on second shift. |
| A. A manager shall ensure poisonous or toxic materials are stored in locked containers inaccessible to residents: Failed to store poisonous or toxic materials in a locked area. |
Report Facts
Inspections on page: 2
Total deficiencies: 15
Complaint inspections: 0
Total capacity: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pirjo Stawisuck | Manager | Named as person responsible for multiple deficiencies including training, medication, resident rights, and environmental safety |
| Piro Stawisuck | Manager | Named as person responsible for fall prevention training deficiency |
| pirjo stawsisuck | Manager | Named as person responsible for environmental standards deficiency |
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