Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 240
Deficiencies: 14
Sep 17, 2025
Visit Reason
State-compiled facility profile showing multiple complaint investigations from 2023 to 2025 with deficiency history.
Findings
Across multiple complaint investigations from 2023 to 2025, the facility was found to have deficiencies primarily related to failure to prevent and report abuse, inadequate monitoring of residents, and failure to prevent accidents such as elopements. Several inspections cited no deficiencies.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, with several intakes investigated per inspection. Some complaint investigations resulted in no deficiencies, while others cited multiple deficiencies related to abuse, neglect, failure to report, and safety issues.
Deficiencies (14)
| Description |
|---|
| §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 as defined in this subpart. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to protect the rights of on resident to be free from abuse (#2) by another resident (#4). The deficient practice could result in residents being physically and emotionally injured. |
| §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. Based on interviews, record reviews, and observations, the facility failed to implement its policies for preventing and prohibiting abuse were implemented consistently by staff, resulting in a delay in reporting resident to resident abuse to the state agencies, physician, abuse coordinator and family. |
| §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Based on observation, interviews, review of documentation, and review of facility policies, the facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two residents (#2) and (#4). The deficient practice could lead to a failure of the facility to report allegations of abuse timely, and could lead to continued abuse for a resident. |
| R9-10-403.F. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe that abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from a nursing care institution's employee or personnel member, an administrator shall: R9-10-403.F.2. Report the suspected abuse, neglect, or exploitation of the resident as follows: R9-10-403.F.2.a. For a resident 18 years of age or older, according to A.R.S. § 46-454; or Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an allegation of abuse was reported to the State Agency for one resident (#69). The deficient practice could result in abuse allegations not being reported. |
| §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 as defined in this subpart. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; Based on clinical record review, resident and staff interviews, and policy review, the facility failed to protect the rights of two residents (#69, #77) to be free from abuse by another resident (#81, #76). The deficient practice could result in other residents being abused. |
| §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an allegation of abuse was reported to the State Agency for one resident (#69). The deficient practice could result in abuse allegations not being reported. |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3. A resident is not subjected to: R9-10-410.B.3.a. Abuse; Based on clinical record review, resident and staff interviews, and policy review, the facility failed to protect the rights of two residents (#69, #77) to be free from abuse by another resident (#81, #76). The deficient practice could result in other residents being abused. |
| R9-10-403.E. If abuse, neglect, or exploitation of a resident is alleged or suspected to have occurred before the resident was admitted or while the resident is not on the premises and not receiving services from a nursing care institution's employee or personnel member, an administrator shall report the alleged or suspected abuse, neglect, or exploitation of the resident as follows: R9-10-403.E.1. For a resident 18 years of age or older, according to A.R.S. § 46-454; or Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an allegation of abuse was reported to the State Agency for one resident (#69). |
| R9-10-412.B. A director of nursing shall ensure that: R9-10-412.B.7. An unnecessary drug is not administered to a resident. Based on clinical review, staff interviews, and facility policy and procedures, the facility failed to ensure that behaviors were monitored and documented prior to medication administration for 2 out of 3 residents sampled (#1, #2). |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: R9-10-414.B.3. Ensures that a resident is provided nursing care institution services that: 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. Based on clinical record review, interviews, and policy review, the facility failed to ensure that one residents (#2) received treatment and care in accordance with professional standards of practice. |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3. A resident is not subjected to: R9-10-410.B.3.a. Abuse; Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure residents were free from abuse. |
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3. A resident is not subjected to: R9-10-410.B.3.a. Abuse; Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#1) and (#2) were free from physical abuse. |
| §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. Based on clinical record review, interviews, and review of facility policies the facility failed to ensure an avoidable elopement was prevented. |
| R9-10-425.A. An administrator shall ensure that: R9-10-425.A.1. A nursing care institution's premises and equipment are: R9-10-425.A.1.b. Free from a condition or situation that may cause a resident or an individual to suffer physical injury; Based on clinical record review, interviews, and review of facility policies the facility failed to ensure an avoidable elopement was prevented. |
Report Facts
Inspections on page: 39
Total deficiencies: 16
Complaint inspections: 37
Total capacity: 240
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christiana Irwin | Administrator | Named as facility administrator in facility information |
| Staff #16 | Director of Nursing | Named in medication error and neurocheck deficiency findings |
| Staff #118 | Director of Nursing | Named in abuse supervision deficiency findings |
| Staff #199 | Assistant Director of Nursing | Named in medication monitoring and neurocheck deficiency findings |
| Staff #181 | Certified Nursing Assistant | Named in medication monitoring and neurocheck deficiency findings |
| Staff #151 | Registered Nurse | Named in medication monitoring and neurocheck deficiency findings |
| Staff #27 | Certified Nursing Assistant | Named in abuse incident findings |
| Staff #81 | Certified Nursing Assistant | Named in abuse incident findings |
| Staff #14 | Licensed Practical Nurse | Named in abuse incident findings |
| Staff #30 | Registered Nurse | Named in abuse incident findings |
| Staff #46 | Certified Nursing Assistant | Named in abuse incident findings |
| Staff #10 | Certified Nursing Assistant | Named in abuse incident findings |
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