Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
69 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Deficiencies: 1
Date: Jul 2, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with resident rights and safety protocols, specifically regarding the implementation of a password protocol for visitation to protect residents from harm.
Findings
The facility failed to implement and properly document a password protocol for visitation to protect one resident (#634) with cognitive impairment and safety concerns. Interviews and record reviews revealed that the password protocol was not reflected in the resident's care plan or clinical record, and involved staff could not locate documentation of the protocol. This deficiency posed a risk of residents being further victimized.
Deficiencies (1)
Failure to implement and document a password protocol for visitation to protect resident #634 from harm.
Report Facts
Residents affected: 4
Residents affected: 1
Frequency of abuse training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) Staff #77 | Interviewed regarding visitation and abuse definitions | |
| Assistant Director of Nursing (ADON) Staff #39 | Interviewed regarding visitation procedures | |
| Licensed Practical Nurse (LPN) Staff #43 | Interviewed regarding abuse definitions | |
| Director of Social Services (DoSS) Staff #10 | Interviewed regarding abuse training and password protocol documentation | |
| Executive Director (ED) Staff #61 | Interviewed regarding password protocol documentation |
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
Complaint survey conducted for complaints AZ00216706 and AZ00216777 with no deficiencies cited.
Complaint Details
Complaint #'s AZ00216706 and AZ00216777
Findings
Complaint survey conducted for complaints AZ00216706 and AZ00216777 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
Onsite investigation of complaints AZ00215637 and AZ00215738 with no deficiencies cited.
Complaint Details
Complaints AZ00215637 and AZ00215738
Findings
Onsite investigation of complaints AZ00215637 and AZ00215738 with no deficiencies cited.
Inspection Report
Capacity: 70
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
Recertification survey for Medicare 2012 Life Safety Code compliance with no deficiencies found.
Findings
Recertification survey for Medicare 2012 Life Safety Code compliance with no deficiencies found.
Inspection Report
Routine
Census: 69
Deficiencies: 3
Date: Sep 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including timely notification of resident transfers or discharges, staffing requirements for registered nurses, and proper administration of medications.
Findings
The facility failed to notify the ombudsman of a resident transfer, did not ensure an RN was on duty for 8 consecutive hours on multiple days, and did not administer pain medication according to physician orders for one resident, potentially resulting in inadequate care and risk to residents.
Deficiencies (3)
Failed to notify the ombudsman of resident transfer or discharge.
Failed to ensure a Registered Nurse was on duty for 8 consecutive hours on multiple days.
Failed to administer pain medication according to physician's orders for one resident.
Report Facts
Census on May 19, 2024: 58
Census on July 1, 2024: 68
Census on August 5, 2024: 68
Census on August 6, 2024: 66
Census on August 12, 2024: 69
Census on August 19, 2024: 67
Census on August 27, 2024: 64
Census on September 1, 2024: 59
Oxycodone administrations below pain rating parameters in July 2024: 33
Oxycodone administrations below pain rating parameters in August 2024: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #66 | Care Manager Licensed Practical Nurse (LPN) | Provided information about resident #70's care plan and discharge process |
| Staff #167 | Care Manager Licensed Practical Nurse (LPN) | Interviewed regarding emergency transfer of resident #70 |
| Staff #172 | Social Services Staff | Stated unawareness of need to notify ombudsman |
| Staff #52 | Certified Nurse Assistant (CNA) | Interviewed about typical resident care and communication |
| Staff #34 | Director of Nursing (DON) | Interviewed about RN coverage and medication administration expectations |
| Staff #110 | Registered Nurse (RN) | Interviewed about pain medication administration and assessment |
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 2
Date: Sep 6, 2024
Visit Reason
State compliance survey with complaint investigation citing 3 deficiencies related to ombudsman notification, nurse staffing, and medication administration.
Complaint Details
Complaints AZ00215422, AZ00193369, AZ00191191, AZ00189364, AZ00188462
Findings
State compliance survey with complaint investigation citing 3 deficiencies related to ombudsman notification, nurse staffing, and medication administration.
Deficiencies (2)
R9-10-408.D — Ombudsman notification on resident discharge or transfer
R9-10-412.B — Nurse staffing and medication administration
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
Onsite complaint survey for multiple intake numbers with no deficiencies cited.
Complaint Details
Intake #s AZ00212312, AZ00203581, AZ00200491, AZ00198118, AZ00197277
Findings
Onsite complaint survey for multiple intake numbers with no deficiencies cited.
Inspection Report
Deficiencies: 2
Date: Apr 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing safe and appropriate dialysis care and services, specifically focusing on dialysis assessments and transportation arrangements for residents requiring dialysis.
Findings
The facility failed to ensure dialysis assessments were completed and transportation to dialysis appointments was arranged for one of three sampled residents (#4). The resident missed a scheduled dialysis session on April 10, 2024, resulting in an emergency room visit. Interviews and record reviews confirmed lack of dialysis assessments and transportation scheduling errors.
Deficiencies (2)
Failure to ensure dialysis assessments were completed for resident #4.
Failure to arrange transportation to dialysis appointments for resident #4, resulting in missed dialysis treatment.
Report Facts
Dialysis frequency: 3
Dialysis appointment time: 1130
Dialysis chair time: 230
Missed dialysis dates: 1
Post dialysis assessments documented: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) staff #90 | Licensed Practical Nurse | Stated no dialysis assessments were completed for resident #4 and responsible for setting up transportation |
| Director of Nursing (DON) staff #88 | Director of Nursing | Confirmed dialysis assessments were not completed and stated expectations for transportation and assessments |
| Unit Clerk staff #76 | Unit Clerk | Responsible for scheduling transportation and explained failure to arrange transport for resident #4 |
| Nurse Care Manager staff #65 | Nurse Care Manager | Conducted admission intake and communicated transportation needs for resident #4 |
| Assistant Director of Nursing (ADON) staff #43 | Assistant Director of Nursing | Provided information on transportation scheduling and resident's hospital stay |
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 2
Date: Apr 17, 2024
Visit Reason
Complaint survey citing 2 deficiencies related to dialysis services and care plan nursing care.
Complaint Details
Intake #AZ00209061
Findings
Complaint survey citing 2 deficiencies related to dialysis services and care plan nursing care.
Deficiencies (2)
§483.25(l) — Dialysis services and assessments
R9-10-414.B — Care plan ensuring nursing care institution standards
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of abuse reported by Resident #45 related to medication management and pain control.
Complaint Details
The complaint was substantiated as the facility did not report the abuse allegation for Resident #45 within the required timeframe. The Executive Director acknowledged the failure and reported the abuse to DHS on 01/31/2024 at 1:47 PM.
Findings
The facility failed to timely report an allegation of abuse concerning Resident #45 to the State within the required timeframe. The resident had concerns about inadequate pain medication and felt abused, but the incident was not reported until the survey date.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Medication dosage: 300
Medication dosage: 800
Date of grievance: Nov 9, 2023
Date of report to DHS: Jan 31, 2024
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 2
Date: Jan 31, 2024
Visit Reason
Complaint survey citing 2 deficiencies related to abuse reporting and response.
Complaint Details
Intake #s AZ00205760, AZ00205859, AZ00205835
Findings
Complaint survey citing 2 deficiencies related to abuse reporting and response.
Deficiencies (2)
R9-10-403.E — Abuse reporting and investigation
§483.12(c) — Response to allegations of abuse, neglect, exploitation
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Jan 25, 2024
Visit Reason
Complaint survey for complaints AZ00205512 and AZ00205307 with no deficiencies cited.
Complaint Details
Complaints AZ00205512, AZ00205307
Findings
Complaint survey for complaints AZ00205512 and AZ00205307 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
Complaint survey for intake #AZ00203652 with no deficiencies cited.
Complaint Details
Intake #AZ00203652
Findings
Complaint survey for intake #AZ00203652 with no deficiencies cited.
Inspection Report
Capacity: 70
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
Inspection with no deficiencies cited.
Findings
Inspection with no deficiencies cited.
Inspection Report
Capacity: 70
Deficiencies: 1
Date: Sep 11, 2023
Visit Reason
Inspection citing 1 deficiency related to COVID-19 reporting to CDC NHSN.
Findings
Inspection citing 1 deficiency related to COVID-19 reporting to CDC NHSN.
Deficiencies (1)
§483.80(g) — COVID-19 reporting to CDC NHSN
Inspection Report
Capacity: 70
Deficiencies: 1
Date: Sep 5, 2023
Visit Reason
Inspection citing 1 deficiency related to COVID-19 reporting to CDC NHSN.
Findings
Inspection citing 1 deficiency related to COVID-19 reporting to CDC NHSN.
Deficiencies (1)
§483.80(g) — COVID-19 reporting to CDC NHSN
Inspection Report
Deficiencies: 5
Date: Nov 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident notification, self-administration of drugs, discharge notification, and food safety in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure residents and/or their representatives were informed about psychotropic medication risks and benefits, medications left unattended with residents not assessed for self-administration, failure to notify the ombudsman of a resident discharge, administration of medication outside physician-ordered parameters, and improper food storage practices in the kitchen.
Deficiencies (5)
Failure to ensure one resident and/or their representatives were informed in advance of the risks and benefits of proposed treatment with psychotropic medications.
Failure to ensure medications were not left unattended for 4 residents who were not assessed for self-administration of medications.
Failure to notify the ombudsman in writing regarding one resident's discharge.
Failure to ensure medications were administered according to physician ordered parameters for one resident.
Failure to ensure food items in the kitchen dry storage were sealed, dated or not expired.
Report Facts
Sample size: 7
Sample size: 16
Sample size: 2
Sample size: 5
Medication administration occurrences: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN/staff #100 | Interviewed regarding psychotropic medication consent |
| Director of Nursing | DON/staff #171 | Interviewed regarding psychotropic medication consent, medication self-administration, and medication administration parameters |
| Licensed Practical Nurse | LPN/staff #107 | Interviewed regarding medication administration observation |
| Registered Nurse | RN/staff #181 | Interviewed regarding medication administration observation |
| Licensed Practical Nurse | LPN/staff #98 | Observed and interviewed regarding medication administration and self-administration |
| Licensed Practical Nurse | LPN/staff #119 | Interviewed regarding medication administration and self-administration |
| Social Services Coordinator | staff #155 | Interviewed regarding ombudsman notification |
| Administrator | staff #182 | Interviewed regarding ombudsman notification |
| Licensed Practical Nurse | LPN/staff #128 | Interviewed regarding medication administration parameters |
| Dietary Manager | staff #139 | Interviewed regarding food storage and labeling |
Inspection Report
Routine
Census: 65
Deficiencies: 8
Date: Oct 8, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, abuse and neglect prevention, infection control, and other facility policies.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with uncovered catheter bags, inconsistent advance directive documentation, improper medication administration resulting in resident death, failure to timely report neglect, improper pain medication administration, inconsistent bathing, unnecessary medication use, and lapses in infection control practices.
Deficiencies (8)
Failure to ensure one resident's urinary catheter bag was covered, compromising dignity and privacy.
Failure to ensure one resident's code status was consistent in the clinical record.
Failure to prevent neglect resulting in administration of oral medications through an intravenous line causing resident death.
Failure to timely report suspected neglect to the State Agency and Adult Protective Services within required timeframe.
Failure to administer pain medications according to physician orders.
Failure to provide consistent showers/bathing to one resident.
Failure to ensure two residents were free from unnecessary medication.
Failure to ensure proper hand hygiene between glove use and urinary catheter bag placement off the floor.
Report Facts
Census: 65
Deficiencies cited: 8
Medication doses: 10
Medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #179 | Certified Nursing Assistant | Mentioned in catheter bag coverage deficiency and infection control observation |
| Staff #159 | Registered Nurse | Mentioned in catheter bag coverage deficiency and infection control observation |
| Staff #182 | Registered Nurse | Involved in medication error leading to resident death |
| Staff #7 | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration and reporting |
| Staff #126 | Registered Nurse | Interviewed regarding advance directive process |
| Staff #176 | Charge Nurse | Involved in code blue response and investigation |
| Staff #180 | Administrator | Interviewed regarding incident reporting and investigation |
| Staff #62 | Assistant Director of Nursing | Interviewed regarding medication administration and bathing policies |
| Staff #37 | Registered Nurse | Interviewed regarding pain medication administration |
| Staff #174 | Certified Nursing Assistant | Observed and interviewed regarding catheter care and infection control |
| Staff #124 | Certified Nursing Assistant | Interviewed regarding bathing documentation |
| Staff #102 | Licensed Nursing Assistant | Interviewed regarding risks of inconsistent showers |
| Staff #212 | Registered Pharmacist | Interviewed regarding medication administration through PICC line |
| Staff #232 | Medical Director | Interviewed regarding medication administration through PICC line |
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