Inspection Report Summary
The most recent inspection on March 27, 2025, found two deficiencies related to tuberculosis screening and medical records during a complaint investigation. Earlier inspections showed a pattern of deficiencies primarily involving fall prevention training, caregiver skills verification, and documentation issues, with several enforcement actions resulting in fines ranging from $250 to $500. Complaint investigations mostly resulted in deficiencies related to staff training and service plan coordination, while many complaints were unsubstantiated. Enforcement actions were taken multiple times for training and documentation lapses, but no license suspensions or immediate jeopardy findings were listed in the available reports. The facility’s record shows ongoing challenges with staff training and documentation, with no clear trend of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 2
Date: Mar 27, 2025
Visit Reason
Two deficiencies found related to tuberculosis screening and medical records during complaint investigation AZ00220229.
Complaint Details
Complaint AZ00220229
Findings
Two deficiencies found related to tuberculosis screening and medical records during complaint investigation AZ00220229.
Deficiencies (2)
R9-10-113.A.1-2. Tuberculosis Screening
R9-10-811.C.17. Medical Records
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Jun 5, 2024
Summary
The enforcement resulted in a civil fine due to the deficient practice posing a risk to the physical health and safety of a resident.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Failure to ensure the healthcare institution developed and administered a training program for all staff regarding fall prevention and fall recovery. | Pending |
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: May 21, 2024
Summary
The enforcement action resulted in a $250 fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Enforcement action fine | Paid |
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 1
Date: May 13, 2024
Visit Reason
One deficiency cited related to fall prevention training during investigation of multiple complaints.
Complaint Details
Complaints AZ00208897, AZ00210065, AZ00210101, AZ00210252, AZ00210299
Findings
One deficiency cited related to fall prevention training during investigation of multiple complaints.
Deficiencies (1)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
No deficiencies cited during complaint investigation AZ00205992.
Complaint Details
Complaint AZ00205992
Findings
No deficiencies cited during complaint investigation AZ00205992.
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 0
Date: Dec 26, 2023
Visit Reason
No deficiencies cited during complaint investigation AZ00198964 and AZ00199312.
Complaint Details
Complaints AZ00198964, AZ00199312
Findings
No deficiencies cited during complaint investigation AZ00198964 and AZ00199312.
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Jul 11, 2023
Summary
The enforcement action resulted in a $500 fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Fine associated with enforcement action #00113013 | Paid |
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 3
Date: Jun 22, 2023
Visit Reason
Three deficiencies cited related to fall prevention training, caregiver skills verification, and service plan coordination during complaint investigations AZ00191753 and AZ00195866.
Complaint Details
Complaints AZ00191753, AZ00195866
Findings
Three deficiencies cited related to fall prevention training, caregiver skills verification, and service plan coordination during complaint investigations AZ00191753 and AZ00195866.
Deficiencies (3)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs
A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented
C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes coordination of communications
Enforcement Action
Enforcement
Fines: 2
Total: $1,000.00
Date: Mar 22, 2023
Summary
The facility failed to provide documentation for caregiver training and CPR demonstration for certain employees, posing a risk and resulting in civil fines.
Fines & Penalties (2)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to ensure a caregiver provided documentation of completion of a caregiver training program. | — |
| $500.00 | Failure to ensure personnel records included documentation of CPR training and demonstration for caregivers. | — |
Inspection Report
Annual Inspection
Capacity: 121
Deficiencies: 11
Date: Jan 23, 2023
Visit Reason
Eleven deficiencies cited during annual compliance inspection related to policies, documentation, personnel records, service plans, medication administration, and disaster plan documentation.
Findings
Eleven deficiencies cited during annual compliance inspection related to policies, documentation, personnel records, service plans, medication administration, and disaster plan documentation.
Deficiencies (11)
C. A manager shall ensure that policies and procedures are established, documented, and implemented to protect the health and safety of a resident
E. A manager shall ensure that documentation required by this Article is provided to the Department within two hours after a Department request
A. A manager shall ensure that a caregiver provides documentation of completion of a caregiver training program approved by the Department
C. A manager shall ensure that a personnel record for each employee or volunteer includes documentation of cardiopulmonary resuscitation (CPR) training
C. A manager shall ensure that a personnel record for each employee or volunteer includes documentation of compliance with A.R.S. 'a7 36-411(C)
B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation dated within 90 calendar days
C. A manager shall not accept or retain an individual if the individual requires continuous behavioral health services
C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes cognitive stimulation and activities
C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes coordination of communications
B. If an assisted living facility provides medication administration, a manager shall ensure that policies and procedures for medication administration are reviewed and approved by a medical practitioner
A. A manager shall ensure that documentation of the disaster plan review includes the date, time, and names of employees involved
Inspection Report
Complaint Investigation
Capacity: 121
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
No deficiencies cited during complaint investigation AZ00190217; four allegations unsubstantiated.
Complaint Details
Complaint AZ00190217
Findings
No deficiencies cited during complaint investigation AZ00190217; four allegations unsubstantiated.
Enforcement Action
Enforcement
Total: $0.00
Date: Nodate Enforcement
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