Inspection Report
Complaint Investigation
Capacity: 42
Deficiencies: 10
May 1, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2023-10 to 2025-05 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies were found related to resident care, medication administration, staff background checks, food safety, emergency preparedness, and life safety code compliance. Some inspections found no deficiencies, while others cited multiple violations including a resident fall due to improper transfer and failure to follow medication orders.
Complaint Details
The Risk Based complaint survey was conducted on May 1, 2025, for the investigation of complaints #AZ00164244, AZ00157386, AZ00158054, AZ00165058, AZ00163850, AZ00166270, AZ00165666. Additional complaint investigations occurred on 9/9/2024 and 8/7/2024 with intake numbers AZ00215696, AZ00215612, AZ00214266, AZ00213926, AZ00213898, AZ00204123. Deficiencies were cited in some complaint investigations, while others found no deficiencies.
Deficiencies (10)
| Description |
|---|
| R9-10-410.B. An administrator shall ensure that: R9-10-410.B.2. A resident is treated with dignity, respect, and consideration; |
| Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. |
| Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but |
| §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. |
| 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; |
| R9-10-403.C. An administrator shall ensure that: R9-10-403.C.2. Policies and procedures for physical health services and behavioral health services are established, documented, and implemented to protect the health and safety of a resident that: R9-10-403.C.2.d. Cover storing, dispensing, administering, and disposing of medication; |
| R9-10-406.F. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: R9-10-406.F.3. Documentation of: R9-10-406.F.3.c. The individual's compliance with the requirements in A.R.S. § 36-411; |
| §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. |
| §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. |
| (2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following: *[For LTC Facilities at §483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:] (i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event. (ii) Conduct an additional exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based. (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For RNHCIs at §403.748 and OPOs at §486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emer |
Report Facts
Inspections on page: 7
Total deficiencies: 10
Complaint inspections: 5
Total capacity: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #26 | Certified Nursing Assistant (CNA) | Named in resident fall with injury finding during complaint investigation |
| Staff #57 | Certified Nursing Assistant (CNA) | Interviewed regarding resident fall incident |
| Staff #147 | Licensed Practical Nurse (LPN) | Involved in resident fall incident and documentation |
| Staff #116 | Certified Nursing Assistant (CNA) | Observed resident after fall and interviewed |
| Staff #32 | Registered Nurse (RN) | Involved in medication administration deficiency |
| Staff #44 | Director of Nursing (DON) | Interviewed regarding medication administration deficiency |
| Staff #85 | Employee with incomplete background check | Named in background check deficiency |
| Staff #111 | Human Resources | Interviewed regarding background check deficiency |
| Staff #121 | Facility Administrator | Interviewed regarding background check and food safety deficiencies |
| Staff #110 | Executive Chef | Named in food safety deficiency |
| Staff #90 | Cook | Named in food safety deficiency |
| Staff #31 | Sous Chef | Named in food safety deficiency |
| Staff #67 | Server | Interviewed regarding food safety practices |
| Staff #99 | Director of Nursing (DON) | Interviewed during complaint investigation of resident fall |
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