12 Reports
Inspection Report — May 1, 2026
State
Date: May 1, 2026
Visit Reason
On-site inspection of type Other at a Nursing Care Institution, conducted 1 May 2026.
Findings
This inspection resulted in no citations or deficiency findings. The facility was found in compliance with federal emergency preparedness and life safety requirements.
Inspection Report — Mar 26, 2026
State
Date: Mar 26, 2026
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 26 March 2026.
Findings
The inspection found four deficiencies related to emergency preparedness drills, door maintenance, fire drills, and improper use of power strips. Plans of correction were provided for all deficiencies.
Deficiencies (4)
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2) — The facility failed to participate in required emergency preparedness drills, which may lead to untrained staff and harm to residents during an emergency.
Corridor - Doors — The facility failed to maintain several doors, which could allow heat and/or smoke to transfer and cause harm to patients and staff.
Fire Drills — The facility failed to provide all required fire drills per NFPA 101, which can result in harm to patients and staff during an actual fire or emergency.
Electrical Equipment - Power Cords and Extension Cords — The facility allowed use of power strips without using wall outlet receptacles for appliances, risking electrical overload or fire that could harm patients and staff.
Report Facts
Deficiencies cited: 4
Inspection Report — May 1, 2025
Complaint Investigation State
Date: May 1, 2025
Visit Reason
On-site complaint investigation of complaints AZ00164244, AZ00157386, AZ00158054, AZ00165058, AZ00163850, AZ00166270, and AZ00165666 at a Nursing Care Institution, conducted 1 May 2025.
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.
Findings
One deficiency was cited related to resident dignity and respect. No evidence text was provided for the deficiency.
Deficiencies (1)
R9-10-410 — The administrator failed to ensure that a resident is treated with dignity, respect, and consideration. No evidence text was provided.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 2, 2025
State
Date: Apr 2, 2025
Visit Reason
On-site inspection of a Nursing Care Institution classified as Other, conducted 2 April 2025.
Findings
Two deficiencies were cited during this inspection. No evidence was provided for either deficiency.
Deficiencies (2)
Corridor doors did not meet required standards; however, no evidence was provided to detail the specific issues.
Gas equipment storage did not comply with design, construction, and ventilation requirements; no evidence was provided to specify the violations.
Report Facts
Deficiencies cited: 2
Inspection Report — Mar 28, 2025
Annual Inspection State
Date: Mar 28, 2025
Visit Reason
On-site complaint investigation of complaint AZ00219855 and AZ00219846, combined with a compliance (annual) survey at a Nursing Care Institution, conducted 25 March 2025 through 28 March 2025.
Complaint Details
The State compliance survey was conducted 03/25/2025 through 03/28/2025, in conjunction with the investigation of Compliaints .The AZ00219855 following deficiencies were cited: The recertification survey was conducted 03/25/2025 through 03/28/2025, in conjunction with the investigation of Compliaints AZ00219846.The following deficiencies were cited:
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Mar 28, 2025
Routine CMS
Date: Mar 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication management, medication storage, food storage, and employee hygiene in the nursing home.
Findings
The facility was found deficient in ensuring medications were not left unattended at bedside, expired medications and supplies were properly disposed of, and food storage and employee hygiene standards were met. Several expired medications, nutritional supplements, and syringes were found and disposed of. Food boxes were improperly stored blocking sprinkler systems, and staff were observed not fully complying with hair covering requirements.
Deficiencies (4)
Medications were left unattended on a bedside table for one resident, risking incorrect administration or consumption by others.
Expired over-the-counter medications, nutritional supplements, and syringes were found readily available for resident use.
Food boxes were stored too close to the ceiling in refrigerators and freezers, blocking sprinkler systems.
Staff were observed wearing hair coverings that did not fully cover hair, risking contamination of food.
Report Facts
Residents sampled for medication unattended: 44
Residents sampled for expired medications: 38
Expired insulin syringes: 11
Expired tuberculin syringes: 20
Expired 10 ml syringes: 1
Loose tablets found in OTC drawer: 4
Boxes of food items blocking sprinkler system: 9
Hair covering violations: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding medication self-administration and expired product expectations | |
| Registered Nurse (RN) / staff #122 | Observed preparing expired medication and interviewed about medication provision | |
| Assistant Director of Nursing (ADON) / staff #45 | Participated in medication room observation and interviewed about medication audits | |
| Central Supply Coordinator (CS) / staff #125 | Responsible for ordering supplies and managing expired items | |
| Registered Nurse (RN) / staff #50 | Reviewed OTC medication cart #1 | |
| Registered Nurse (RN) / staff #250 | Observed medication disposal practices and OTC drawer | |
| Licensed Practical Nurse (LPN) / staff #59 | Reviewed OTC medication cart #3 | |
| Licensed Practical Nurse (LPN) / staff #58 | Reviewed OTC medication cart #2 and long term care medication cart | |
| Executive Chef / staff #231 | Interviewed regarding food storage and sprinkler system clearance | |
| Dietician / staff #214 | Interviewed regarding food storage clearance requirements | |
| Center Administrator (CA) / staff #35 | Interviewed regarding staff expectations for food storage and hygiene | |
| Chef de Cuisine / staff #31 | Interviewed regarding hair covering expectations | |
| Server / staff #101 | Observed wearing inadequate hair covering |
Inspection Report — Sep 10, 2024
Complaint Investigation State
Date: Sep 10, 2024
Visit Reason
On-site complaint investigation of intakes AZ00215696, AZ00215612, and AZ00215694 at a Nursing Care Institution, conducted 9 through 10 September 2024.
Complaint Details
An investigation of intake #AZ00215696 and AZ00215612 was conducted on September 9 through September 10, 2024. The following deficiencies were cited. An investigation of intake #AZ00215694 and AZ00215612 was conducted on September 9 through September 10, 2024. The following deficiencies were cited.
Findings
The facility failed to follow the comprehensive care plan requiring a two-person transfer for resident #1, resulting in a fall with injury. Two deficiencies were cited related to accident prevention and premises safety.
Deficiencies (2)
§483.25(d) — The facility failed to use a two-person transfer as required by the care plan, resulting in resident #1's fall with injury and increased risk of harm.
R9-10-425 — The facility failed to ensure the premises were free from conditions that could cause physical injury, contributing to resident #1's fall during transfer.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #26 | Certified Nursing Assistant | Staff #26 transferred resident #1 using an improper method, sliding the resident to the floor. |
| Staff #57 | Certified Nursing Assistant | Staff #57 observed the transfer and was asked for assistance after the resident slid down. |
| Staff #147 | Licensed Practical Nurse | Staff #147 responded to the fall and assisted resident #1. |
| Staff #53 | Licensed Practical Nurse | Staff #53 documented resident #1's complaints of pain after the fall. |
| Staff #138 | Registered Nurse | Staff #138 documented x-ray results confirming fracture. |
| Staff #116 | Certified Nursing Assistant | Staff #116 assisted after the fall and reported on resident condition. |
| Staff #99 | Director of Nursing | Staff #99 was interviewed regarding the incident and facility practices. |
Inspection Report — Aug 7, 2024
Complaint Investigation State
Date: Aug 7, 2024
Visit Reason
On-site complaint investigation of intakes AZ00214266, AZ00213926, AZ00213898, and AZ00204123 at a Nursing Care Institution, conducted 7 August 2024.
Complaint Details
An onsite complaint survey was conducted on August 7, 2024 for the investigation of intake # AZ00214266, AZ00213926, AZ00213898, AZ00204123. Federal comments also note investigation of intake # AZ00214265, AZ00213925, AZ00213898, AZ00204123. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Oct 6, 2023
CMS
Date: Oct 6, 2023
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services and food safety standards at the facility.
Findings
The facility failed to ensure that medications were administered as ordered for one resident, specifically administering enteric coated aspirin instead of chewable aspirin as prescribed. Additionally, the facility failed to ensure proper storage of cleaning rags and the use of beard nets by kitchen staff, posing a risk for food-borne illnesses.
Deficiencies (2)
Failed to ensure medications were administered as ordered for resident #21, administering enteric coated aspirin instead of chewable aspirin.
Failed to ensure cleaning clothes were stored properly and beard nets were worn by kitchen staff, risking food-borne illness.
Report Facts
Resident affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #32 | Registered Nurse | Administered incorrect form of aspirin to resident #21 |
| Staff #44 | Director of Nursing | Interviewed regarding medication administration expectations |
| Staff #110 | Executive Chef | Interviewed regarding kitchen safety and beard net use |
| Staff #31 | Sous Chef | Interviewed and removed improperly placed cleaning rag |
| Staff #67 | Server | Interviewed regarding hair and beard net expectations |
| Staff #121 | Administrator | Interviewed regarding sanitary practices and risks |
Inspection Report — Oct 6, 2023
Annual Inspection State
Date: Oct 6, 2023
Visit Reason
On-site combined complaint and annual recertification survey conducted October 2 through October 6, 2023, including investigation of complaints AZ00192635 and AZ00187800 at a Nursing Care Institution.
Complaint Details
The Recertification Survey was conducted October 2, 2023 through October 6, 2023, in conjunction with the investigation of Complaints #AZ00192635 and AZ00187800. The following deficiencies were cited:
Findings
The inspection found four deficiencies related to medication administration, personnel background checks, pharmacy services, and food safety practices. Plans of correction were provided for all deficiencies.
Deficiencies (4)
R9-10-403 — The facility failed to ensure medications were administered as ordered for one resident, as enteric coated aspirin was given instead of the prescribed chewable aspirin.
R9-10-406 — The facility failed to ensure a background check was completed prior to an employee working onsite, as staff #85 did not have a valid fingerprint card on file.
§483.45 — The facility failed to ensure medications were administered as ordered by the physician for one resident, risking decreased deep vein thrombosis prophylaxis.
§483.60(i) — The facility failed to ensure cleaning clothes were stored properly and beard nets were worn by two staff members, risking food-borne illness.
Report Facts
Deficiencies cited: 4
Complaints investigated: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #32 | Registered Nurse | Administered incorrect form of aspirin to resident #21 |
| Staff #44 | Director of Nursing | Interviewed regarding medication administration expectations |
| Staff #85 | Employee | Did not have a valid fingerprint card on file |
| Staff #111 | Human Resources | Interviewed about background check process |
| Staff #121 | Administrator | Interviewed about background check expectations and food safety practices |
| Staff #110 | Executive Chef | Observed without beard net and interviewed about food safety |
| Staff #90 | Cook | Observed without beard net |
| Staff #31 | Sous Chef | Removed cleaning rag from food preparation counter |
| Staff #67 | Server | Interviewed about hair and beard net expectations |
Inspection Report — Oct 6, 2023
Routine CMS
Date: Oct 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with pharmaceutical services and food safety standards in the facility.
Findings
The facility failed to ensure medications were administered as ordered for one resident, potentially affecting deep vein thrombosis prophylaxis. Additionally, the facility did not properly store cleaning rags and staff failed to wear beard nets in the kitchen, posing a risk for food-borne illnesses.
Deficiencies (2)
Failed to ensure medications were administered as ordered by the physician for one resident (#21), specifically administering enteric coated aspirin instead of chewable aspirin.
Failed to ensure cleaning clothes were stored properly and beard nets were worn by kitchen staff, risking food-borne illnesses.
Report Facts
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN/staff #32) | Administered incorrect form of aspirin to resident #21 | |
| Director of Nursing (DON/staff #44) | Stated expectation that provider orders be followed and that administration did not meet expectations | |
| Executive Chef (staff #110) | Observed not wearing beard net and discussed cleaning rag storage | |
| Cook and Executive Chef (staff #90) | Observed not wearing beard net | |
| Sous Chef (staff #31) | Removed cleaning rag from food preparation counter | |
| Server (staff #67) | Stated expectation that hair and beard nets be worn in kitchen | |
| Administrator (staff #121) | Stated expectations for sanitary practices and risks of not wearing hair/beard nets |
Inspection Report — Aug 25, 2022
Routine CMS
Date: Aug 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication management, discharge planning, and psychotropic medication monitoring at the nursing facility.
Findings
The facility was found deficient in ensuring residents' call lights and water were accessible, monitoring for adverse side effects of anticoagulant use, providing complete discharge summaries and post-discharge plans, and monitoring target behaviors and adverse effects for residents on psychotropic medications. These deficiencies posed potential or minimal harm to residents.
Deficiencies (4)
Failed to ensure one resident's call light and water was accessible, potentially resulting in unmet resident needs.
Failed to monitor one resident for adverse side effects related to anticoagulant use, risking delayed identification of complications.
Failed to ensure complete discharge summaries and post-discharge plans for two residents, risking inadequate communication at discharge.
Failed to monitor target behaviors and adverse effects for three residents receiving psychotropic medications, risking inadequate medication monitoring.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN/staff #97) | Interviewed regarding call light accessibility and psychotropic medication monitoring | |
| Licensed Practical Nurse (LPN/staff #26) | Interviewed regarding anticoagulant side effect monitoring and psychotropic medication monitoring | |
| Director of Nursing (DON/staff #5) | Interviewed regarding expectations for call light accessibility, anticoagulant monitoring, discharge planning, and psychotropic medication monitoring | |
| Social Services Director (staff #106) | Interviewed regarding discharge planning process and documentation |
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