Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
11% better than Arizona average
Arizona average: 3.7 deficiencies/year
Deficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 4
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
Complaint Investigation
Deficiencies: 1
Date: Sep 10, 2024
Visit Reason
The inspection was conducted following a complaint and facility self-report regarding a resident's fall during transfer, which resulted in injury. The investigation focused on the facility's adherence to transfer protocols and resident safety measures.
Complaint Details
The complaint investigation was substantiated. Resident #1 fell on September 2, 2024, during transfer by a CNA who did not use the required two-person assist and Hoyer lift. The fall caused a fracture confirmed by x-ray. Staff interviews indicated lack of awareness and training gaps. The facility self-reported the incident and awaited x-ray results at the time.
Findings
The facility failed to use a two-person transfer as required by the resident's care plan, resulting in a fall with injury to resident #1. The resident sustained a comminuted distal perihardware fracture confirmed by x-ray. Interviews revealed staff were not fully aware or compliant with the required transfer methods, and communication during shift changes was insufficient.
Deficiencies (1)
Failure to use a two-person transfer as identified by the comprehensive care plan, resulting in resident #1's fall with injury.
Report Facts
Date of fall: Sep 2, 2024
Date of x-ray order: Sep 3, 2024
Date of x-ray result: Sep 5, 2024
Date of facility self-report: Sep 4, 2024
Staff absence duration: 3
Neuro checks interval: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #26 | Certified Nursing Assistant (CNA) | Involved in resident #1 transfer resulting in fall |
| Staff #147 | Licensed Practical Nurse (LPN) | Responded to fall, conducted pain assessment |
| Staff #53 | Licensed Practical Nurse (LPN) | Documented resident pain and bruising post-fall |
| Staff #138 | Registered Nurse (RN) | Reported x-ray results and notified medical team and family |
| Staff #57 | Certified Nursing Assistant (CNA) | Witnessed transfer, assisted after fall |
| Staff #116 | Certified Nursing Assistant (CNA) | Observed resident post-fall, implemented neuro checks |
| Staff #99 | Director of Nursing (DON) | Provided information on transfer protocols and investigation |
| Staff #93 | Facility Administrator (ADM) | Discussed incident, communication, and expectations with staff |
Inspection Report
Deficiencies: 2
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
Routine
Deficiencies: 2
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
Routine
Deficiencies: 4
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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