The most recent inspection on October 22, 2025, identified one deficiency related to environmental standards, which was addressed with floor repairs after the inspection. Earlier inspections showed a pattern of deficiencies involving medication storage, fire safety, infection control, resident service plans, documentation, and premises safety, with several enforcement actions resulting in fines totaling several thousand dollars. Inspectors frequently cited issues with resident care planning, infection control, and maintaining a safe environment, while complaint investigations were mostly unsubstantiated except for a few environmental and safety concerns. Enforcement actions included fines ranging from $250 to $1,750, all of which have been paid in full, and no license suspensions or immediate jeopardy findings were listed in the available reports. The facility’s record shows ongoing challenges with compliance, though the most recent inspection suggests some corrective actions have been made.
Deficiencies (last 3 years)
Deficiencies (over 3 years)11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The facility was found deficient in health and safety practices related to infection control, resident care planning, and cleanliness, resulting in civil fines totaling $1000.
Fines & Penalties (3)
Amount
Reason
Status
$250.00
Failure to ensure freedom from infectious tuberculosis posing potential illness risk to residents.
—
$500.00
Failure to ensure resident service plan was reviewed and updated, posing risk if residents' current needs were not identified.
—
$250.00
Failure to ensure premises were cleaned, posing a risk to health and safety of residents.
Nineteen deficiencies found involving compliance with multiple health and safety regulations including documentation, service plans, medical records, food safety, drills, and premises safety.
Findings
Nineteen deficiencies found involving compliance with multiple health and safety regulations including documentation, service plans, medical records, food safety, drills, and premises safety.
A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.
C. A manager shall ensure that policies and procedures are established, documented, and implemented to protect health and safety.
C. A manager shall ensure policies and procedures are reviewed at least once every three years and updated as needed.
A manager shall ensure documented reports are submitted to governing authority including identification of concerns.
A. A manager shall ensure caregivers provide evidence of freedom from infectious tuberculosis (TB).
A. Except as provided in R9-10-808(B)(2), a manager shall ensure residents provide evidence of freedom from infectious tuberculosis before or within seven days.
B. A manager shall ensure acceptance documentation is dated within 90 calendar days before acceptance.
D. A manager shall ensure documented residency agreements are in place before or at acceptance.
A. A manager shall ensure residents have written service plans reviewed and updated based on condition changes.
A. A manager shall ensure residents' written service plans are signed by resident, manager, and nurse reviewer.
C. A manager shall ensure residents' medical records contain medication orders from medical practitioners.
C. A manager shall ensure residents' medical records contain documentation of orientation to exits.
B. A manager shall ensure medication administration policies and procedures are reviewed and approved by medical practitioners.
C. A manager shall ensure food is protected from potential contamination.
C. A manager shall ensure facility equipment and food contact surfaces are clean.
A. A manager shall ensure disaster drills for employees are conducted on each shift at least quarterly and documented.
A. A manager shall ensure evacuation drills for employees and residents are conducted at least semiannually.
A. A manager shall ensure premises and equipment are cleaned and disinfected as applicable.
F. A manager shall ensure swimming pool gates are locked when not in use.
The enforcement resulted in an agreement to pay civil fines totaling $1750 for repeat deficiencies and hazards identified during inspections and complaint investigations.
Fines & Penalties (1)
Amount
Reason
Status
$1,750.00
Civil fines for five repeat deficiencies and hazards including fingerprint clearance, service plan errors, medical determinations, and facility hazards.
Nine deficiencies found including failures in fall prevention training, fingerprint clearance compliance, tuberculosis documentation, resident service plans, medical record notifications, and premises safety.
Findings
Nine deficiencies found including failures in fall prevention training, fingerprint clearance compliance, tuberculosis documentation, resident service plans, medical record notifications, and premises safety.
Deficiencies (9)
Description
36-420.01. — Health care institutions; fall prevention and fall recovery; training programs
A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.
A. A manager shall ensure that: 8. Medical documentation of freedom from infectious tuberculosis (TB).
A. A resident must have a written service plan including level of service expected.
A. A resident's written service plan must be reviewed and updated based on condition changes.
A. A resident's written service plan must be signed by resident, manager, and nurse reviewer.
C. A resident's medical record must contain documentation of vaccination availability notification.
B. A manager must ensure residents confined to bed or chair have PCP or other documentation.
A. A manager shall ensure premises are free from conditions causing physical injury.