Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 16
Oct 7, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-12 to 2025-10 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies were found related to fall prevention training, emergency responder documentation, opioid administration documentation, food storage temperatures, disaster plan reviews, evacuation drills, licensing of facility animals, and notification of management changes. Several inspections found no deficiencies.
Complaint Details
This page includes multiple complaint investigations with findings from complaints numbered 00136978, 00142339, 00145237, 00146553, 00146559, 00146919, 00136531, 00135791, 00133986, 00130644, 00116447, AZ00218853, AZ00221290, AZ00222502, AZ00213338, AZ00212801, AZ00194617, AZ00196704, AZ00187194, and AZ00188216.
Deficiencies (16)
| Description |
|---|
| A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition: Failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. |
| A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to provide a written document including all required information to emergency responders for four of five residents sampled. |
| A.R.S. § 36-420.04.C. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to maintain a standardized form for each resident with required information for five of five residents sampled. |
| R9-10-120.F.4.a-c. Opioid Prescribing and Treatment: Failed to document in the patient’s medical record an identification of the patient’s need for the opioid before administration for two of nine residents sampled. |
| R9-10-817.C.4.a. Food Services: Failed to ensure foods requiring refrigeration were maintained at 41° F or below; refrigerator temperatures observed at 49° F and 57° F. |
| A.R.S. § 36-420.04.D. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to maintain a copy of the document provided to emergency responders for two years after the emergency. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in condition no later than 14 calendar days: Failed to update service plan timely for one of eight sampled residents. |
| A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months: Failed to ensure disaster plan was reviewed within past 12 months. |
| A. A manager shall ensure that: 5. An evacuation drill for employees and residents is conducted at least once every six months: Failed to conduct evacuation drill at required frequency. |
| A. A manager shall ensure that: 9. Soiled linen and soiled clothing are stored separate from clean linen and in closed containers away from food storage, kitchen, and dining areas: Failed to store soiled linens in closed container away from food storage. |
| A. A manager shall ensure that: 14. If pets or animals are allowed, they are licensed consistent with local ordinances: Failed to ensure two dogs residing at facility were licensed. |
| A. A manager shall ensure that: 1. The premises and equipment are free from conditions that may cause physical injury: Failed to ensure resident's bed mattress did not pose injury risk due to raised sides. |
| A. A governing authority shall: 7. Notify the Department of change in manager with name and qualifications: Failed to notify Department in writing of manager change. |
| C. A manager shall ensure that policies and procedures are established to protect health and safety covering whereabouts of residents: Failed to establish and implement such policies and procedures. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that includes the level of service expected: Failed to include actual level of care in service plan for one of eight sampled residents. |
| C. A manager shall ensure that food is obtained, prepared, served, and stored properly: Failed to ensure frozen foods were stored at 0° F or below; freezer temperature observed at +5° F. |
Report Facts
Inspections on page: 10
Total deficiencies: 16
Complaint inspections: 8
Total capacity: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Thompson | Manager | Named as person responsible in deficiencies related to fall prevention training and emergency responder documentation |
| Chad Draper | Executive Director | Named as person responsible in deficiencies related to opioid documentation, food storage, emergency responder documentation, and facility management |
| Chad Draper | ED | Named as person responsible in food services and emergency responder documentation deficiencies |
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