Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations from 2023 through May 30, 2025, being unsubstantiated. The most recent report dated May 30, 2025, also had no deficiencies. Earlier inspections identified some issues related to fire safety equipment, exit door locking mechanisms, and resident safety concerning medication administration and property protection, but these were isolated and not severe. There were no fines, enforcement actions, or license suspensions listed in the available reports. The facility’s record shows improvement over time, with the latest inspection free of any cited deficiencies.
Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 6
May 30, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2023-09 to 2025-05 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility had a total of 6 deficiencies cited, including issues with fire safety equipment, exit door locking mechanisms, and resident safety related to medication administration and property protection. Several complaint investigations found no deficiencies.
Complaint Details
The Risk-Based complaint survey conducted May 29-30, 2025 investigated intake #s AZ00155680 and AZ00157412 with no deficiencies cited. Multiple other complaint investigations from 2023-2025 also found no deficiencies.
Deficiencies (6)
| Description |
|---|
| Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 |
| 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 |
| Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with |
| §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;§483.10(i)(3) Clean bed and bath linens that are in good condition;§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);§483.10(i)(5) Adequate and comfortable lighting levels in all areas;§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and§483.10(i)(7) For the maintenance of comfortable sound levels. |
| §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. |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident:R9-10-414.B.3. Ensures that a resident is provided nursing care institution services that:R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. |
Report Facts
Inspections on page: 8
Total deficiencies: 6
Complaint inspections: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN Staff #210 | Registered Nurse | Named in medication self-administration deficiency finding |
| Staff #357 | Director of Nursing (DON) | Named in medication self-administration deficiency finding |
| Staff #235 | Executive Director | Named in missing property deficiency finding |
| Staff #50 | Licensed Practical Nurse, Director of Case Management | Named in missing property deficiency finding |
| Staff #421 | Registered Nurse, MDS Coordinator | Named in missing property deficiency finding |
| Staff #740 | Staff Development Coordinator | Named in missing property deficiency finding |
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