15 Reports
Inspection Report — Nov 21, 2025
Complaint Investigation
Date: Nov 21, 2025
Visit Reason
On-site complaint investigation of complaints 00147112 and 2637121 at a Nursing Care Institution, conducted 21 November 2025.
Complaint Details
The investigation of the complaint # 00147112 was conducted on October 29, 2025. The investigation of the complaint # 2637121 was conducted on October 29, 2025. There were no deficiencies cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — May 30, 2025
Complaint Investigation
Date: May 30, 2025
Visit Reason
On-site complaint investigation of intake numbers AZ00155680 and AZ00157412 at a Nursing Care Institution, conducted 29-30 May 2025.
Complaint Details
The Risk-Based complaint survey was conducted on May 29, 2025 through May 30, 2025 for the investigation of intake #s: AZ00155680 and AZ00157412. There were no deficiencies cited.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — May 6, 2025
Annual Inspection
Date: May 6, 2025
Visit Reason
On-site annual compliance inspection of a Nursing Care Institution conducted 6 May 2025.
Findings
Two deficiencies were cited related to portable fire extinguishers and gas equipment storage. No evidence details were provided for either deficiency.
Deficiencies (2)
Portable fire extinguishers — No evidence was provided regarding the selection, installation, inspection, or maintenance of portable fire extinguishers as required by NFPA 10.
Gas equipment storage — No evidence was provided regarding the design, construction, or ventilation of storage locations for gas cylinders greater than or equal to 3,000 cubic feet.
Report Facts
Deficiencies cited: 2
Inspection Report — May 2, 2025
Routine
Date: May 2, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medication self-administration policies and practices, specifically regarding medications left at the bedside and resident assessment for self-administration.
Findings
The facility failed to ensure medications were not left at the resident's bedside without proper assessment and orders for self-administration, as evidenced by medications found at the bedside without appropriate self-medication evaluations or orders. The facility's staff and policies were reviewed, and corrective actions were initiated to address these deficiencies.
Deficiencies (1)
Allow residents to self-administer drugs if determined clinically appropriate; failed to ensure medications were not left in the room and resident was assessed for self-administration of medication for one resident (#148).
Report Facts
Self-Medication Evaluation: 1
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)/Staff #62 | Interviewed regarding medications found at resident's bedside. | |
| Director of Nursing (DON)/Staff #186 | Interviewed about self-administration policies and procedures. | |
| Licensed Practical Nurse (LPN)/Staff #85 | Interviewed about medication administration practices and safety. |
Inspection Report — May 2, 2025
Date: May 2, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medication administration policies, specifically regarding residents' self-administration of medications and ensuring medications are not left unattended in resident rooms.
Findings
The facility failed to ensure medications were not left in the resident's room without proper assessment and orders for self-administration. One resident (#148) was found with medications left at bedside without a completed self-medication evaluation for all medications. The facility's staff and policies regarding medication self-administration and safety were reviewed, revealing gaps in following procedures.
Deficiencies (1)
Allow residents to self-administer drugs if determined clinically appropriate; failed to ensure medications were not left in the room and resident was assessed for self-administration.
Report Facts
Resident ID: 148
BIMS score: 10
Date of physician order: Apr 24, 2025
Date of observation: Apr 29, 2025
Date of self-medication evaluation: Apr 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)/Staff #62 | Staff who did not realize medications were left in resident's room | |
| Director of Nursing (DON)/Staff #186 | Provided information on self-administration policies and procedures | |
| LPN/Staff #85 | Described medication administration procedures and safety concerns |
Inspection Report — Mar 31, 2025
Complaint Investigation
Date: Mar 31, 2025
Visit Reason
On-site complaint investigation of complaints 00123343 and AZ00223879 at a Nursing Care Institution, conducted 31 March 2025.
Complaint Details
Investigation of complaint intakes #00123343 and #AZ00223879 was conducted on March 31, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Mar 18, 2025
Complaint Investigation
Date: Mar 18, 2025
Visit Reason
On-site complaint investigation of complaints 00121829, AZ00220567, AZ00223726, and AZ00220558 at a Nursing Care Institution, conducted 18 March 2025.
Complaint Details
Investigation of complaint intakes #00121829, AZ00220567, AZ00223726, and AZ00220558 was conducted on March 18, 2025. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Dec 18, 2024
Complaint Investigation
Date: Dec 18, 2024
Visit Reason
On-site complaint investigation of complaints AZ00220418 and AZ00220417 at a Nursing Care Institution, conducted 18 December 2024.
Complaint Details
The complaint survey was conducted on December 18, 2024 of the following complaint #AZ00220418. The complaint survey was conducted on December 18, 2024 of the following complaint #AZ00220417. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Report Facts
Complaints investigated: 2
Inspection Report — Dec 29, 2023
Annual Inspection
Date: Dec 29, 2023
Visit Reason
Recertification survey conducted December 26 through December 29, 2023, combined with complaint investigations of complaints AZ00189516, AZ00186749, AZ00189515, and AZ00186748 at a Nursing Care Institution.
Complaint Details
The recertification survey was conducted in conjunction with investigations of complaints AZ00189516, AZ00186749, AZ00189515, and AZ00186748.
Findings
The inspection found three deficiencies related to the facility's failure to protect a resident's medical assistive property from loss or theft, failure to prevent a resident from self-administering medications not ordered by a physician, and failure to ensure care plans assist residents in maintaining their highest practicable well-being.
Deficiencies (3)
§483.10(i) — The facility failed to ensure reasonable care for the protection of a resident's medical assistive property from loss or theft, resulting in missing hearing aids for Resident #219.
§483.25(d) — The facility failed to ensure one resident was free from the accident hazard of self-administering medications not ordered by the physician, risking potential medication contraindications.
R9-10-414 — The facility failed to ensure the care plan assisted a resident in maintaining their highest practicable well-being, related to the management of medications and self-administration safety.
Report Facts
Deficiencies cited: 3
Complaints investigated: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #60 | Licensed Practical Nurse | Annotated resident to use hearing aids on admission. |
| Staff #421 | Registered Nurse, MDS Coordinator | Created and revised resident care plan regarding hearing aids. |
| Staff #210 | Registered Nurse | Observed passing medication and interviewed regarding self-administration assessment. |
| Staff #740 | Staff Development Coordinator | Interviewed about facility policy on missing property. |
| Staff #50 | Licensed Practical Nurse, Director of Case Management | Interviewed about missing hearing aids and facility policy. |
| Staff #235 | Executive Director | Interviewed about facility policy on personal property and missing medical assistive devices. |
| Staff #357 | Director of Nursing | Interviewed about medication safety, self-administration assessment, and resident care plans. |
Inspection Report — Dec 29, 2023
Date: Dec 29, 2023
Visit Reason
On-site inspection of a Nursing Care Institution conducted 25-29 December 2023 classified as Other.
Findings
The inspection found one deficiency related to the failure to maintain special locking exit doors, resulting in excessive force required to release delayed egress doors on multiple floors.
Deficiencies (1)
Egress Doors — The facility failed to maintain several special locking exit doors, requiring excessive force (25 to 46 lbf) to release delayed egress doors, which could cause harm in an emergency.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 29, 2023
Complaint Investigation
Date: Dec 29, 2023
Visit Reason
The inspection was conducted following complaints regarding the loss of a resident's hearing aids and concerns about medication self-administration by another resident.
Complaint Details
The complaint investigation involved resident #219's lost hearing aids, which were reported missing shortly after admission, and resident #42's self-administration of medications without physician orders. The investigation included interviews with staff, family, and review of policies and records. The hearing aids were not found, and the facility's documentation was incomplete. Resident #42 was found to have medications in her room without proper orders or assessments for self-administration.
Findings
The facility failed to ensure reasonable care for the protection of a resident's medical assistive property (hearing aids) and failed to prevent a resident from self-administering medications not ordered by the physician. Both deficiencies posed minimal harm or potential for actual harm to a few residents.
Deficiencies (2)
Failed to ensure reasonable care for the protection of resident #219's medical assistive property (hearing aids) from loss or theft.
Failed to ensure resident #42 was free from the accident hazard of self-administering medications not ordered by the physician.
Report Facts
BIMS score: 8
BIMS score: 10
Medication dosage: 40
Medication dosage: 500
Medication dosage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #60 | Licensed Practical Nurse | Annotated resident #219 to use hearing aids on admission; was educated by DON for incomplete charting |
| Staff #421 | Registered Nurse, MDS Coordinator | Created and revised resident #219's Care Plan regarding hearing aids |
| Staff #210 | Registered Nurse | Interviewed regarding resident #219's hearing aids and resident #42's medication self-administration |
| Staff #740 | Staff Development Coordinator | Interviewed regarding facility policy on missing property and grievance process |
| Staff #50 | Licensed Practical Nurse, Director of Case Management | Interviewed about resident #219's missing hearing aids and facility property policies |
| Staff #235 | Executive Director | Interviewed about facility policies on personal property and medical assistive devices |
| Staff #357 | Director of Nursing | Presented staff interviews and documentation; educated staff; interviewed about medication self-administration and resident #42 |
Inspection Report — Sep 22, 2023
Complaint Investigation
Date: Sep 22, 2023
Visit Reason
On-site complaint investigation of complaints AZ00200845 and AZ00200843 at a Nursing Care Institution, conducted 22 September 2023.
Complaint Details
The Complaint AZ00200845 was investigated on 9/22/23. The Complaint AZ00200843 was investigated on 9/22/23. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Oct 6, 2022
Date: Oct 6, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for The Center at Val Vista, LLC, related to a regulatory survey completed on 10/06/2022.
Findings
No health deficiencies were found during the survey.
Inspection Report — Oct 6, 2022
Annual Inspection
Date: Oct 6, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at The Center at Val Vista, LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Jun 23, 2021
Routine
Date: Jun 23, 2021
Visit Reason
The inspection was conducted to evaluate compliance with nursing staffing postings, medical record accuracy, and infection prevention and control protocols at the facility.
Findings
The facility failed to ensure accurate daily nursing staffing postings, complete and accurate medical records for one resident regarding medication administration, and proper infection control practices related to mask usage by staff. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to ensure the daily nursing staffing information posted was accurate, specifically missing actual hours worked by staff responsible for resident care.
Failed to ensure one resident's medical record was accurate and complete, including medication administration outside ordered parameters without proper documentation or physician notification.
Failed to ensure infection control protocol was implemented related to improper donning of the face mask for one staff member.
Report Facts
Medication Dosage: 100
Medication Dosage: 25
Blood Pressure: 117
Blood Pressure: 75
Blood Pressure: 125
Blood Pressure: 67
Blood Pressure: 132
Blood Pressure: 65
Blood Pressure: 134
Blood Pressure: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #2 | Scheduler | Responsible for ensuring the Daily Staff Posting is correct, completed, and posted |
| Staff #51 | Director of Nursing (DON) | Responsible for sending posting information and reviewing the Daily Staff Posting |
| Staff #133 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration documentation |
| Staff #124 | Charge Nurse | Interviewed regarding medication administration and documentation |
| Staff #106 | Wound Care Nurse | Observed improperly wearing face mask during wound care treatment |
| Staff #67 | Executive Director | Present during interview with Director of Nursing about medication administration |
4 CMS Surveys
CMS Survey — May 2, 2025
May 2, 2025
CMS Survey — Jun 23, 2021
Jun 23, 2021
CMS Survey — Oct 6, 2022
Oct 6, 2022
CMS Survey — Dec 29, 2023
Dec 29, 2023
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