Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% better than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 0
Date: May 30, 2025
Visit Reason
Risk-Based complaint survey conducted May 29-30, 2025 for intake #s AZ00155680 and AZ00157412. No deficiencies cited.
Findings
Risk-Based complaint survey conducted May 29-30, 2025 for intake #s AZ00155680 and AZ00157412. No deficiencies cited.
Inspection Report
Annual Inspection
Capacity: 96
Deficiencies: 2
Date: May 6, 2025
Visit Reason
Recertification survey for Medicare under LSC 2012 cited deficiencies related to portable fire extinguishers and gas equipment storage.
Findings
Recertification survey for Medicare under LSC 2012 cited deficiencies related to portable fire extinguishers and gas equipment storage.
Deficiencies (2)
Portable Fire Extinguishers — Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10
Gas Equipment - Cylinder and Container Storage — Storage locations are designed, constructed, and ventilated in accordance with regulations
Inspection Report
Routine
Deficiencies: 1
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
Deficiencies: 1
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
Complaint Investigation
Capacity: 96
Deficiencies: 0
Date: Mar 31, 2025
Visit Reason
Investigation of complaint intake #00123343 conducted with no deficiencies cited.
Findings
Investigation of complaint intake #00123343 conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
Investigation of complaint intakes #00121829 and AZ00220567 conducted with no deficiencies cited.
Findings
Investigation of complaint intakes #00121829 and AZ00220567 conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 0
Date: Dec 18, 2024
Visit Reason
Complaint survey conducted December 18, 2024 for complaint #AZ00220418 with no deficiencies cited.
Findings
Complaint survey conducted December 18, 2024 for complaint #AZ00220418 with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 29, 2023
Visit Reason
The inspection was conducted due to complaints regarding the loss of a resident's hearing aids and concerns about a resident self-administering medications not ordered by the physician.
Complaint Details
The complaint involved the loss of hearing aids for resident #219, who reported the hearing aids were lost upon admission. The facility staff denied the resident had hearing aids at admission. Additionally, resident #42 was found to be self-administering medications without physician orders or proper assessment, posing a risk of medication contraindications.
Findings
The facility failed to ensure reasonable care for the protection of a resident's medical assistive property (hearing aids) resulting in loss, and failed to ensure that a resident was free from the accident hazard of self-administering medications without physician orders. 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 a resident's medical assistive property (hearing aids) from loss or theft.
Failed to ensure that a resident was free from the accident hazard of self-administering medications not ordered by the physician.
Report Facts
BIMS score: 8
BIMS score: 10
Medication dose: 40
Medication count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #60 | Licensed Practical Nurse | Annotated resident #219 to use hearing aids on admission; documentation was incomplete. |
| Staff #421 | Registered Nurse, MDS Coordinator | Created and revised the care plan for resident #219 regarding hearing aid use. |
| Staff #210 | Registered Nurse | Interviewed regarding medication administration and self-administration assessment for resident #42. |
| 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 missing hearing aids and facility policy on personal property. |
| Staff #235 | Executive Director | Interviewed about facility policy on personal property, missing medical assistive devices, and staff expectations. |
| Staff #357 | Director of Nursing | Interviewed about missing hearing aids, staff education, medication policies, and self-administration assessment. |
Inspection Report
Capacity: 96
Deficiencies: 1
Date: Dec 29, 2023
Visit Reason
Recertification survey for Medicare under LSC 2012 found deficiency related to egress door locking mechanisms; facility meets standards based on plan of correction.
Findings
Recertification survey for Medicare under LSC 2012 found deficiency related to egress door locking mechanisms; facility meets standards based on plan of correction.
Deficiencies (1)
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
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 3
Date: Dec 29, 2023
Visit Reason
Recertification survey conducted with investigation of complaints #s AZ00189516 and AZ00186749 citing deficiencies related to safe environment, accident prevention, and care plan compliance.
Findings
Recertification survey conducted with investigation of complaints #s AZ00189516 and AZ00186749 citing deficiencies related to safe environment, accident prevention, and care plan compliance.
Deficiencies (3)
§483.10(i) Safe Environment — The resident has a right to a safe, clean, comfortable and homelike environment
§483.25(d) Accidents — The facility must ensure the resident environment remains as free of accident hazards as possible
R9-10-414.B — An administrator shall ensure that a care plan for a resident ensures nursing care institution compliance
Inspection Report
Complaint Investigation
Deficiencies: 2
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
Complaint Investigation
Capacity: 96
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
Complaint AZ00200845 investigated with no deficiencies cited.
Findings
Complaint AZ00200845 investigated with no deficiencies cited.
Inspection Report
Deficiencies: 0
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
Annual Inspection
Deficiencies: 0
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
Routine
Census: 59
Deficiencies: 3
Date: Jun 23, 2021
Visit Reason
The inspection was conducted to assess compliance with nursing staffing postings, accuracy and completeness of resident medical records, and infection prevention and control protocols.
Findings
The facility failed to ensure accurate daily nursing staffing postings, complete and accurate medical records for one resident including medication administration outside ordered parameters, and proper infection control practices related to mask wearing by staff. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failure to ensure the daily nursing staffing information posted was accurate and included actual hours worked by staff.
Failure to ensure one resident's medical record was accurate and complete, including medication administration outside ordered parameters without proper documentation or physician notification.
Failure to implement infection control protocol related to improper donning of face mask by one staff member.
Report Facts
Census: 52
Census: 48
Census: 59
Medication administration dates: 2
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; involved in medication administration review and infection control interviews |
| Staff #133 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration documentation |
| Staff #124 | Charge Nurse | Interviewed regarding medication administration and documentation procedures |
| Staff #106 | Wound Care Nurse / Director of Nursing | Observed improperly wearing face mask during wound care; interviewed about infection control |
| Staff #67 | Executive Director | Present during interview with Director of Nursing about medication administration |
Inspection Report
Routine
Census: 59
Deficiencies: 3
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
Census: 52
Census: 48
Census: 59
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 |
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