Inspection Report Summary
The most recent inspection on December 3, 2024, identified deficiencies related to unsafe storage of toxic materials and inadequate staff training on fall prevention and recovery. Earlier inspections showed a pattern of similar issues, including repeated citations for toxic material storage, fall prevention training, abuse reporting, and caregiver documentation. Enforcement actions have resulted in several fines totaling at least $1,750, all of which have been paid in full, with no license suspensions or immediate jeopardy findings listed in the available reports. Complaint investigations were generally unsubstantiated, and no substantiated complaints were noted. The facility’s record shows ongoing challenges with training and safety protocols, with deficiencies persisting over time despite enforcement efforts.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Enforcement Action
Enforcement
Fines: 2
Total: $500.00
Date: Dec 3, 2024
Summary
The facility was found to have repeated deficiencies posing risks to resident health and safety, resulting in civil fines totaling $500.
Fines & Penalties (2)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Failure to ensure toxic materials were stored in a locked area inaccessible to residents. | — |
| $250.00 | Failure to develop and administer a staff training program on fall prevention and recovery. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Nov 19, 2024
Summary
The facility was fined $500.00 which has been paid in full, indicating resolution of the enforcement action.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Fine related to enforcement action #00110232 | Paid |
Inspection Report
Complaint Investigation
Capacity: 133
Deficiencies: 4
Date: Oct 31, 2024
Visit Reason
Four deficiencies found related to fall prevention training, service plan updates, toxic material storage, and tuberculosis screening.
Findings
Four deficiencies found related to fall prevention training, service plan updates, toxic material storage, and tuberculosis screening.
Deficiencies (4)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition — failure to implement fall prevention training
Written service plan requirements — failure to update service plan at least every six months
Poisonous or toxic materials storage — failure to store toxic materials in locked, labeled containers
R9-10-113. Tuberculosis Screening — failure to implement TB infection control activities and training
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Sep 26, 2024
Summary
The facility was found to have violated reporting requirements, posing a risk of residents' rights violations related to abuse, resulting in a civil fine.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to immediately report suspected abuse according to A.R.S. § 46-454. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $500.00
Date: Sep 17, 2024
Summary
A fine of $500 was imposed and has been paid in full as part of the enforcement action.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Fine associated with enforcement action #00110587 | Paid |
Inspection Report
Complaint Investigation
Capacity: 133
Deficiencies: 3
Date: Sep 3, 2024
Visit Reason
Three deficiencies found related to abuse reporting, service plan signatures, and caregiver notification after incidents.
Findings
Three deficiencies found related to abuse reporting, service plan signatures, and caregiver notification after incidents.
Deficiencies (3)
A.R.S. § 46-454 — failure to immediately report suspected abuse
Written service plan requirements — failure to ensure service plan signed and dated by resident or representative
Caregiver notification and documentation — failure to notify primary care provider and document actions after resident incidents
Inspection Report
Complaint Investigation
Capacity: 133
Deficiencies: 1
Date: Aug 15, 2024
Visit Reason
One deficiency found related to failure to implement fall prevention and fall recovery training.
Findings
One deficiency found related to failure to implement fall prevention and fall recovery training.
Deficiencies (1)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition — failure to implement fall prevention training
Inspection Report
Complaint Investigation
Capacity: 133
Deficiencies: 1
Date: Aug 13, 2024
Visit Reason
One deficiency found related to failure to document caregiver actions after resident incidents.
Findings
One deficiency found related to failure to document caregiver actions after resident incidents.
Deficiencies (1)
Caregiver notification and documentation — failure to document actions after resident incidents
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Apr 11, 2024
Summary
The enforcement resulted in a civil fine of $250 for the violation of not verifying and documenting caregiver qualifications prior to service provision.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | One caregiver's skills and knowledge were not verified and documented before providing physical health services to residents. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Apr 2, 2024
Summary
The enforcement resulted in a fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Fine associated with enforcement action #00111463 | Paid |
Inspection Report
Complaint Investigation
Capacity: 133
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
One deficiency found related to failure to verify and document caregiver skills before assignment.
Findings
One deficiency found related to failure to verify and document caregiver skills before assignment.
Deficiencies (1)
Caregiver skill verification — failure to verify and document caregiver skills before assignment
Inspection Report
Complaint Investigation
Capacity: 133
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
No deficiencies cited during this inspection.
Findings
No deficiencies cited during this inspection.
Inspection Report
Complaint Investigation
Capacity: 133
Deficiencies: 0
Date: Jul 18, 2023
Visit Reason
No deficiencies cited during this inspection.
Findings
No deficiencies cited during this inspection.
Enforcement Action
Enforcement
Fines: 1
Total: $750.00
Date: Apr 11, 2023
Summary
The enforcement outcome identified three repeat deficiencies from a prior inspection, resulting in a civil fine and an agreement to correct the violations.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $750.00 | Civil fines for three repeat deficiencies related to service plan omissions and facility cleanliness. | — |
Inspection Report
Complaint Investigation
Capacity: 133
Deficiencies: 8
Date: Mar 1, 2023
Visit Reason
Eight deficiencies found related to policies and procedures review, residency agreement documentation, service plan content and signatures, disaster plan review, premises cleaning, toxic material storage, and pet vaccination.
Findings
Eight deficiencies found related to policies and procedures review, residency agreement documentation, service plan content and signatures, disaster plan review, premises cleaning, toxic material storage, and pet vaccination.
Deficiencies (8)
Policies and procedures review — failure to review and update policies at least every three years
Residency agreement documentation — failure to document residency agreement before or at acceptance
Written service plan requirements — failure to include medication storage and control in service plan
Written service plan requirements — failure to ensure service plans signed and dated by resident or representative
Disaster plan review — failure to review disaster plan at least once every 12 months
Premises cleaning and disinfection — failure to clean and disinfect premises and equipment properly
Poisonous or toxic materials storage — failure to store toxic materials in locked, labeled containers
Pet vaccination — failure to ensure resident cat vaccinated against rabies
Enforcement Action
Enforcement
Total: $0.00
Date: Nodate Enforcement
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