Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 11
Apr 11, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2022-12 to 2025-04 with deficiency history and complaint investigations.
Findings
Across six inspections, multiple deficiencies were identified including failures in quality management reporting, staff training, resident service plan updates, medication storage and control, evacuation drills, and misappropriation of resident property. Several deficiencies were repeat citations from prior inspections.
Complaint Details
Multiple complaint investigations were conducted including complaints AZ00206779, AZ00200496, AZ00203793, AZ00203830, AZ00203828, AZ00203124, AZ00193976, AZ00195990, AZ00189698, and AZ00186517 with deficiencies cited in several inspections.
Deficiencies (11)
| Description |
|---|
| R9-10-804.2.a-b. Quality Management: A manager failed to ensure a documented report identifying concerns about the delivery of services and any changes or actions taken was submitted to the governing authority. |
| A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults: Failed to ensure current documentation of first aid training certification for one of six sampled caregivers. |
| B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation dated within 90 calendar days before acceptance and includes required medical information: Failed for two of 10 residents sampled. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that is reviewed and updated at least once every three months for directed care residents: Failed for one of five residents reviewed. |
| A. A manager shall ensure that: 5. An evacuation drill for employees and residents is conducted at least once every six months: Failed to ensure evacuation drills were conducted at least every six months. |
| B. A manager shall ensure that: 2.k. A resident is not subjected to misappropriation of personal and private property by facility staff: Failed for three of eleven residents sampled related to missing narcotics. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to ensure staff completed fall prevention and fall recovery training. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that includes how medication will be stored and controlled for residents self-administering medication: Failed for one of nine residents sampled. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan reviewed and updated at least once every six months for personal care residents and at least once every three months for directed care residents: Failed for multiple residents. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan signed and dated by required parties when initially developed and updated: Failed for five of nine residents sampled. |
| C. A manager shall ensure that the service plan for a resident receiving directed care services includes hydration, safety strategies, cognitive stimulation, encouragement to eat, and weight documentation: Failed for five of five directed care residents sampled. |
Report Facts
Inspections on page: 6
Total deficiencies: 13
Complaint inspections: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Miguel Soto | Executive Director | Named as person responsible in quality management deficiency |
| E1 | Acknowledged multiple deficiencies including missing documentation and investigations | |
| E2 | Wellness Director | Interviewed regarding medication storage and monitoring |
| E7 | Wellness Director | Mentioned in fall prevention training deficiency |
| E4 | Caregiver | Lacked current first aid training documentation |
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