Inspection Report
Enforcement
Capacity: 142
Deficiencies: 11
Sep 29, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2023-06 to 2025-09 with deficiency history and enforcement actions.
Findings
Across multiple complaint and compliance inspections, deficiencies were found related to medication administration, documentation of services, service plan updates, tuberculosis screening, residency agreements, and safety measures for resident egress. Some inspections found no deficiencies, while the most recent enforcement inspection cited a critical deficiency regarding resident egress safety.
Complaint Details
Multiple complaint investigations were conducted, including complaints numbered 00142456, 00142919, 00105267, 00132664, AZ00221666, AZ00221325, AZ00215072, AZ00215451, AZ00214571, AZ00209657, AZ00207567, AZ00198066, AZ00210398, and AZ00196856. Deficiencies were cited in several complaint investigations.
Deficiencies (11)
| Description |
|---|
| R9-10-815.F.2.a-c. Directed Care Services: Failed to ensure a means of exiting the facility that provided access to an outdoor area and controlled or alerted employees to a resident’s egress. |
| R9-10-817.B.3.b. Medication Services: Medication administered to residents was not in compliance with medication orders for two of three sampled residents. |
| C. A manager shall ensure that a caregiver documents the services provided in the resident's medical record; failed for two of three residents sampled. |
| A. A manager shall ensure that a caregiver provides documentation of completion of a caregiver training program approved by the Department or NCIA Board; failed for one of four caregivers reviewed. |
| A. A manager shall ensure that a resident has a written service plan updated no later than 14 calendar days after a significant change in condition; failed for one resident. |
| A. A manager shall ensure that a written service plan is updated at least once every six months for residents receiving personal care services; failed for one resident. |
| B. Medication administered to a resident was not in compliance with a medication order for one of six residents reviewed. |
| D. Manager failed to ensure documentation of incidents resulting in medical services including date/time, description, observers, actions taken, notifications, and prevention measures for one resident. |
| A. Manager failed to ensure employees provided documentation of freedom from infectious tuberculosis as specified in R9-10-113 for two of five caregivers. |
| A. Manager failed to ensure a written service plan was updated no later than 14 days after a significant change in condition for one resident. |
| D. Manager failed to ensure documented residency agreements included all required elements for two of four residents sampled. |
Report Facts
Inspections on page: 9
Total deficiencies: 11
Complaint inspections: 8
Total capacity: 142
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Korina Izaguirre | Manager | Named as person responsible in medication administration deficiency |
| E1 | Interviewed multiple times acknowledging deficiencies and findings | |
| E2 | Caregiver lacking tuberculosis documentation | |
| E3 | Caregiver lacking tuberculosis documentation and caregiver training documentation | |
| E4 | Acknowledged documentation failures | |
| O1 | Reported on residency agreements |
Loading inspection reports...
