Inspection Report
Complaint Investigation
Capacity: 16
Deficiencies: 16
Aug 20, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-09 to 2025-08 with deficiency history and enforcement actions.
Findings
Across all inspections, multiple deficiencies were found including failures in personnel management, documentation, service plan updates, infection control, and emergency preparedness. Several repeat deficiencies and enforcement actions were noted, indicating ongoing compliance challenges.
Complaint Details
The inspections included complaint investigations for multiple complaints including 00141183, 00104451, 00136706, 00104908, 00104450, AZ00215292, AZ00189555, AZ00190550, AZ00191111, AZ00191749, AZ00191750, and AZ00191751.
Deficiencies (16)
| Description |
|---|
| R9-10-803.A.9. Administration: Failed to make documented good faith effort to contact previous employers relevant to employee fitness to work. |
| R9-10-803.A.3.b.i-ii. Administration: Failed to designate in writing a qualified manager with required certificate; gaps in management coverage noted. |
| R9-10-803.A.7. Administration: Failed to notify Department of manager change and identify new manager's qualifications. |
| R9-10-806.A.8.a-b. Personnel: Failed to ensure employee provided documentation of freedom from infectious tuberculosis on or before service start date. |
| R9-10-806.C.1.a-c. Personnel: Failed to ensure personnel record was available for one employee reviewed. |
| R9-10-808.A.4.b.iii. Service Plans: Failed to review and update written service plans at least every three months for residents receiving directed care services. |
| R9-10-811.C.17. Medical Records: Failed to document notification of availability of influenza and pneumonia vaccinations for residents. |
| R9-10-819.A.3.a-d. Emergency and Safety Standards: Failed to include time, critique, and recommendations in disaster plan review documentation. |
| R9-10-803.A.3.a. Administration: Failed to designate in writing a manager who is 21 years or older. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to develop and administer fall prevention and recovery training for all staff. |
| A governing authority shall: Ensure compliance with A.R.S. § 36-411: Failed to ensure compliance for one caregiver with fingerprint clearance card requirements. |
| B. A manager shall ensure documentation dated within 90 days before acceptance includes medical service needs and is signed by authorized medical personnel: Failed for one resident admitted in 2023. |
| C. A manager shall ensure caregiver documents services provided in resident's medical record: Failed for five residents with service plans. |
| D. A manager shall ensure immediate notification of emergency contacts and primary care provider when resident has accident/emergency/injury: Failed for one resident. |
| D. A manager shall ensure documentation of accident/emergency/injury details: Failed for one resident. |
| A. A manager shall ensure premises and equipment are cleaned and disinfected to prevent infection: Failed to maintain cleanliness in resident rooms and bathrooms. |
Report Facts
Inspections on page: 4
Total deficiencies: 24
Complaint Inspections: 4
Total capacity: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dana Pulec | Manager | Named as person responsible in multiple deficiency findings related to personnel management, service plans, and compliance. |
| E1 | Interviewed and referenced in findings related to personnel records, management, and compliance. | |
| E2 | Interviewed and referenced in multiple findings and exit interviews. | |
| E3 | Referenced in findings related to caregiver compliance and fingerprint clearance. | |
| E4 | Referenced in findings related to personnel records and training. | |
| E5 | Referenced in findings related to tuberculosis documentation. |
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