Inspection Report
Annual Inspection
Capacity: 10
Deficiencies: 11
Oct 7, 2025
Visit Reason
State-compiled facility profile showing 2 inspections from 2023-12 to 2025-10 with deficiency history
Findings
Across two inspections, the facility showed no deficiencies in the initial inspection in December 2023, but the most recent annual compliance inspection in October 2025 identified 11 deficiencies related to staff training, documentation, tuberculosis screening, medication storage, disaster drills, and environmental safety.
Deficiencies (11)
| Description |
|---|
| A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition: Failed to ensure personnel records included initial and continued competency training in fall prevention and fall recovery for one of two employees sampled. |
| A.R.S. § 36-420.04.C. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to maintain a standardized emergency responder form for two residents sampled. |
| R9-10-113.A.2.a-f. Tuberculosis Screening: Failed to annually assess the health care institution's risk of exposure to infectious tuberculosis. |
| R9-10-803.C.1.a. Administration: Failed to establish, document, and implement policies and procedures verifying staff qualifications, skills, and knowledge. |
| R9-10-806.A.8.a-b. Personnel: Failed to ensure documentation of freedom from infectious tuberculosis for one of two caregivers sampled. |
| R9-10-808.A.3.b. Service Plans: Failed to ensure a resident's service plan included the level of service expected for one of two residents sampled. |
| R9-10-808.C.1.g. Service Plans: Failed to ensure caregiver documented services provided in the resident’s medical record for two residents sampled. |
| R9-10-814.B.1-2. Personal Care Services: Failed to obtain required written medical determination for a resident confined to a bed or chair due to inability to ambulate. |
| R9-10-817.F.1. Medication Services: Failed to ensure medication was stored in a separate locked area; medications and ointments were found unsecured. |
| R9-10-819.A.4. Emergency and Safety Standards: Failed to conduct and document disaster drills on each shift at least quarterly. |
| R9-10-820.A.6. Environmental Standards: Failed to maintain hot water temperatures between 95º F and 120º F in resident areas; water temperature exceeded 130º F. |
Report Facts
Inspections on page: 2
Total deficiencies: 11
Complaint inspections: 0
Total capacity: 10
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