Inspection Report
Complaint Investigation
Census: 46
Capacity: 60
Deficiencies: 23
Oct 17, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2024-01 to 2025-10 with deficiency history and complaint investigations
Findings
Across multiple complaint and compliance inspections, numerous deficiencies were found including failures in staff training, medication administration, emergency notification, service plan completeness, and reporting of abuse or incidents. Some inspections found no deficiencies.
Complaint Details
The page includes multiple complaint investigations with findings of deficiencies related to complaints numbered AZ00203018, AZ00204038, AZ00204874, AZ00204914, AZ00205172, AZ00209973, AZ00209989, AZ00214944, AZ00221476, 00133784, 00136286, and 00147832.
Deficiencies (23)
| Description |
|---|
| A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition. Failed to administer a training program for all staff regarding fall prevention and fall recovery. |
| R9-10-819.D.1. Emergency and Safety Standards. Failed to ensure immediate notification of resident's emergency contact and primary care provider after emergency requiring medical services. |
| R9-10-803.C.1.m. Administration. Failed to establish policies and procedures covering methods to be aware of resident whereabouts based on level of assisted living services. |
| R9-10-803.A.10. Administration. Failed to ensure resident health, safety, or welfare was not placed at risk of harm. |
| R9-10-803.J.1-6. Administration. Failed to report suspected abuse, neglect, or exploitation according to A.R.S. § 46-454. |
| 36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document. Failed to maintain documentation provided to emergency responders. |
| C. A manager shall ensure that: 1.g. Documents the services provided in the resident's medical record. Failed to ensure caregiver documented services provided in medical records. |
| R9-10-803.G.2.a-d. Administration. Failed to maintain separate records for resident personal funds accounts including receipts and expenditures. |
| R9-10-808.A.3.e.i.1-4. Service Plans. Failed to ensure resident's written service plan included psychosocial interactions, psychotropic medications, planned strategies, and goals for behavioral care. |
| R9-10-812.1-3. Behavioral Care. Failed to ensure behavioral health professional or medical practitioner completed and signed required written determination for behavioral care. |
| R9-10-816.B.3.b. Medication Services. Failed to ensure medication administered to residents was in compliance with medication orders. |
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411. Failed to ensure compliance with fingerprint clearance card requirements for employees. |
| C. A manager shall ensure that policies and procedures cover cardiopulmonary resuscitation training including demonstration of ability. Failed to implement adequate CPR training policies. |
| C. A manager shall ensure policies and procedures are reviewed at least once every three years and updated as needed. Failed to ensure policy manual was reviewed and updated timely. |
| A. A manager shall ensure personnel records include individual's starting date of employment. Failed to include starting date for one employee. |
| A. Except as provided in R9-10-808(B)(2), a manager shall ensure resident provides evidence of freedom from infectious tuberculosis. Failed to provide complete TB screening documentation for residents and employees. |
| B. If an assisted living facility provides medication administration, a manager shall ensure medication is administered in compliance with orders. Failed to comply with medication administration orders for multiple residents. |
| A. A manager shall ensure resident is provided diet meeting nutritional needs as specified in service plan. Failed to provide diet as specified for one resident. |
| D. When a resident has an accident, emergency, or injury requiring medical services, a manager shall ensure immediate notification of emergency contacts and primary care provider. Failed to ensure immediate notification. |
| D. When a resident has an accident, emergency, or injury requiring medical services, a manager shall ensure documentation of description of incident. Failed to document incident details adequately. |
| R9-10-120.F. Opioid Prescribing and Treatment. Failed to document identification of need and effect of opioid administration in medical records. |
| A. A manager shall ensure caregiver provides resident with assisted living services in service plan. Failed to provide services as specified in service plan. |
| A. A manager shall ensure disaster drills are conducted on each shift at least once every three months and documented. Failed to conduct and document timely disaster drills. |
Report Facts
Inspections on page: 9
Total deficiencies: 30
Complaint inspections: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Meredith Miller | Administrator | Named in fall prevention training and emergency notification deficiencies |
| Mary Mizer | Administrator | Named in multiple deficiencies including policy, abuse reporting, medication administration, and service plan issues |
| Dawn Van Cleave | Wellness Director | Named in deficiencies related to medication administration and reporting |
| Kathy Stogsdill | Business Services Director | Named in personal funds account deficiency |
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