Inspection Report
Enforcement
Capacity: 138
Deficiencies: 30
Oct 17, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-08-09 to 2025-10-17 with deficiency history and enforcement actions.
Findings
Across multiple inspections, numerous deficiencies were found including failures in tuberculosis screening and training, abuse reporting and investigation, caregiver orientation and training, documentation of services, medication administration, emergency preparedness, and service plan completeness. Some inspections found no deficiencies.
Complaint Details
Multiple complaint investigations are included, with deficiencies cited in investigations conducted on various dates including complaints 00147958, 00147934, 00145069, AZ00211254, AZ00211976, AZ00212099, AZ00218398, AZ00210284, AZ00207514, AZ00207553, AZ00204896, AZ00205711, AZ00206000, AZ00206289, AZ00199195, AZ00199936, AZ00200975, AZ00202203, AZ00202243, AZ00203716, and others.
Deficiencies (30)
| Description |
|---|
| R9-10-113.A.1-2. Tuberculosis Screening: Failed to implement tuberculosis infection control activities including providing training and education related to recognizing the signs and symptoms of TB to employees. |
| R9-10-803.J.1-6. Administration: Failed to report suspected abuse and document investigation details as required by statute. |
| R9-10-806.A.9. Personnel: Failed to ensure caregiver received orientation specific to duties before providing services. |
| R9-10-808.C.1.g. Service Plans: Failed to ensure caregivers documented services provided in residents' medical records. |
| R9-10-811.C.18. Medical Records: Failed to ensure residents' medical records contained documentation of orientation to exits. |
| R9-10-814.F.1. Personal Care Services: Failed to ensure service plans included skin maintenance to prevent and treat injuries and infections. |
| R9-10-815.C.1. Directed Care Services: Failed to ensure service plans included skin maintenance to prevent and treat injuries and infections. |
| R9-10-819.A.4. Emergency and Safety Standards: Failed to conduct and document disaster drills on each shift quarterly. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to administer fall prevention and recovery training to staff. |
| 36-420.04. Emergency responders; patient information: Failed to provide emergency responders with all required resident information. |
| A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented before providing physical health services. |
| A. A manager shall ensure that: 8. Evidence of freedom from infectious tuberculosis is provided on or before the date services begin. |
| A. A manager shall ensure that: 10. Caregivers provide current documentation of first aid and CPR training before providing services. |
| A. A manager shall ensure that: Disaster plan is developed, documented, maintained, and implemented. |
| A. A manager shall ensure that: Documentation of evacuation drills includes required details. |
| D. When a resident has an accident or injury, caregiver immediately notifies emergency contact and primary care provider. |
| R9-10-113. Tuberculosis Screening: Failed to implement tuberculosis infection control activities for residents. |
| C. A manager shall ensure that policies and procedures cover methods to be aware of resident whereabouts. |
| J. If a manager has reasonable basis to believe abuse occurred, must document suspected abuse, actions taken, and report timely. |
| K. A manager shall provide written notification to the Department of a resident's death as required by statute. |
| A. A manager shall ensure that a resident has a written service plan updated timely after significant change. |
| A. A manager shall ensure that a resident has a written service plan completed no later than 14 days after acceptance. |
| A. A manager shall ensure that a resident's written service plan includes level of service expected. |
| A. A manager shall ensure that a resident's written service plan includes amount and frequency of services provided. |
| A. A manager shall ensure that a caregiver documents services provided in resident's medical record. |
| A. A manager shall ensure policies and procedures for medication services include procedures for assisting residents in procuring medication. |
| B. A manager shall ensure medication is administered in compliance with medication orders. |
| B. A manager shall ensure medication administration is documented in resident's medical record. |
| A. A manager shall ensure that a caregiver provides documentation of completion of approved caregiver training program. |
| A. A manager shall ensure personnel records include documentation of compliance with fingerprint clearance requirements. |
Report Facts
Inspections on page: 10
Total deficiencies: 39
Complaint inspections: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Named in multiple findings including acknowledgment of deficiencies and interviews | |
| E2 | Named in findings related to abuse reporting, medication administration, and resident monitoring | |
| E3 | Named in abuse and neglect findings and investigations | |
| E4 | Medical Technician/Caregiver | Named in tuberculosis training and orientation deficiencies |
| E5 | Caregiver/Medication Technician | Named in multiple deficiencies including training, medication administration, and documentation |
| E6 | Caregiver/Medication Technician | Named in caregiver training program deficiency |
| E7 | Named in tuberculosis documentation deficiency | |
| E8 | Named in tuberculosis documentation deficiency | |
| E9 | Medication Technician | Named in deficiencies related to training, fingerprint clearance, and documentation |
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