Inspection Report Summary
The most recent inspection on October 31, 2025, found one deficiency related to a failure to notify the Department immediately of a change in manager during a complaint investigation. Earlier inspections showed a pattern of deficiencies primarily involving documentation issues, medication administration, resident service plans, and abuse reporting. Enforcement actions included several fines totaling over $8,500, with the most recent fines paid in full and no license suspensions or immediate jeopardy findings listed in the available reports. Complaint investigations were mostly unsubstantiated, with no notable substantiated cases reported. The facility’s record shows ongoing challenges with regulatory compliance, though recent inspections indicate fewer deficiencies compared to earlier reports.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 1
Date: Oct 31, 2025
Visit Reason
One deficiency found related to failure to notify the Department immediately of a change in manager during complaint investigation.
Findings
One deficiency found related to failure to notify the Department immediately of a change in manager during complaint investigation.
Deficiencies (1)
R9-10-803.A.7. — Administration notification failure
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 0
Date: Oct 6, 2025
Visit Reason
No deficiencies found during investigation of multiple complaints.
Findings
No deficiencies found during investigation of multiple complaints.
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Aug 16, 2025
Summary
The enforcement resulted in a fine of $250.00 which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Fine associated with enforcement action #00131737 | Paid |
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 0
Date: Aug 11, 2025
Visit Reason
No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Jul 9, 2025
Summary
The enforcement resulted in a civil fine of $250 for the documented violation of not recording services provided to a resident, confirming non-compliance with regulatory requirements.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Failure to document services provided to one resident, a repeat deficiency from a prior inspection. | — |
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 0
Date: May 12, 2025
Visit Reason
No deficiencies found during complaint investigation of multiple complaints.
Findings
No deficiencies found during complaint investigation of multiple complaints.
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
No deficiencies found during complaint investigation and documentation review.
Findings
No deficiencies found during complaint investigation and documentation review.
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 1
Date: Aug 5, 2024
Visit Reason
One deficiency cited for failure to immediately report suspected abuse according to A.R.S. § 46-454.
Findings
One deficiency cited for failure to immediately report suspected abuse according to A.R.S. § 46-454.
Deficiencies (1)
J. A.R.S. § 46-454 — Abuse reporting failure
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 1
Date: May 8, 2024
Visit Reason
One deficiency cited for failure to immediately report suspected abuse according to A.R.S. § 46-454.
Findings
One deficiency cited for failure to immediately report suspected abuse according to A.R.S. § 46-454.
Deficiencies (1)
J. A.R.S. § 46-454 — Abuse reporting failure
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
No deficiencies found during complaint investigation.
Findings
No deficiencies found during complaint investigation.
Enforcement Action
Enforcement
Fines: 5
Total: $3,000.00
Date: Dec 1, 2023
Summary
The enforcement resulted in a total civil fine of $3,000 for repeated violations of healthcare regulations, with the licensee agreeing to pay the fines and comply with corrective actions to avoid further enforcement.
Fines & Penalties (5)
| Amount | Reason | Status |
|---|---|---|
| $1,500.00 | One employee had no documentation of CPR training; one employee's CPR and first aid training was expired; one employee's CPR training was invalid as it was online-only without a return demonstration. | — |
| $250.00 | One resident's service plan was not updated after a change in condition. | — |
| $500.00 | One non-ambulatory resident did not have a written determination from a medical practitioner at least once every six months. | — |
| $500.00 | Two residents' medications were not administered in compliance with medication orders. | — |
| $250.00 | One resident had an incident resulting in the resident needing medical services; however, no documentation of the incident was in the resident's medical record. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $3,000.00
Date: Nov 21, 2023
Summary
A fine of $3,000.00 was imposed and has been fully paid as of the completion date.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $3,000.00 | Enforcement action fine | Paid |
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 1
Date: Oct 31, 2023
Visit Reason
Sixteen deficiencies found during compliance inspection and complaint investigation including failures in fall prevention training, governing authority compliance, tuberculosis screening, medication administration, resident service plans, and documentation.
Findings
Sixteen deficiencies found during compliance inspection and complaint investigation including failures in fall prevention training, governing authority compliance, tuberculosis screening, medication administration, resident service plans, and documentation.
Deficiencies (1)
36-420.01 — Fall prevention training; A.R.S. § 36-411 — Governing authority compliance; R9-10-113 — Tuberculosis screening; Medication administration rules; Resident service plan requirements; Documentation failures; Resident acceptance and retention criteria violations
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 1
Date: Jun 13, 2023
Visit Reason
Two deficiencies cited related to resident documentation and service plan updates.
Findings
Two deficiencies cited related to resident documentation and service plan updates.
Deficiencies (1)
Resident documentation and service plan update failures
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Feb 28, 2023
Summary
The enforcement resulted in a civil fine of $250.00 for the repeat deficiency related to medication administration non-compliance.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Civil fine for repeat deficiency of medication administration non-compliance. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Feb 7, 2023
Summary
A fine of $250.00 was imposed and has been paid in full, completing the enforcement action.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Fine associated with enforcement action #00113821 | Paid |
Enforcement Action
Enforcement
Fines: 1
Total: $1,750.00
Date: Jan 31, 2023
Summary
The enforcement action resulted in a fine of $1,750.00 which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,750.00 | Enforcement action fine | Paid |
Enforcement Action
Enforcement
Fines: 4
Total: $1,750.00
Date: Jan 19, 2023
Summary
The facility was found to have multiple repeat deficiencies from previous inspections, resulting in civil fines totaling $1750.00 for failure to comply with regulatory requirements.
Fines & Penalties (4)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Quality management reports were not completed according to the facility's policies and procedures. | — |
| $500.00 | One employee's CPR and first aid training was expired. | — |
| $500.00 | Two residents' residency agreements did not include the correct reasons for the manager to terminate residency. | — |
| $500.00 | Two bedbound residents did not have a written determination from a medical practitioner. | — |
Inspection Report
Annual Inspection
Capacity: 56
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
Six deficiencies found during compliance inspection including failures in documented reporting, CPR training documentation, residency agreement provisions, service documentation, resident acceptance criteria, and incident documentation.
Findings
Six deficiencies found during compliance inspection including failures in documented reporting, CPR training documentation, residency agreement provisions, service documentation, resident acceptance criteria, and incident documentation.
Deficiencies (1)
Documented reporting failures; CPR training documentation; Residency agreement provisions; Service documentation; Resident acceptance criteria; Incident documentation
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
Four deficiencies cited related to medication policies, verbal order verification, medication administration compliance, and medication documentation.
Findings
Four deficiencies cited related to medication policies, verbal order verification, medication administration compliance, and medication documentation.
Deficiencies (1)
Medication policies and procedures failures; Verbal order verification; Medication administration compliance; Medication documentation
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