Inspection Report Summary
The most recent inspection on April 30, 2024, resulted in enforcement action with a $1,000 fine that has been paid in full. Earlier inspections showed repeated deficiencies including lack of a certified manager, expired employee training, incomplete service plans, and missing disaster preparedness drills, leading to multiple fines totaling several thousand dollars. Inspectors cited issues mainly related to staff qualifications, training documentation, resident care planning, and emergency preparedness. No complaint investigations were noted in the available reports. The facility’s inspection history shows ongoing challenges with regulatory compliance and enforcement actions have continued through the most recent inspection.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Capacity: 136
Deficiencies: 3
Date: Jan 13, 2025
Visit Reason
Deficiencies found related to emergency responder documentation, resident orientation, and accident/injury reporting during complaint and compliance inspection.
Complaint Details
Complaints AZ00221817 and AZ00221003
Findings
Deficiencies found related to emergency responder documentation, resident orientation, and accident/injury reporting during complaint and compliance inspection.
Deficiencies (3)
36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center failed to provide required documentation to emergency responders
Manager failed to ensure resident orientation to exits and evacuation routes
Manager failed to ensure caregiver notification and documentation for resident accidents, emergencies, or injuries requiring medical services
Inspection Report
Complaint Investigation
Capacity: 136
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
On-site investigation of complaints AZ00215842 and AZ00216216 with no deficiencies cited.
Complaint Details
Complaints AZ00215842 and AZ00216216
Findings
On-site investigation of complaints AZ00215842 and AZ00216216 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 136
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
On-site investigation of complaint AZ00215599 with no deficiencies cited.
Complaint Details
Complaint AZ00215599
Findings
On-site investigation of complaint AZ00215599 with no deficiencies cited.
Enforcement Action
Enforcement
Fines: 1
Total: $1,000.00
Date: Apr 30, 2024
Summary
The enforcement resulted in a $1,000 fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,000.00 | Fine imposed as part of enforcement action | Paid |
Enforcement Action
Enforcement
Fines: 1
Total: $1,000.00
Date: Apr 18, 2024
Summary
The facility was cited for not having a certified manager for a period of 10 days, resulting in a civil fine.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,000.00 | Facility did not have a certified manager from April 8 to April 18, 2024. | — |
Inspection Report
Complaint Investigation
Capacity: 136
Deficiencies: 0
Date: Mar 1, 2024
Visit Reason
On-site investigation of complaint AZ00196064 with no deficiencies cited.
Complaint Details
Complaint AZ00196064
Findings
On-site investigation of complaint AZ00196064 with no deficiencies cited.
Enforcement Action
Enforcement
Fines: 3
Total: $4,550.00
Date: Nov 6, 2023
Summary
The investigation found three violations posing risks to resident health and safety, including absence of a certified manager, expired caregiver first aid and CPR certifications, and lack of staff training on fall prevention and recovery. Civil money penalties totaling $4,550.00 were assessed.
Fines & Penalties (3)
| Amount | Reason | Status |
|---|---|---|
| $3,800.00 | Failure to designate a certified Manager for 38 days. | Unpaid |
| $500.00 | Three caregivers lacked current first aid and CPR training. | Unpaid |
| $250.00 | Failure to provide fall prevention and fall recovery training to staff. | Unpaid |
Enforcement Action
Enforcement
Fines: 11
Total: $4,500.00
Date: Sep 7, 2023
Summary
The enforcement resulted in civil fines totaling $4500.00 for repeated violations identified during the compliance inspection conducted on September 7, 2023, which were also noted in a prior inspection on October 21, 2022.
Fines & Penalties (11)
| Amount | Reason | Status |
|---|---|---|
| $1,500.00 | Three employees did not have current and valid fingerprint clearance cards and did not apply within 20 working days of employment. | Pending |
| $500.00 | Two employees' skills and knowledge were not verified and documented. | Pending |
| $500.00 | One employee's CPR training was expired and another's CPR training was invalid. | Pending |
| $250.00 | The service plan for one resident storing medication did not include storage and control details. | Pending |
| $250.00 | One personal care resident's service plan was not updated at least once every six months. | Pending |
| $250.00 | Two non-ambulatory residents did not have written determination from a medical practitioner every six months. | Pending |
| $250.00 | The disaster plan was not reviewed at least once every 12 months. | Pending |
| $250.00 | Employee disaster drills were not conducted on each shift at least once every three months. | Pending |
| $250.00 | Evacuation drills for employees and residents were not conducted at least once every six months. | Pending |
| $250.00 | One dog was not licensed as per local ordinances. | Pending |
| $250.00 | One employee did not have documentation of fall prevention and fall recovery training. | Pending |
Inspection Report
Complaint Investigation
Capacity: 136
Deficiencies: 14
Date: Sep 6, 2023
Visit Reason
Multiple deficiencies found during complaint and compliance inspection related to fall prevention training, governing authority compliance, policy implementation, personnel documentation, service plans, disaster and evacuation drills, and pet licensing.
Complaint Details
Complaints AZ00196625, AZ00196703, AZ00197494, AZ00198287, AZ00199445
Findings
Multiple deficiencies found during complaint and compliance inspection related to fall prevention training, governing authority compliance, policy implementation, personnel documentation, service plans, disaster and evacuation drills, and pet licensing.
Deficiencies (14)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Failed to administer staff training program on fall prevention and recovery
Governing authority failed to ensure compliance with fingerprint clearance card requirements
Manager failed to establish, document, and implement policies and procedures to protect resident health and safety
Manager failed to verify and document caregiver or assistant caregiver skills and knowledge before service provision
Manager failed to ensure caregivers provided current documentation of cardiopulmonary resuscitation and first aid training
Manager failed to ensure written service plans included medication storage and control details
Manager failed to review and update written service plans based on changes in resident condition
Manager failed to ensure residents unable to ambulate had primary care provider oversight
Manager failed to ensure availability of current drug reference guide for personnel
Manager failed to review disaster plan at least once every 12 months
Manager failed to conduct and document employee disaster drills on each shift at least quarterly
Manager failed to conduct evacuation drills for employees and residents at least semiannually
Manager failed to maintain poisonous or toxic materials in labeled containers in locked areas
Manager failed to ensure pets were licensed consistent with local ordinances
Enforcement Action
Enforcement
Fines: 1
Total: $4,550.00
Date: May 16, 2023
Summary
The enforcement resulted in a fine of $4,550.00 which has been fully paid as of 2024-04-22.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $4,550.00 | Fine related to enforcement action #00113339 | Paid |
Inspection Report
Complaint Investigation
Capacity: 136
Deficiencies: 3
Date: May 4, 2023
Visit Reason
Deficiencies cited related to fall prevention training, manager designation, and caregiver training documentation during complaint investigation.
Complaint Details
Complaints AZ00191679, AZ00191826, AZ00191924, AZ00192667, AZ00192673, AZ00193256
Findings
Deficiencies cited related to fall prevention training, manager designation, and caregiver training documentation during complaint investigation.
Deficiencies (3)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Failed to administer staff training program on fall prevention and recovery
Governing authority failed to designate a qualified manager with required certification
Manager failed to ensure caregivers provided current documentation of first aid training and cardiopulmonary resuscitation
Inspection Report
Capacity: 136
Deficiencies: 0
Date: Dec 22, 2022
Visit Reason
No deficiencies found during off-site amendment inspection to change of name.
Findings
No deficiencies found during off-site amendment inspection to change of name.
Enforcement Action
Enforcement
Total: $0.00
Date: Nodate Enforcement
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