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Deficiency Category | Inspection Date: 5/6/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 12/15/22 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 9/23/21 Complaint Reporting Period: 4/1/22 - 3/31/23 |
---|---|---|---|
Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
Quality of Life and Care Deficiencies | |||
Infection Control Deficiencies | |||
Resident Assessment and Care Planning Deficiencies | |||
Nursing and Physician Services Deficiencies | |||
Resident Rights Deficiencies | |||
Nutrition and Dietary Deficiencies | |||
Pharmacy Service Deficiencies | |||
Environmental Deficiencies | |||
Administration Deficiencies |
Date of last standard health inspection: | 5/6/24Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 10/22/24Read the full report (PDF) 4/11/24Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Arizona: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide routine and 24-hour emergency dental care for each resident. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide activities to meet all resident's needs. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Some |
No Infection Control Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/22/24 | 11/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 4/11/24 | 6/5/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | 8/1/24 | 8/20/24 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Some |
No Environmental Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Some |
Develop, implement, and/or maintain an effective training program for all new and existing staff members. | 5/6/24 | 7/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Date of last standard health inspection: | 12/15/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 1/10/24Read the full report (PDF) 4/28/23Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Arizona: | |
Average number of Health Deficiencies in the United States: |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 4/28/23 | 7/14/23 | 3 - Actual harm | Few |
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide safe and appropriate respiratory care for a resident when needed. | 1/10/24 | 1/11/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure services provided by the nursing facility meet professional standards of quality. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
No Nutrition and Dietary Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure medication error rates are not 5 percent or greater. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Some |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 9/23/21Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 12/15/22Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Arizona: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Some |
Assist a resident in gaining access to vision and hearing services. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
Provide routine and 24-hour emergency dental care for each resident. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Report COVID19 data to residents and families. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure services provided by the nursing facility meet professional standards of quality. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
No Resident Rights Deficiencies were found during this inspection period. |
No Nutrition and Dietary Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure medication error rates are not 5 percent or greater. | 9/23/21 | 11/1/21 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/22/24 | 11/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 4/11/24 | 6/5/24 | 2 - Minimal harm or potential for actual harm | Few |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | 8/1/24 | 8/20/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 4/28/23 | 7/14/23 | 3 - Actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 1/10/24 | 1/11/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 12/15/22 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Few |
This nursing home has not had any infection control inspections in the past 3 years. |