Inspection Reports for
A Golden Retreat Care Home
18330 W Macaroni Ave, Surprise, AZ 85388, AZ, 85388
Back to Facility Profile6 Reports
Inspection Report — Jun 16, 2025
Enforcement
Date: Jun 16, 2025
Visit Reason
Civil monetary penalty, action 00128388 (invoice INV-276390), assessed 16 June 2025.
Findings
A $1,000.00 penalty was assessed and paid in full on 16 June 2025.
Report Facts
Penalty amount: 1000
Amount paid: 1000
Amount remaining: 0
Inspection Report — Apr 21, 2025
Annual Inspection
Date: Apr 21, 2025
Visit Reason
On-site compliance (annual) inspection of Assisted Living Home AL10702H conducted on April 21, 2025.
Findings
The inspection found eight deficiencies related to caregiver training, service plan updates, documentation of services and medication administration, retention of a resident with a stage 4 pressure sore without proper determination, bathroom supplies, and emergency responder documentation.
Deficiencies (8)
R9-10-806 — The manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing wound care services, posing a health and safety risk to a resident with an open sacral wound.
R9-10-808 — The manager failed to ensure a resident's service plan was reviewed and updated after a significant change in condition, specifically the development of a stage 4 pressure ulcer, risking inadequate care planning.
R9-10-808 — The manager failed to ensure a caregiver documented the wound care services provided in the resident's medical record, preventing verification that services followed the physician's orders.
R9-10-811 — The manager failed to ensure a resident's medical record included the dosage of medication administered, risking incorrect medication administration.
R9-10-815 — The manager failed to ensure the facility did not retain a resident with a stage 4 pressure sore without a signed and dated determination from a registered nurse or medical practitioner that the resident's needs could be met.
R9-10-816 — The manager failed to ensure medications were administered in compliance with orders, including insulin and hydralazine, posing a health and safety risk to the resident.
R9-10-820 — The manager failed to ensure a resident bathroom contained paper towels in a dispenser or a mechanical air hand dryer, posing a health risk due to lack of proper hand drying supplies.
A.R.S. § 36-420.04.C — The facility failed to maintain a standardized emergency responder form for each resident, risking lack of required patient information during emergencies.
Report Facts
Deficiencies cited: 8
Inspection Report — Aug 29, 2023
Enforcement
Date: Aug 29, 2023
Visit Reason
Civil monetary penalty, action 00112610 (invoice INV-259071), assessed 29 August 2023.
Findings
A $500.00 penalty was assessed and paid in full on 15 October 2023.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Aug 4, 2023
Annual Inspection
Date: Aug 4, 2023
Visit Reason
On-site compliance (annual) inspection of an Assisted Living Home conducted on August 4, 2023.
Findings
Two deficiencies were found related to medication administration and documentation of opioid use. Both deficiencies posed risks to resident health and safety.
Deficiencies (2)
The manager failed to ensure a medication was administered in compliance with a medication order for one resident, despite the resident's heart rate being below the specified threshold on multiple days. This deficiency was a repeat from prior compliance inspections.
R9-10-120 — The manager failed to ensure that documentation in the resident's medical record included identification of the resident's need for an opioid and the effect of the opioid administered for one resident. This posed a risk to the resident's physical health and safety.
Report Facts
Deficiencies cited: 2
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