25 Reports
Inspection Report — Mar 17, 2026
Complaint Investigation
Date: Mar 17, 2026
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On-site complaint investigation at an Assisted Living Center, conducted 17 March 2026.
Complaint Details
On March 17, 2026, an off-site review of the plan of correction (POC) was conducted. Although some of the POC requirements were not met, the POC was accepted for all citations due to the compliance inspection conducted November 13, 2025.
Findings
One deficiency was found related to the resident service plan review requirements. No evidence text was provided for the deficiency.
Deficiencies (1)
The facility failed to provide evidence that resident service plans were reviewed and updated at least once every three months for residents receiving directed care services.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 22, 2026
Enforcement
Date: Jan 22, 2026
Visit Reason
Civil monetary penalty, action 00151490 (invoice INV-314840), assessed 22 January 2026.
Findings
A $2,750.00 penalty was assessed and paid in full on 26 December 2025.
Report Facts
Penalty amount: 2750
Amount paid: 2750
Amount remaining: 0
Inspection Report — Nov 14, 2025
Annual Inspection
Date: Nov 14, 2025
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints 00149683, 00148357, 00104594, 00103216, 00101892, and 00100852 at an Assisted Living Center, conducted November 13-14, 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00149683, 00148357, 00104594, 00103216, 00101892, and 00100852 conducted on November 13, 2025, and November 14, 2025.
Findings
This inspection found twelve deficiencies related to emergency documentation, tuberculosis screening, staff orientation, service plan completeness, medication administration, resident dignity, medication storage, and environmental safety. All deficiencies had plans of correction provided.
Deficiencies (12)
A.R.S. § 36-420.04.D — The manager failed to ensure the facility maintained copies of documents provided to emergency responders and documentation of required actions for a period of two years for multiple residents. Missing EMS packets posed a risk of emergency responders lacking critical health information.
R9-10-806 — The manager failed to ensure four of seven employees provided documentation of freedom from infectious tuberculosis as required. This posed a potential TB exposure risk to residents.
R9-10-806 — The manager failed to ensure five of seven employees received orientation specific to their duties before providing assisted living services. This posed a risk if employees were unable to meet residents' needs.
R9-10-808 — The manager failed to ensure two residents' written service plans included documentation of their medical or health problems, including physical, behavioral, cognitive, or functional impairments. This posed a risk if health problems were not addressed.
R9-10-808 — The manager failed to ensure one resident's service plan included the amount, type, and frequency of assisted living services provided, including medication assistance. This posed a risk as service plans did not clarify services to be provided.
R9-10-808 — The manager failed to ensure a caregiver documented services provided according to the resident’s service plan for one resident. This posed a risk as services could not be verified and false information was provided to the Department.
R9-10-810 — The manager failed to ensure a resident was treated with dignity, respect, and consideration. Observations and records showed caregivers scolding and neglecting proper care, leading to a resident fall and subsequent termination of involved staff.
R9-10-817 — The manager failed to ensure medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. This was confirmed by lack of signatures on medication policies.
R9-10-817 — The manager failed to ensure medication was administered in compliance with medication orders for one resident. Blood pressure parameters were not consistently followed, risking resident condition changes.
R9-10-817 — The manager failed to ensure medication administration was accurately documented in the resident's medical record for one resident. Blood sugar readings were taken but not documented as required.
R9-10-817 — The manager failed to ensure medication was stored in a separate locked area used only for medication storage. Medications were found unsecured in resident bathrooms and on nightstands, risking resident access.
R9-10-820 — The manager failed to ensure poisonous or toxic materials were stored in locked areas inaccessible to residents. Cabinets and carts containing chemicals were found unlocked and accessible, posing safety risks.
Report Facts
Deficiencies cited: 12
Complaints investigated: 6
Inspection Report — Sep 17, 2025
Date: Sep 17, 2025
Visit Reason
Off-site desktop review conducted on 17 September 2025 to modify the licensed capacity from 89 directed care to 30 directed care and 44 personal care at an Assisted Living Center.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Jul 24, 2025
Complaint Investigation
Date: Jul 24, 2025
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On-site complaint investigation at an Assisted Living Center conducted 24 July 2025.
Findings
The inspection found 42 deficiencies. No evidence text was provided for the deficiencies listed.
Deficiencies (42)
No evidence text provided for deficiency #1 regarding emergency responder documentation requirements.
No evidence text provided for deficiency #2 regarding emergency responder documentation requirements.
The facility failed to designate in writing a manager with the required assisted living facility manager certificate or temporary certificate.
The facility failed to designate in writing a manager with the required assisted living facility manager certificate or temporary certificate.
The facility failed to verify and document caregiver or assistant caregiver skills and knowledge before providing physical or behavioral health services.
The facility failed to verify and document caregiver or assistant caregiver skills and knowledge before providing physical or behavioral health services.
R9-10-113 — The facility failed to ensure that staff provide evidence of freedom from infectious tuberculosis before beginning services.
R9-10-113 — The facility failed to ensure that staff provide evidence of freedom from infectious tuberculosis before beginning services.
The facility failed to ensure that a resident has a written service plan including a description of medical or health problems.
The facility failed to ensure that a resident has a written service plan including a description of medical or health problems.
The facility failed to ensure that a resident has a written service plan including the level of service expected.
The facility failed to ensure that a resident has a written service plan including the level of service expected.
The facility failed to ensure that a resident has a written service plan including the amount, type, and frequency of assisted living services provided.
The facility failed to ensure that a resident has a written service plan including the amount, type, and frequency of assisted living services provided.
The facility failed to ensure that the resident's service plan is signed and dated by the manager when initially developed and updated.
The facility failed to ensure that the resident's service plan is signed and dated by the manager when initially developed and updated.
The facility failed to ensure caregivers provide assisted living services according to the resident's service plan and document services provided.
The facility failed to ensure caregivers provide assisted living services according to the resident's service plan and document services provided.
The facility failed to ensure that residents are treated with dignity, respect, and consideration.
The facility failed to ensure that residents are treated with dignity, respect, and consideration.
R9-10-808 — The facility failed to ensure that the service plan for residents receiving personal care includes skin maintenance, hydration, incontinence care, and applicable determinations.
R9-10-808 — The facility failed to ensure that the service plan for residents receiving personal care includes skin maintenance, hydration, incontinence care, and applicable determinations.
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes required elements per R9-10-814(F)(1) through (3).
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes required elements per R9-10-814(F)(1) through (3).
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes applicable determinations per R9-10-814(B)(2)(b)(iii).
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes applicable determinations per R9-10-814(B)(2)(b)(iii).
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes cognitive stimulation and activities to maximize functioning.
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes cognitive stimulation and activities to maximize functioning.
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes documentation of resident weight or medical contraindications to weighing.
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes documentation of resident weight or medical contraindications to weighing.
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes coordination of communications with the resident's representative, family, and others.
R9-10-808 — The facility failed to ensure that the service plan for residents receiving directed care includes coordination of communications with the resident's representative, family, and others.
R9-10-808 — The facility failed to ensure that residents who lack keys or special knowledge have a means of exiting the facility that allows at least 30 feet distance and alerts employees.
R9-10-808 — The facility failed to ensure that residents who lack keys or special knowledge have a means of exiting the facility that allows at least 30 feet distance and alerts employees.
B. The facility failed to ensure that medication administration is documented in the resident's medical record.
B. The facility failed to ensure that medication administration is documented in the resident's medical record.
D. The facility failed to ensure that caregivers immediately notify the resident's emergency contact and primary care provider after an accident, emergency, or injury requiring medical services.
D. The facility failed to ensure that caregivers immediately notify the resident's emergency contact and primary care provider after an accident, emergency, or injury requiring medical services.
D. The facility failed to ensure that caregivers document the date, time, description, witnesses, actions taken, notifications, and prevention measures for accidents, emergencies, or injuries requiring medical services.
D. The facility failed to ensure that caregivers document the date, time, description, witnesses, actions taken, notifications, and prevention measures for accidents, emergencies, or injuries requiring medical services.
R9-10-113 — The facility failed to annually provide training and education on recognizing tuberculosis signs and symptoms to employees and volunteers.
R9-10-113 — The facility failed to annually provide training and education on recognizing tuberculosis signs and symptoms to employees and volunteers.
Report Facts
Deficiencies cited: 42
Inspection Report — Jul 22, 2025
Complaint Investigation
Date: Jul 22, 2025
Visit Reason
On-site complaint investigation of complaints 00124377 and 00124427 at an Assisted Living Center, conducted 22 July 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00124377 and 00124427 conducted on July 22, 2025.
Findings
No deficiencies were found during this inspection.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 1, 2025
Enforcement
Date: Apr 1, 2025
Visit Reason
Civil monetary penalty, action 00125478 (invoice INV-289564), assessed 1 April 2025.
Findings
An $8,800.00 penalty was assessed and paid in full on 4 September 2025.
Report Facts
Penalty amount: 8800
Amount paid: 8800
Amount remaining: 0
Inspection Report — Feb 18, 2025
Enforcement
Date: Feb 18, 2025
Visit Reason
Civil monetary penalty, action 00121439 (invoice INV-272305), assessed 18 February 2025.
Findings
A $7,850.00 penalty was assessed and paid in full on 23 May 2025.
Report Facts
Penalty amount: 7850
Amount paid: 7850
Amount remaining: 0
Inspection Report — Jan 3, 2025
Complaint Investigation
Date: Jan 3, 2025
Visit Reason
On-site complaint investigation of complaints AZ00220663, AZ00218096, and AZ00217451 at an Assisted Living Center, conducted 2-3 January 2025.
Complaint Details
An on-site investigation of complaints AZ00220663, AZ00218096, and AZ00217451 was conducted on January 2, 2025 and completed on January 3, 2025, and the following deficiencies were cited:
Findings
This inspection found multiple deficiencies related to failure to provide required documentation to emergency responders, lack of a designated licensed manager, incomplete verification of caregiver skills, missing tuberculosis screenings, incomplete resident service plans, failure to treat residents with dignity and respect, inadequate medication documentation, and failure to notify emergency contacts and primary care providers after incidents. Twenty-one deficiencies were cited.
Deficiencies (21)
36-420.04 — The facility failed to provide emergency responders with required written documentation for two residents during emergency incidents, posing a risk of lack of critical health information.
The governing authority failed to designate in writing a manager with a valid assisted living facility manager certificate, leaving the facility without a qualified manager from November 3, 2024 until a new manager was scheduled to start January 6, 2025.
The manager failed to verify and document the skills and knowledge of two caregivers before they provided physical health services, risking inadequate resident care.
R9-10-113 — The manager failed to ensure five personnel provided evidence of freedom from infectious tuberculosis before beginning work, posing a potential TB infection risk.
The manager failed to ensure seven residents had written service plans that included descriptions of their medical or health problems, risking unclear service provision.
The manager failed to ensure seven residents' service plans specified the level of service expected, such as supervisory, personal, or directed care, risking unclear care expectations.
The manager failed to ensure seven residents' service plans included the amount, type, and frequency of assisted living services provided, risking unclear service delivery.
The manager failed to ensure seven residents' updated service plans were signed and dated by the manager, risking lack of documented agreement on care plans.
The manager failed to ensure caregivers provided residents with activities of daily living according to their service plans, risking unmet resident needs.
The manager failed to ensure a resident was treated with dignity, respect, and consideration, as evidenced by inadequate staff response and short staffing impacting resident care.
R9-10-808 — The manager failed to ensure service plans for six residents receiving personal care included skin maintenance and hydration services, posing health and safety risks.
R9-10-808 — The manager failed to ensure the service plan for one resident receiving directed care included skin maintenance and hydration services, risking unmet care needs.
R9-10-808 — The manager failed to obtain a current medical determination that a resident confined to bed or chair could be served within the facility's scope of services, risking inadequate care.
R9-10-808 — The manager failed to ensure the service plan for one resident receiving directed care included cognitive stimulation and activities to maximize functioning, risking unmet needs.
R9-10-808 — The manager failed to ensure the service plan for one resident receiving directed care included documentation of the resident's weight or contraindication, risking incomplete care documentation.
R9-10-808 — The manager failed to ensure the service plan for one resident receiving directed care included coordination of communications with the resident's representative and family, risking poor communication.
R9-10-808 — The manager failed to ensure means of exiting the facility controlled or alerted employees of resident egress, with multiple alert systems turned off or broken, risking resident safety.
The manager failed to ensure medication administration was documented in residents' medical records for two residents, risking inability to verify medication delivery.
The manager failed to ensure caregivers immediately notified residents' emergency contacts and primary care providers after accidents or emergencies requiring medical services, risking lack of timely communication.
The manager failed to ensure caregivers documented required details of accidents or emergencies for two residents, risking incomplete incident records needed for investigations.
R9-10-113 — The chief administrative officer failed to ensure annual tuberculosis training and education was provided to two personnel, risking potential illness transmission.
Report Facts
Deficiencies cited: 21
Inspection Report — Sep 17, 2024
Enforcement
Date: Sep 17, 2024
Visit Reason
Civil monetary penalty, action 00110590 (invoice INV-257579), assessed 17 September 2024.
Findings
A $500.00 penalty was assessed and paid in full on 30 October 2024.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Aug 30, 2024
Complaint Investigation
Date: Aug 30, 2024
Visit Reason
On-site complaint investigation of complaint AZ00215333 at an Assisted Living Center, conducted 30 August 2024.
Complaint Details
An on-site investigation of complaint AZ00215333 was conducted on August 30, 2024, and the following deficiency was cited.
Findings
The inspection found one deficiency related to incomplete personnel records for caregiver certification. The facility failed to provide current certification documentation for one caregiver, resulting in false or misleading information being submitted to the Department.
Deficiencies (1)
A manager failed to ensure a personnel record included documentation of the individual's current caregiver certification. One caregiver worked without valid certification from 2015 until obtaining certification in 2021, and false information was provided to the Department.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 20, 2024
Complaint Investigation
Date: Aug 20, 2024
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On-site complaint investigation of complaints AZ00214644 and AZ00214538 at an Assisted Living Center, conducted 20 August 2024.
Complaint Details
This revised Statement of Deficiencies (SOD) replaces the SOD sent on September 4, 2024. An on-site investigation of complaints AZ00214644 and AZ00214538 was conducted on August 20, 2024, and the following deficiencies were cited.
Findings
The inspection found one deficiency related to the failure to review and update a resident's written service plan at least once every three months as required. This posed a risk that services to the resident were not properly reinforced or clarified.
Deficiencies (1)
The manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months for a resident receiving directed care services. The most recent service plan for the resident was dated April 19, 2024, with no updates available at the time of inspection.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 23, 2024
Complaint Investigation
Date: Jul 23, 2024
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On-site complaint investigation of complaints AZ00213433 and AZ00213437 at an Assisted Living Center, conducted 23 July 2024.
Complaint Details
An on-site investigation of complaint AZ00213433 and AZ00213437 was conducted on July 23, 2024, resulting in one deficiency cited.
Findings
The inspection found one deficiency related to the failure to develop a comprehensive fall prevention and fall recovery training program for all staff. This deficiency was uncorrected from a prior complaint investigation conducted on July 17, 2024.
Deficiencies (1)
36-420.01 — The facility failed to develop a training program for all staff regarding fall prevention and fall recovery, lacking documentation of training that included fall recovery. The deficient practice posed a risk as organized instruction related to resident care and safety was not implemented.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 17, 2024
Complaint Investigation
Date: Jul 17, 2024
Visit Reason
On-site complaint investigation of complaint AZ00213148 at an Assisted Living Center, conducted 17 July 2024.
Complaint Details
An on-site investigation of complaint AZ00213148 was conducted on July 17, 2024, and the following deficiencies were cited.
Findings
Two deficiencies were cited related to fall prevention training and the availability of emergency alert systems. The facility failed to ensure staff training on fall prevention and did not provide a working mechanical alert system in a resident's unit.
Deficiencies (2)
36-420.01 — The manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery, posing a risk to resident safety. An incident report showed emergency services were not notified after a resident's fall with head bruises.
Bell/intercom availability — The manager failed to ensure a mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a residential unit. The call pendant system did not alert caregivers when pressed, and staff were unaware of the alerts.
Report Facts
Deficiencies cited: 2
Inspection Report — May 7, 2024
Annual Inspection
Date: May 7, 2024
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints AZ00209561, AZ00205914, AZ00204019, AZ00203757 and AZ00197831 at an Assisted Living Center, conducted 7 May 2024.
Complaint Details
This Statement of Deficiencies supercedes the SOD sent on May 22, 2024. Deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00209561, AZ00205914, AZ00204019, AZ00203757 and AZ00197831 conducted on May 8, 2024.
Findings
The inspection found seven deficiencies related to emergency responder documentation, service plan signatures, medication administration policies, medication storage, disaster plan documentation and drills, and storage of toxic materials. Plans of correction were provided for all deficiencies.
Deficiencies (7)
36-420.04 — The facility failed to provide required documentation to an emergency responder for a resident transported to the hospital after a fall with head injury.
Service plan signatures — The manager failed to ensure six residents had written service plans signed and dated by the resident or representative and the manager as required.
R9-10-816 — The manager failed to ensure medication administration policies included a process for documenting individuals authorized by a medical practitioner to administer medication under direction.
Medication storage — The manager failed to ensure medication was stored in a separate locked area; unsecured medications were observed in an unlocked office and refrigerator.
Disaster plan documentation — The manager failed to ensure the disaster plan review included the time of review, a critique, and recommendations for improvement.
Disaster drills — The manager failed to ensure disaster drills were conducted and documented on each shift at least once every three months.
Toxic materials storage — The manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents; unlocked laundry room contained toxic materials.
Report Facts
Deficiencies cited: 7
Inspection Report — Jul 25, 2023
Enforcement
Date: Jul 25, 2023
Visit Reason
Civil monetary penalty, action 00112908 (invoice INV-259311), assessed 25 July 2023.
Findings
A $500.00 penalty was assessed and paid in full on 10 September 2023.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Jul 12, 2023
Complaint Investigation
Date: Jul 12, 2023
Visit Reason
On-site complaint investigation of complaints AZ00197063, AZ00197245, AZ00197688, and AZ00197693 at an Assisted Living Center, conducted 12 July 2023.
Complaint Details
An on-site investigation of complaints AZ00197063, AZ00197245, AZ00197688, and AZ00197693 was conducted on July 12, 2023 and the following deficiencies were cited.
Findings
This inspection found six deficiencies related to caregiver qualifications, personnel record documentation, and incomplete service plan documentation. The facility failed to ensure caregivers had verified skills and knowledge, and service plans lacked required skin maintenance provisions.
Deficiencies (6)
The manager failed to ensure caregivers had the qualifications, experience, skills, and knowledge necessary to meet residents' needs and ensure their health and safety in Cottage 7 (memory care unit). Documentation verifying caregiver qualifications for two employees was not available.
The manager failed to ensure personnel records included documentation of the individual's skills and knowledge applicable to job duties for two caregivers. Verification documentation for these caregivers was missing.
The manager failed to ensure personnel records included documentation of the individual's experience applicable to job duties for one caregiver. Documentation of experience was not available for review.
The manager failed to ensure caregivers documented the services provided in residents' medical records for four residents. Documentation of assistance with activities of daily living was missing for multiple dates in June 2023.
R9-10-808 — The manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections for one resident receiving personal care services.
R9-10-808 — The manager failed to ensure written service plans for residents receiving directed care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections for two of three residents sampled.
Report Facts
Deficiencies cited: 6
Inspection Report — Jun 20, 2023
Enforcement
Date: Jun 20, 2023
Visit Reason
Civil monetary penalty, action 00113165 (invoice INV-259530), assessed 20 June 2023.
Findings
A $750.00 penalty was assessed and paid in full on 6 August 2023.
Report Facts
Penalty amount: 750
Amount paid: 750
Amount remaining: 0
Inspection Report — Jun 5, 2023
Annual Inspection
Date: Jun 5, 2023
Visit Reason
On-site complaint investigation and annual compliance inspection of complaint AZ00193335 at an Assisted Living Center, conducted 5 June 2023.
Complaint Details
The following deficiencies were found during the compliance inspection and investigation of complaint #AZ00193335 conducted on June 5, 2023.
Findings
The inspection found 11 deficiencies related to staff training, policy implementation, documentation, and resident orientation. The facility failed to develop and administer required training programs, maintain updated policies, and properly document services and personnel records.
Deficiencies (11)
36-420.01 — The facility failed to develop and administer a training program for all staff regarding fall prevention and fall recovery, lacking policy, procedure, and training documentation.
R9-10-101.134 — The manager failed to implement policies and procedures covering medication administration, including improper use of medication bubble packs assigned to the wrong resident.
Policies and procedures review — The manager failed to ensure policies and procedures were reviewed at least once every three years, with a manual dated January 1, 2000.
The manager failed to provide documentation required by Article 8 to the Department within two hours after a Department request, including personnel records and evidence of freedom from infectious tuberculosis.
The manager failed to ensure personnel records included documentation of employees' skills and knowledge applicable to their job duties for two caregivers, with incomplete onboarding checklists and missing verification.
The manager failed to ensure personnel records included documentation of employees' experience applicable to their job duties for one employee, with missing requested documentation.
R9-10-101.155 — The manager failed to ensure personnel records included documentation of completed orientation and in-service education for two employees, with missing documentation despite reported completion.
The manager failed to ensure personnel records included documentation of evidence of freedom from infectious tuberculosis for one employee, with documentation unavailable for review.
The manager failed to ensure residents submitted documentation dated within 90 days before acceptance indicating whether continuous medical services, nursing services, or restraints were required, with one resident's record showing continuous medical services not provided by the facility.
The manager failed to ensure caregivers documented services provided in residents' medical records for three residents, with missing bathing assistance documentation.
The manager failed to ensure residents received and had documented orientation to facility exits and evacuation routes within 24 hours of acceptance for three residents.
Report Facts
Deficiencies cited: 11
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