14 Reports
Inspection Report — Aug 1, 2025
Enforcement State
Date: Aug 1, 2025
Visit Reason
Civil monetary penalty, action 00132057 (invoice INV-288722), assessed 1 August 2025.
Findings
A $2,750.00 penalty was assessed and paid in full on 30 August 2025.
Report Facts
Penalty amount: 2750
Amount paid: 2750
Amount remaining: 0
Inspection Report — Jun 24, 2025
Complaint Investigation State
Date: Jun 24, 2025
Visit Reason
On-site complaint investigation of complaints 00133123 and 00133789 at an Assisted Living Center, conducted 24 June 2025.
Complaint Details
The following deficiency was found during the on-site investigation of complaints 00133123 and 00133789 conducted on June 24, 2025.
Findings
The inspection found one deficiency related to failure to provide emergency responders with a complete written document containing all required resident information. The deficiency posed a risk due to missing critical health and contact information.
Deficiencies (1)
A.R.S. § 36-420.04.A.1-9. — The manager failed to provide emergency responders with a written document including the reason for the emergency response, the facility's point-of-contact email address, and the resident's HIPAA release authorization. This incomplete documentation posed a risk if responders lacked critical health information.
Report Facts
Deficiencies cited: 1
Complaints investigated: 2
Inspection Report — Jun 23, 2025
State
Date: Jun 23, 2025
Visit Reason
Off-site desktop review to increase the licensed capacity from 141 to 155 at an Assisted Living Center, conducted 23 June 2025.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Apr 16, 2025
Annual Inspection State
Date: Apr 16, 2025
Visit Reason
On-site complaint investigation of complaints 00106879, 00108187, 00104853, 00105305, 00105494, 00123150, and 00125014 combined with a compliance (annual) inspection at an Assisted Living Center, conducted 16 April 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00106879, 00108187, 00104853, 00105305, 00105494, 00123150, and 00125014 conducted on April 3, 2025.
Findings
This inspection found twelve deficiencies including failures in providing appropriate first aid, ensuring proper employee background checks, maintaining current CPR and first aid certifications, documenting services provided, medication administration compliance, resident dignity, disaster drill documentation, and environmental safety measures. Several deficiencies were repeat citations from prior inspections.
Deficiencies (12)
A.R.S. § 36-420.B.2. — The facility failed to provide appropriate first aid before EMS arrival to a non-injured resident who fell and was unable to recover independently, with no incident report documented and staff unaware of the incident.
R9-10-803 — The governing authority failed to ensure compliance with A.R.S. § 36-411 by not contacting previous employers for one of ten sampled employees before employment, contrary to the plan of correction.
R9-10-803 — The manager failed to establish and document policies and procedures covering the method and qualifications for CPR training for employees and volunteers, posing a risk to resident safety.
R9-10-806 — The manager failed to ensure a caregiver provided current documentation of first aid and CPR certification before providing assisted living services, with expired certifications noted for one of nine sampled caregivers.
R9-10-806 — The manager failed to ensure evidence of freedom from infectious tuberculosis was provided on or before the date personnel began providing services for three of ten sampled staff, posing a potential TB exposure risk.
R9-10-808 — The manager failed to ensure a caregiver documented services provided in the resident's medical record for one of ten residents, with missing documentation for assistance with dressing and fewer showers than required.
R9-10-810 — The manager failed to ensure a resident was treated with dignity, respect, and consideration, as evidenced by neglect complaints and miscommunication among staff regarding care.
R9-10-816 — The manager failed to ensure medication was administered in compliance with orders for four of ten sampled residents, including missed doses and medication omissions leading to adverse effects.
R9-10-818 — The manager failed to ensure disaster drills were conducted on each shift at least once every three months and documented, with missing drills on the first shift in April and October 2024.
R9-10-819 — The manager failed to ensure the premises were free from conditions that could cause physical injury, with an unlocked pool fence accessible to residents and unsecured medications in a resident's unit.
R9-10-819 — The manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents, with an unlocked pool shed containing hazardous materials.
R9-10-819 — The manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags, with uncovered garbage observed in multiple locations posing infection risk.
Report Facts
Deficiencies cited: 12
Complaints investigated: 7
Inspection Report — Nov 21, 2024
Complaint Investigation State
Date: Nov 21, 2024
Visit Reason
On-site complaint investigation of complaint AZ00219040 at an Assisted Living Center, conducted 21 November 2024.
Complaint Details
An on-site investigation of complaint AZ00219040 was conducted on November 21, 2024, and the following deficiency was cited.
Findings
The inspection found one deficiency where a manager failed to report suspected abuse of a resident in a timely manner, delaying the report to Adult Protective Services by over three hours.
Deficiencies (1)
J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall: 2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454; — A manager who had a reasonable basis to believe abuse occurred failed to report the suspected abuse immediately, resulting in a delay of over three hours before notifying Adult Protective Services.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 30, 2024
Enforcement State
Date: Apr 30, 2024
Visit Reason
Civil monetary penalty, action 00111321 (invoice INV-258094), assessed 30 April 2024.
Findings
A $2,250.00 penalty was assessed and paid in full on 24 July 2024.
Report Facts
Penalty amount: 2250
Amount paid: 2250
Amount remaining: 0
Inspection Report — Mar 11, 2024
Complaint Investigation State
Date: Mar 11, 2024
Visit Reason
On-site complaint investigation of complaints AZ00204702, AZ00205138, and AZ00206527 at an Assisted Living Center, conducted 11 March 2024.
Complaint Details
An on-site investigation of complaints AZ00204702, AZ00205138, and AZ00206527 was conducted on March 11, 2024, and the following deficiencies were cited.
Findings
This inspection found six deficiencies related to personnel compliance, caregiver skills verification, CPR certification, resident service plans, documentation of services, and incident reporting. All deficiencies posed risks to resident care and safety.
Deficiencies (6)
R9-10-403.E — The governing authority failed to ensure compliance with fingerprint clearance card requirements for five personnel, including expired cards and delayed or missing applications. This posed a risk of unqualified personnel working in the facility.
The manager failed to ensure caregivers' or assistant caregivers' skills and knowledge were verified and documented before providing physical health services for three of five sampled staff. This posed a risk if staff were unprepared to meet resident needs.
The manager failed to ensure a caregiver provided current adult-specific CPR training certification before providing assisted living services for one of three caregivers sampled. This posed a risk during emergencies.
The manager failed to ensure a resident's written service plan accurately included the level of service expected, as one resident's plans incorrectly indicated personal care services after moving to memory care. This posed a risk of inappropriate care.
The manager failed to ensure caregivers documented services provided in residents' medical records for two residents, resulting in missing documentation of showering and bathing services. This posed a risk to verifying care delivery.
The manager failed to ensure documentation of actions taken to prevent recurrence after a resident's accident requiring medical services. This posed a potential risk of re-injury.
Report Facts
Deficiencies cited: 6
Complaints investigated: 3
Inspection Report — Nov 7, 2023
Enforcement State
Date: Nov 7, 2023
Visit Reason
Civil monetary penalty, action 00112231 (invoice INV-258781), assessed 7 November 2023.
Findings
A $2,250.00 penalty was assessed and paid in full on 4 February 2024.
Report Facts
Penalty amount: 2250
Amount paid: 2250
Amount remaining: 0
Inspection Report — Oct 12, 2023
Annual Inspection State
Date: Oct 12, 2023
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints AZ00186901, AZ00191337, AZ00198770, AZ00200034, and AZ00200080 at an Assisted Living Center, conducted October 11-12, 2023.
Complaint Details
This revised statement of deficiencies supersedes the previous statement of deficiencies for event ID 3ML411. The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00186901, AZ00191337, AZ00198770, AZ00200034, and AZ00200080 conducted on October 11-12, 2023:
Findings
The inspection found nine deficiencies including failures in personnel documentation, training, resident care documentation, dignity and respect for residents, medication administration, food menu posting, evacuation drills, garbage storage, and tuberculosis screening. Several deficiencies were repeat citations from previous inspections.
Deficiencies (9)
A.R.S. § 36-411 — The governing authority failed to document good faith efforts to contact previous employers and verify fingerprint clearance cards for two personnel members, posing a risk to vulnerable populations.
The manager failed to ensure caregivers provided current documentation of first aid and CPR training specific to adults before providing assisted living services, risking inability to meet resident emergency needs.
The manager failed to ensure a caregiver or assistant caregiver documented services provided to a resident accurately, resulting in false or misleading information.
The manager failed to ensure a resident was treated with dignity, respect, and consideration, violating resident rights and resulting in termination of the responsible employee.
The manager failed to ensure medication was administered in compliance with medication orders, resulting in multiple missed doses for one resident and risk of adverse health conditions.
The manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal was served, with no current menu posted during inspection.
The manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months, risking unpreparedness for emergencies.
The manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags, posing a health and safety risk due to uncovered garbage.
R9-10-113 — The chief administrative officer failed to implement tuberculosis infection control activities including baseline screening for personnel and residents, posing a potential TB exposure risk.
Report Facts
Deficiencies cited: 9
Complaints investigated: 5
Inspection Report — Jan 10, 2023
Enforcement State
Date: Jan 10, 2023
Visit Reason
Civil monetary penalty, action 00113988 (invoice INV-260241), assessed 10 January 2023.
Findings
A $750.00 penalty was assessed and paid in full on 28 March 2023.
Report Facts
Penalty amount: 750
Amount paid: 750
Amount remaining: 0
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