20 Reports
Inspection Report — Feb 3, 2026
Annual Inspection
Date: Feb 3, 2026
Visit Reason
On-site complaint investigation of complaint 00157905 combined with an annual compliance inspection at an Assisted Living Center, conducted 3 February 2026.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00157905 conducted on February 3, 2026.
Findings
The inspection found five deficiencies related to emergency responder forms, tuberculosis infection control activities, resident tuberculosis screening, required medical documentation upon acceptance, and resident orientation to emergency exits. Plans of correction were provided for all deficiencies.
Deficiencies (5)
A.R.S. § 36-420.04.C — The facility failed to maintain standardized emergency responder forms for four of six residents, missing medication service information and HIPAA release authorizations, posing a risk in emergencies.
R9-10-113 — The facility failed to annually assess the risk of exposure to infectious tuberculosis, posing a TB exposure risk to residents.
R9-10-807 — The manager failed to ensure four of six residents provided evidence of freedom from infectious tuberculosis within seven calendar days of occupancy, posing a TB exposure risk.
R9-10-807 — The manager failed to ensure two of six residents submitted documentation signed by a medical practitioner stating whether continuous medical or nursing services or restraints were required, risking unmet resident needs.
R9-10-819 — The manager failed to ensure three of six residents received and documented orientation to emergency exits within 24 hours of acceptance, posing a health and safety risk.
Report Facts
Deficiencies cited: 5
Inspection Report — Nov 3, 2025
Complaint Investigation
Date: Nov 3, 2025
Visit Reason
On-site complaint investigation of complaints 00148383, 00145224, 00140891, 00140650, and 00135743 at an Assisted Living Center, conducted 3 November 2025.
Complaint Details
The following deficiencies were found during the on-site investigation of complaints 00148383, 00145224, 00140891, 00140650, and 00135743 conducted on November 3, 2025.
Findings
This inspection found four deficiencies related to failure to document services provided, failure to treat residents with dignity and respect, failure to meet nutritional needs, and failure to maintain appropriate room temperature. Plans of correction were provided for all deficiencies.
Deficiencies (4)
R9-10-808 — The manager failed to ensure the caregiver documented the services provided in the resident's medical record for one of six residents reviewed, posing a risk as services could not be verified as provided against the service plan.
R9-10-810 — The manager failed to ensure that residents were treated with dignity, respect, and consideration, as evidenced by a caregiver falling asleep, leaving a window open, and not changing a resident's wet brief.
R9-10-818 — The manager failed to ensure a resident was provided a diet that met the resident’s nutritional needs, with documentation showing the resident did not receive breakfast on two occasions.
R9-10-820 — The manager failed to ensure that the temperature of a resident's room was maintained between 70° F and 84° F, with documentation showing a room temperature of 50° F.
Report Facts
Deficiencies cited: 4
Complaints investigated: 5
Inspection Report — Oct 10, 2025
Date: Oct 10, 2025
Visit Reason
Off-site desktop review to modify the licensed capacity from 74 directed care to 21 directed care and 53 personal care at an Assisted Living Center, conducted 10 October 2025.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Jul 9, 2025
Enforcement
Date: Jul 9, 2025
Visit Reason
Civil monetary penalty, action 00130800 (invoice INV-281257), assessed 9 July 2025.
Findings
A $500.00 penalty was assessed and paid in full on 9 July 2025.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Jun 10, 2025
Complaint Investigation
Date: Jun 10, 2025
Visit Reason
On-site complaint investigation of complaints 00131852 and 00130714 at an Assisted Living Center, conducted 10 June 2025.
Complaint Details
The following deficiency was found during the on-site investigation of complaints 00131852 and 00130714 conducted on June 10, 2025.
Findings
The inspection found one deficiency related to the facility's failure to ensure a means of exiting the facility that controlled or alerted employees of resident egress. This posed a risk as a resident eloped through an uncontrolled memory care exit door.
Deficiencies (1)
R9-10-815 — The manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident, resulting in a resident eloping through an uncontrolled memory care exit door.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 2, 2025
Enforcement
Date: Jun 2, 2025
Visit Reason
Civil monetary penalty, action 00126098 (invoice INV-274603), assessed 2 June 2025.
Findings
A $250.00 penalty was assessed and paid in full on 2 June 2025.
Report Facts
Penalty amount: 250
Amount paid: 250
Amount remaining: 0
Inspection Report — Apr 24, 2025
Complaint Investigation
Date: Apr 24, 2025
Visit Reason
On-site complaint investigation of complaint 00126264 at an Assisted Living Center, conducted 24 April 2025.
Complaint Details
The following deficiencies were found during the on-site investigation of complaint 00126264 conducted on April 24, 2025.
Findings
The inspection found three deficiencies related to employee tuberculosis screening and resident service plans. Two deficiencies were repeats from prior inspections.
Deficiencies (3)
R9-10-806 — The manager failed to ensure that two employees provided documentation of freedom from infectious tuberculosis on or before their hire dates, posing a potential TB exposure risk to residents.
R9-10-808 — The manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, risking unclear service provision.
R9-10-808 — The manager failed to ensure a resident's service plan included how medication stored in the resident's unit would be stored and controlled, posing a health and safety risk.
Report Facts
Deficiencies cited: 3
Inspection Report — Apr 2, 2025
Complaint Investigation
Date: Apr 2, 2025
Visit Reason
On-site complaint investigation of complaints 00124977, 00124970, 00124915, and 00124916 at an Assisted Living Center, conducted 2 April 2025.
Complaint Details
The following deficiencies were found during the on-site investigation of cases 00124977, 00124970, 00124915, and 00124916 conducted on April 2, 2025:
Findings
The inspection found one deficiency related to the failure to implement policies and procedures addressing caregiver responses to residents' sudden or out-of-control behavior to prevent harm. The facility did not include appropriate behavioral interventions in residents' service plans as required.
Deficiencies (1)
R9-10-803 — The manager failed to ensure policies and procedures were implemented to protect residents by covering caregiver responses to sudden or out-of-control behavior. Service plans for residents involved in physical altercations did not reflect the interventions implemented to manage their behaviors.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 25, 2025
Complaint Investigation
Date: Mar 25, 2025
Visit Reason
On-site complaint investigation of complaints 00123805, 00123713, and 00123809 at an Assisted Living Center, conducted 25 March 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00123805, 00123713, and 00123809 conducted on March 25, 2025.
Findings
No deficiencies were found during the inspection.
Report Facts
Complaints investigated: 3
Inspection Report — Mar 17, 2025
Annual Inspection
Date: Mar 17, 2025
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints 00105482, 00105618, and 00121659 at an Assisted Living Center, conducted 17 March 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00105482, 00105618, and 00121659 conducted on March 17, 2025.
Findings
The inspection found three deficiencies related to food safety, environmental cleanliness, and chemical storage. The facility failed to ensure food was free from spoilage, maintain clean premises and equipment, and secure poisonous or toxic materials in locked areas.
Deficiencies (3)
R9-10-817 — The manager failed to ensure food stored by the facility was free from spoilage and safe for human consumption, including moldy cheese, expired pickles, watery yogurt and sour cream, and dried white spots on cheese slices.
R9-10-819 — The manager failed to ensure premises and equipment were cleaned and disinfected, evidenced by dried fecal matter on a toilet seat, large dark carpet stains, and a strong urine odor in resident areas.
R9-10-819 — The manager failed to ensure poisonous or toxic materials were maintained in locked areas and inaccessible to residents, with multiple cleaning chemicals found unsecured in the activity room and a resident's bathroom.
Report Facts
Deficiencies cited: 3
Complaints investigated: 3
Inspection Report — Nov 7, 2024
Complaint Investigation
Date: Nov 7, 2024
Visit Reason
On-site complaint investigation of complaint AZ00217949 at an Assisted Living Center, conducted 7 November 2024.
Complaint Details
The following deficiency was found during the investigation of complaint AZ00217949 conducted on November 7, 2024.
Findings
The inspection found one deficiency related to incomplete documentation of a resident's medical emergency. The facility failed to document required details about the emergency and notifications.
Deficiencies (1)
The manager failed to ensure that caregivers documented all required information when a resident experienced a medical emergency requiring medical services. Specifically, the documentation omitted the names of individuals who observed the emergency, all individuals notified, and any actions taken to prevent future occurrences.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 16, 2024
Complaint Investigation
Date: Aug 16, 2024
Visit Reason
On-site complaint investigation of complaints AZ00214454 and AZ00213937 at an Assisted Living Center, conducted 16 August 2024.
Complaint Details
No deficiencies were found during the investigation of complaints AZ00214454 and AZ00213937 conducted on August 16, 2024.
Findings
No deficiencies were found during the investigation of the complaints.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 20, 2024
Enforcement
Date: Feb 20, 2024
Visit Reason
Civil monetary penalty, action 00111694 (invoice INV-258390), assessed 20 February 2024.
Findings
A $3,250.00 penalty was assessed and paid in full on 7 April 2024.
Report Facts
Penalty amount: 3250
Amount paid: 3250
Amount remaining: 0
Inspection Report — Jan 31, 2024
Complaint Investigation
Date: Jan 31, 2024
Visit Reason
On-site complaint investigation of complaints AZ00205713 and AZ00205272 at an Assisted Living Center, conducted 31 January 2024.
Complaint Details
An on-site investigation of complaints AZ00205713 and AZ00205272 was conducted on January 31, 2024 and the following deficiencies were cited.
Findings
The inspection found ten deficiencies related to documentation, caregiver qualifications, supervision, service plans, resident dignity, medication storage, oxygen container safety, and toxic material storage. The facility failed to provide required documentation timely and had multiple issues with caregiver certification and resident care practices.
Deficiencies (10)
The manager failed to provide documentation required by Article 8 within two hours after a Department request, including a missing caregiver certificate for E7.
The manager failed to ensure five caregivers provided documentation of completion of a caregiver training program approved by the Board of Examiners, as caregiver certificates were missing for E2, E3, E6, E7, and E8.
The manager failed to ensure an assistant caregiver interacted with residents under supervision, as E3 worked unsupervised and provided care independently.
The manager failed to verify and document caregivers' and assistant caregivers' skills and knowledge before providing physical health services, with no documentation found for eight caregivers or assistant caregivers.
The manager failed to ensure caregivers provided current documentation of CPR training, with two employees lacking valid CPR certification including a gap in E9's certification and E8's certificate being from an online-only program without hands-on demonstration.
The manager failed to ensure a written service plan was signed and dated by the manager for one resident, R1.
The manager failed to ensure a resident was treated with dignity, respect, and consideration, as staff member E1 cursed at and slapped resident R2 during a shower.
The manager failed to ensure medication was stored in a separate locked area, with medications found unlocked and accessible in multiple residents' bedrooms and bathrooms.
The manager failed to ensure oxygen containers were secured in an upright position, with several containers unsecured in multiple residents' rooms.
The manager failed to ensure poisonous or toxic materials were maintained in locked areas inaccessible to residents, with unlocked toxic materials observed in resident bedrooms and facility areas.
Report Facts
Deficiencies cited: 10
Inspection Report — Dec 27, 2023
Annual Inspection
Date: Dec 27, 2023
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints AZ00200626, AZ00201265, AZ00203168, and AZ00203670 at an Assisted Living Center, conducted 27 December 2023.
Complaint Details
This revised Statement of Deficiencies (SOD) replaces the SOD sent on January 31, 2024. The following deficiencies were found during the compliance inspection and investigation of complaints AZ00200626, AZ00201265, AZ00203168, and AZ00203670 conducted on December 27, 2023.
Findings
This inspection found six deficiencies related to quality management, tuberculosis documentation, resident service plans, resident retention documentation, medication administration, and oxygen cylinder safety.
Deficiencies (6)
The manager failed to ensure that a quality management plan was established and documented that included the frequency of submitting a documented report to the governing authority.
R9-10-113 — The manager failed to ensure that three of four personnel records contained evidence of freedom from infectious tuberculosis as required before providing services.
The manager failed to ensure that a resident's service plan included how medication stored in the resident's bedroom would be stored and controlled.
R9-10-814 — The manager failed to obtain documentation that the resident or representative requested to remain in the facility and a current medical practitioner's statement that the resident's needs were met as per the facility's scope of services.
The manager failed to ensure that medication was administered in compliance with the medication order, as a resident was given the incorrect medication.
The manager failed to ensure that oxygen cylinders were secured; multiple unsecured oxygen cylinders were observed in resident apartments.
Report Facts
Deficiencies cited: 6
Inspection Report — Jan 24, 2023
Enforcement
Date: Jan 24, 2023
Visit Reason
Civil monetary penalty, action 00113890 (invoice INV-260146), assessed 24 January 2023.
Findings
A $750.00 penalty was assessed and paid in full on 7 March 2023.
Report Facts
Penalty amount: 750
Amount paid: 750
Amount remaining: 0
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