Inspection Reports for
Heritage Oaks Assisted Living Residence
6569 E Carondelet Dr., Tucson, AZ 85710, Tucson, AZ
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Inspection Report — Apr 17, 2026
Complaint Investigation
Date: Apr 17, 2026
Visit Reason
On-site complaint investigation of complaints 00165974, 00165666, and 00165655 at an Assisted Living Center, conducted 17 April 2026.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00165974, 00165666, and 00165655 conducted on April 17, 2026.
Findings
No deficiencies were found during this inspection.
Report Facts
Complaints investigated: 3
Inspection Report — Mar 31, 2026
Annual Inspection
Date: Mar 31, 2026
Visit Reason
On-site complaint investigation and annual compliance inspection of complaint 00163532 at an Assisted Living Center, conducted 31 March 2026.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00163532 conducted on March 31, 2026.
Findings
The inspection found six deficiencies related to failure to maintain emergency documentation, opioid medication documentation, personnel record compliance, tuberculosis screening, medication administration compliance, and emergency incident documentation.
Deficiencies (6)
A.R.S. § 36-420.04.D — The assisted living center failed to maintain a copy of documentation provided to an emergency responder for two years after the date of an emergency for one sampled resident.
R9-10-120 — The manager failed to ensure a caregiver documented a patient's need for an opioid and the effect of the opioid administered in the medical record for one sampled resident.
R9-10-803 — The governing authority failed to ensure compliance with A.R.S. § 36-411 by not documenting good-faith attempts to contact previous employers for one sampled personnel.
R9-10-807 — The manager failed to ensure three residents provided evidence of freedom from infectious tuberculosis before or within seven days after occupancy.
R9-10-817 — The manager failed to ensure medication was administered in compliance with a medication order for one sampled resident, including failure to hold medication based on blood pressure readings.
R9-10-819 — The manager failed to ensure a caregiver documented an emergency incident requiring medical services for one resident.
Report Facts
Deficiencies cited: 6
Inspection Report — Jun 8, 2025
Enforcement
Date: Jun 8, 2025
Visit Reason
Civil monetary penalty, action 00127815 (invoice INV-274997), assessed 8 June 2025.
Findings
A $500.00 penalty was assessed and paid in full on 8 May 2025.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — May 7, 2025
Date: May 7, 2025
Visit Reason
On-site modification inspection to increase the total beds to 38 and add adult day health care services at an Assisted Living Center, conducted 7 May 2025.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Apr 15, 2025
Annual Inspection
Date: Apr 15, 2025
Visit Reason
On-site complaint investigation of complaint AZ00218652 combined with an annual compliance inspection at an Assisted Living Center, conducted 14-15 April 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00218652 conducted on April 14, 2025.
Findings
This inspection found five deficiencies related to tuberculosis infection control, personnel record compliance, exit door alarms, medication administration, and fall prevention training. The facility failed to document required tuberculosis screenings and training, did not comply with fingerprint clearance and APS registry checks, lacked functioning door alarms on exit doors, did not administer medication as ordered, and failed to provide fall prevention training to all staff.
Deficiencies (5)
R9-10-113 — The facility failed to document and implement required tuberculosis infection control activities, including annual training for employees and baseline screenings for residents.
R9-10-803 — The governing authority failed to ensure compliance with fingerprint clearance card requirements and Adult Protective Services registry checks for personnel, including documentation of prior employer contacts and employment history gaps.
R9-10-815 — The facility lacked a means to alert employees of resident egress as required; exit doors were missing door alarms or magnets, so alarms did not sound when doors were opened.
R9-10-816 — Medication was not administered in compliance with orders; a resident did not receive Memantine as ordered due to medication unavailability and lack of a hold order or termination notice.
The facility failed to administer a fall prevention and recovery training program that included initial and continued competency training for all staff, as documentation was missing for one employee.
Report Facts
Deficiencies cited: 5
Complaints investigated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Manager | Acknowledged failures in tuberculosis infection control activities and medication administration. |
| Staff #2 | Acknowledged failures in tuberculosis infection control activities and exit door alarms. | |
| Staff #3 | Personnel record missing documentation of prior employer contact and APS registry check. | |
| Staff #4 | Personnel record with employment history gap and missing APS registry check. | |
| Staff #5 | Personnel record missing APS registry check. |
Inspection Report — Jan 3, 2024
Annual Inspection
Date: Jan 3, 2024
Visit Reason
On-site complaint investigation of complaint AZ00203368 combined with an annual compliance inspection at an Assisted Living Center, conducted 3 January 2024.
Complaint Details
The following deficiency was found during the on-site compliance inspection and investigation of complaint AZ00203368 conducted on January 3, 2024:
Findings
The inspection found one deficiency related to incomplete documentation of services provided to a resident as required by the service plan.
Deficiencies (1)
A manager failed to ensure a caregiver documented the services provided in the resident's medical record, specifically missing documentation of bowel movements for one resident as required by the service plan.
Report Facts
Deficiencies cited: 1
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