11 Reports
Inspection Report — Apr 30, 2026
Complaint Investigation
Date: Apr 30, 2026
Visit Reason
On-site complaint investigation of complaints 00166730 and 00158847 at an Assisted Living Center, conducted 30 April 2026.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00166730 and 00158847 on April 30, 2026.
Findings
No deficiencies were found during the inspection.
Report Facts
Complaints investigated: 2
Inspection Report — Oct 28, 2025
Complaint Investigation
Date: Oct 28, 2025
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On-site complaint investigation of complaint 00148872 at an Assisted Living Center, conducted 28 October 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00148872 conducted on October 28, 2025.
Findings
No deficiencies were found during the complaint investigation.
Report Facts
Complaints investigated: 1
Inspection Report — Aug 19, 2025
Annual Inspection
Date: Aug 19, 2025
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints 00141373, 00139080, 00105383, 00105227, 00106422, and 00106295 at an Assisted Living Center, conducted 19 August 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00141373, 00139080, 00105383, 00105227, 00106422, and 00106295 conducted on August 19, 2025:
Findings
Two deficiencies were found related to food refrigeration temperatures and unsecured poisonous or toxic materials. Plans of correction were provided for both deficiencies.
Deficiencies (2)
R9-10-818 — The manager failed to ensure foods requiring refrigeration were maintained at 41° F or below, as a refrigerator in the Memory Care area was observed at 50° F. This posed a risk for potential food borne illnesses.
R9-10-820 — The manager failed to ensure poisonous or toxic materials were inaccessible to residents, as a cabinet under the sink in the Memory Care kitchen was unlocked and contained various chemicals. This posed a risk to the physical health and safety of a resident.
Report Facts
Deficiencies cited: 2
Complaints investigated: 6
Inspection Report — May 28, 2024
Enforcement
Date: May 28, 2024
Visit Reason
Civil monetary penalty, action 00111164 (invoice INV-257974), assessed 28 May 2024.
Findings
A $1,750.00 penalty was assessed and paid in full on 7 July 2024.
Report Facts
Penalty amount: 1750
Amount paid: 1750
Amount remaining: 0
Inspection Report — Apr 18, 2024
Complaint Investigation
Date: Apr 18, 2024
Visit Reason
On-site complaint investigation of complaints AZ00208701, AZ00208932, and AZ00209252 at an Assisted Living Center, conducted 18 April 2024.
Complaint Details
An on-site investigation of complaints #AZ00208701, AZ00208932, and AZ00209252 was conducted on April 18, 2024, resulting in ten deficiencies cited.
Findings
This inspection found ten deficiencies related to failure to establish policies for managing aggressive resident behavior, failure to report suspected abuse, inadequate verification of caregiver skills and training, incomplete resident service plans, and medication administration issues.
Deficiencies (10)
The manager failed to establish and document policies and procedures covering how caregivers respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to residents or others.
The administrator failed to report an allegation of abuse according to Arizona Revised Statutes § 46-454, posing a risk as the Department could not assess immediate health and safety concerns for residents.
The manager failed to ensure verification and documentation of skills and knowledge before three caregivers provided services, posing a health and safety risk to residents.
R9-10-113 — The manager failed to ensure three caregivers provided evidence of freedom from infectious tuberculosis, posing a potential health and safety risk of TB exposure to residents and staff.
The manager failed to ensure two caregivers received orientation specific to their duties before providing assisted living services, posing a health and safety risk to residents.
The manager failed to ensure three caregivers provided documentation of current first aid and CPR training specific to adults, posing a health and safety risk to residents.
The manager failed to ensure two residents had written service plans that included the level of service the resident was expected to receive, risking unclear service provision.
The manager failed to ensure two residents had written service plans signed and dated by the resident or representative, the manager, and the nurse or medical practitioner when required, posing a health and safety risk.
The manager failed to ensure medication service policies included procedures for assisting residents in procuring medication, risking residents not receiving prescribed medications.
The manager failed to ensure medications were administered in compliance with a medication order for one resident, resulting in missed doses of Clonidine from April 1 through April 17, 2024.
Report Facts
Deficiencies cited: 10
Complaints investigated: 3
Inspection Report — Feb 20, 2024
Enforcement
Date: Feb 20, 2024
Visit Reason
Civil monetary penalty, action 00111670 (invoice INV-258370), assessed 20 February 2024.
Findings
A $1,250.00 penalty was assessed and paid in full on 14 April 2024.
Report Facts
Penalty amount: 1250
Amount paid: 1250
Amount remaining: 0
Inspection Report — Feb 5, 2024
Complaint Investigation
Date: Feb 5, 2024
Visit Reason
On-site complaint investigation of complaints AZ00205917, AZ00196761, AZ00205228, AZ00202031, AZ00200921, and AZ00205559 at an Assisted Living Center, conducted 5 February 2024.
Complaint Details
An on-site investigation of complaints #AZ00205917, #AZ00196761, #AZ00205228, #AZ00202031, #AZ00200921, and #AZ00205559 was conducted on February 5, 2024, resulting in cited deficiencies.
Findings
This inspection found multiple deficiencies related to staff training, incident reporting, abuse reporting, notification of resident deaths, quality management, caregiver verification and orientation, resident documentation, service plan updates, vaccination notifications, and medication administration compliance.
Deficiencies (13)
36-420.01 — The facility failed to administer a fall prevention and fall recovery training program for all staff, lacking documentation and implementation of such training.
Incident reporting — The manager failed to implement the facility's incident reporting policy for two residents, resulting in incomplete documentation and lack of incident reports for significant events.
Abuse reporting — The administrator failed to report and document an alleged incident of abuse as required by Arizona Revised Statutes, with no documentation of investigation or reporting.
Resident death notification — The manager failed to provide written notification to the Department of two unexpected resident deaths as required by statute.
Quality management program — The manager failed to ensure the facility's quality management policies and procedures were documented and implemented, with inconsistent reporting.
Caregiver verification — The manager failed to verify and document the skills and knowledge of five caregivers before they provided physical or behavioral health services.
Caregiver orientation — The manager failed to ensure four caregivers received orientation specific to their duties before providing assisted living services.
Admission documentation — The manager failed to ensure one resident submitted required signed and dated documentation regarding medical services and restraints before acceptance.
Service plan review — The manager failed to ensure one resident's written service plan was reviewed and updated at least once every three months as required.
Medical record maintenance — The manager failed to maintain a medical record for one resident, preventing verification of required information.
Vaccination notification — The manager failed to document notification of pneumonia vaccination availability for three residents, risking lack of resident or representative knowledge.
R9-10-808 — The manager failed to ensure one resident's service plan included strategies to ensure personal safety despite a history of multiple falls.
Medication administration — The manager failed to ensure medications were administered in compliance with orders for one resident, with documented missed doses due to pharmacy issues.
Report Facts
Deficiencies cited: 13
Complaints investigated: 6
Inspection Report — Jun 27, 2023
Enforcement
Date: Jun 27, 2023
Visit Reason
Civil monetary penalty, action 00113118 (invoice INV-259494), assessed 27 June 2023.
Findings
A $1,250.00 penalty was assessed and paid in full on 18 August 2023.
Report Facts
Penalty amount: 1250
Amount paid: 1250
Amount remaining: 0
Inspection Report — Jun 2, 2023
Annual Inspection
Date: Jun 2, 2023
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints AZ00187866, AZ00191533, AZ00191755, AZ00192522, and AZ00192999 at an Assisted Living Center, conducted on June 2, 2023.
Complaint Details
The following deficiencies were found during the compliance inspection and investigation of complaints AZ00187866, AZ00191533, AZ00191755, AZ00192522, and AZ00192999, conducted on June 2, 2023.
Findings
The inspection found 11 deficiencies related to staff training, documentation, medication administration, and resident safety. The facility failed to provide required documentation and ensure compliance with policies and procedures in multiple areas.
Deficiencies (11)
36-420.01 — The facility failed to develop and administer a fall prevention and fall recovery training program for all staff, and documentation of such training was not available for multiple employees.
Documentation — The administrator failed to provide required documentation to the Department within two hours after a request, including verification of skills, orientation, CPR and first aid training, tuberculosis freedom, and incident notifications.
Skills verification — The manager failed to ensure caregivers' and assistant caregivers' skills and knowledge were verified and documented before providing physical health services, and documentation was missing for all sampled staff.
Orientation documentation — The manager failed to ensure personnel records included documentation of completed orientation for five of eight employees sampled.
CPR and first aid training — The manager failed to ensure personnel records included documentation of CPR and first aid training for two assistant caregivers sampled.
Documentation of services — The manager failed to ensure a caregiver or assistant caregiver documented services provided to a resident in the medical record for one of eight residents sampled.
Means of egress — The manager failed to ensure that a door to an outside area in the memory care section controlled or alerted employees of resident egress, posing a risk of unmonitored resident exit.
Medication refusal documentation — The manager failed to implement policies and procedures covering documentation of a resident's refusal to take prescribed medication in the medical record.
Medication administration compliance — The manager failed to ensure medications were administered in compliance with orders for two of seven residents sampled, including an incident of medication given to the wrong resident.
Notification of PCP — The manager failed to ensure immediate notification of the resident's primary care provider after an accident or emergency requiring medical services.
Documentation of preventive actions — The manager failed to ensure documentation of actions taken to prevent recurrence of an accident or emergency requiring medical services.
Report Facts
Deficiencies cited: 11
Complaints investigated: 5
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