Inspection Reports for
Liberty Care Home II
1178 West Laredo Avenue, Gilbert,AZ 85233, Gilbert, AZ, 85233
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Inspection Report — Oct 3, 2025
Complaint Investigation
Date: Oct 3, 2025
Visit Reason
On-site complaint investigation at an Assisted Living Home, conducted 3 October 2025.
Findings
Seventeen deficiencies were cited, but no evidence was provided for any of the violations. Plans of correction were provided for all deficiencies.
Deficiencies (17)
No evidence was provided to show that the facility developed and administered a fall prevention and fall recovery training program for all staff.
No evidence was provided to show that the facility maintained and periodically updated a standardized emergency responder form for each resident.
No evidence was provided to show that policies and procedures were reviewed at least once every three years and updated as needed.
No evidence was provided to show that current phone numbers for licensing, Adult Protective Services, the Ombudsman, and the Arizona Center for Disability Law were conspicuously posted.
No evidence was provided to show that a list of resident rights was conspicuously posted.
No evidence was provided to show that the assisted living facility's license was conspicuously posted.
No evidence was provided to show that documentation dated within 90 days before acceptance was submitted for individuals requesting or expected to receive supervisory, personal, or directed care services.
No evidence was provided to show that resident service plans were reviewed and updated at least once every six months for residents receiving personal care services.
No evidence was provided to show that each resident's medical record contained a medication order from a medical practitioner for each administered medication.
No evidence was provided to show that documentation of notification of influenza and pneumonia vaccination availability was maintained.
No evidence was provided to show that residents confined to bed or chair were examined by a primary care provider at onset and at least every six months thereafter.
No evidence was provided to show that residents without keys or special knowledge had a means of exiting the facility that met specified safety criteria.
No evidence was provided to show that medication was stored in a separate locked area used only for medication storage.
No evidence was provided to show that documentation of accidents, emergencies, or injuries included required details such as date, description, witnesses, actions taken, notifications, and prevention measures.
No evidence was provided to show that the premises and equipment were free from conditions that could cause physical injury to residents or others.
R9-10-113 — No evidence was provided to show that annual training and education on recognizing tuberculosis signs and symptoms was provided to employees and volunteers.
R9-10-113 — No evidence was provided to show that the facility annually assessed its risk of exposure to infectious tuberculosis.
Report Facts
Deficiencies cited: 17
Inspection Report — Feb 18, 2025
Enforcement
Date: Feb 18, 2025
Visit Reason
Civil monetary penalty, action 00121442 (invoice INV-276638), assessed 18 February 2025.
Findings
A $500.00 penalty was assessed and paid in full on 16 June 2025.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Jan 28, 2025
Annual Inspection
Date: Jan 28, 2025
Visit Reason
On-site complaint investigation of complaints AZ00221308 and AZ00221259 combined with an annual compliance inspection at an Assisted Living Home, conducted 28 January 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00221308 and AZ00221259 conducted on January 28, 2025.
Findings
The inspection found 17 deficiencies related to staff training, documentation, posting of required information, medication storage, and resident care plans. The facility was undergoing renovations which affected conspicuous posting of required notices and alarms. Several records and policies were incomplete or outdated, posing risks to resident safety and care.
Deficiencies (17)
36-420.01 — The manager failed to ensure the facility administered a fall prevention and recovery training program for all staff that included initial and continued competency training for two personnel sampled.
36-420.04 — The assisted living home failed to maintain a standardized form for each resident that included all required emergency responder information.
Policies and procedures — The manager failed to ensure the facility's policies and procedures were reviewed at least once every three years and updated as needed.
The manager failed to ensure that current phone numbers required by R9-10-803.D.3.a-d were conspicuously posted; postings were removed during renovations.
The manager failed to ensure that a list of resident rights was conspicuously posted; postings were removed during renovations.
The manager failed to ensure that the assisted living facility's license was conspicuously posted; postings were removed during renovations.
The manager failed to ensure that documentation dated within 90 days before acceptance included whether a resident required continuous medical services, nursing services, or restraints, signed by a medical practitioner, for one resident sampled.
The manager failed to ensure that residents receiving personal care services had written service plans reviewed and updated at least once every six months, for two residents sampled.
The manager failed to ensure that a resident's medical record contained medication orders from a medical practitioner for each medication administered, for one resident sampled.
The manager failed to ensure that a resident's medical record contained documentation of notification of the availability of influenza and pneumonia vaccinations, for two residents sampled.
The manager retained a resident confined to a bed or chair without required documentation of examination and determination updated at least every six months, for one resident sampled.
The manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of resident egress; alarms were removed during renovations.
The manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit; medication was found in an unlocked kitchen refrigerator.
The manager failed to ensure that when a resident had an accident, emergency, or injury requiring medical services, a caregiver documented required details including date, description, observers, actions taken, notifications, and prevention measures.
The manager failed to ensure the premises were free from conditions that may cause physical injury; a large precariously stacked pile of materials was observed on the back patio.
R9-10-113 — The chief administrative officer failed to ensure annual training and education related to recognizing signs and symptoms of tuberculosis was provided to staff, for two personnel sampled.
R9-10-113 — The healthcare institution failed to annually assess the risk of exposure to infectious tuberculosis as required.
Report Facts
Deficiencies cited: 17
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