22 Reports
Inspection Report — Apr 3, 2026
Annual Inspection
Date: Apr 3, 2026
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints 00153429, 00161269, 00161946, 00161964, 00163112, and 00163113 at an Assisted Living Center, conducted 2-3 April 2026.
Complaint Details
This revised Statement of Deficiencies replaces the SOD sent on May 15, 2026. Deficiencies were found during the on-site compliance inspection and investigation of complaints 00153429, 00161269, 00161946, 00161964, 00163112, and 00163113 conducted on April 2-3, 2026.
Findings
The inspection found 15 deficiencies related to staff training, policy implementation, resident rights, medical record protection, and emergency preparedness. Several deficiencies were repeat citations from prior inspections.
Deficiencies (15)
A.R.S. § 36-420.01.A — The governing authority failed to administer a fall prevention and fall recovery training program for all staff, with two of eight sampled staff lacking annual training updates.
R9-10-803 — The manager failed to ensure policies and procedures covered all required elements of cardiopulmonary resuscitation training, including content, trainer qualifications, and renewal timeframes.
R9-10-803 — The manager failed to establish policies and procedures to ensure awareness of residents' general or specific whereabouts based on authorized assisted living services.
R9-10-803 — After suspecting exploitation, the manager failed to immediately report, investigate, and document the suspected exploitation as required by statute and rule.
R9-10-806 — The manager failed to ensure two caregivers provided evidence of freedom from infectious tuberculosis on or before the date they began providing services.
R9-10-806 — The manager failed to ensure two caregivers had current first aid and adult CPR training certification before providing assisted living services.
R9-10-807 — The manager failed to ensure five residents provided evidence of freedom from infectious tuberculosis before or within seven days after occupancy as required.
R9-10-808 — The manager failed to ensure caregivers documented services provided to residents in medical records for three residents, including documentation errors during leave periods.
R9-10-810 — The manager failed to prevent misappropriation of a resident's personal property, with approximately $7,500 taken from a resident's bank account without permission.
R9-10-811 — The manager failed to protect a resident's medical record from unauthorized use, evidenced by an unattended unlocked laptop displaying resident records.
R9-10-811 — The manager failed to ensure one resident's medical record contained documentation of assisted living services provided, due to a system issue preventing ADL documentation.
R9-10-815 — The manager failed to ensure a means of egress for residents without keys or special knowledge that alerted employees when residents exited the facility.
R9-10-817 — The manager failed to ensure medication was administered in compliance with a medication order for one resident, who did not receive prescribed quetiapine due to medication unavailability.
R9-10-819 — The manager failed to conduct and document disaster drills for employees on each shift at least once every three months.
R9-10-819 — The manager failed to conduct evacuation drills for employees and residents at least once every six months.
Report Facts
Deficiencies cited: 15
Complaints investigated: 6
Inspection Report — Nov 19, 2025
Complaint Investigation
Date: Nov 19, 2025
Visit Reason
On-site complaint investigation of complaint 00151033 at an Assisted Living Center, conducted 19 November 2025.
Complaint Details
The following deficiency was found during the on-site investigation of complaint 00151033 conducted on November 19, 2025:
Findings
The inspection found one deficiency related to incomplete personnel records for CPR and first aid training documentation for one employee.
Deficiencies (1)
R9-10-806 — The manager failed to ensure a personnel record included current documentation of cardiopulmonary resuscitation and first aid training for one of three employees sampled.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 18, 2025
Enforcement
Date: Aug 18, 2025
Visit Reason
Civil monetary penalty, action 00135056 (invoice INV-288730), assessed 18 August 2025.
Findings
A $4,500.00 penalty was assessed and paid in full on 18 August 2025.
Report Facts
Penalty amount: 4500
Amount paid: 4500
Amount remaining: 0
Inspection Report — Jul 16, 2025
Date: Jul 16, 2025
Visit Reason
On-site modification inspection to change occupancy to 38 directed care beds and 86 personal care beds at an Assisted Living Center, conducted 16 July 2025.
Findings
No deficiencies were found during this modification inspection.
Inspection Report — Jun 19, 2025
Complaint Investigation
Date: Jun 19, 2025
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On-site complaint investigation of complaint 00131841 at an Assisted Living Center, conducted 19 June 2025.
Complaint Details
The following deficiency was found during the onsite investigation of complaint 00131841 conducted on June 19, 2025.
Findings
The inspection found one deficiency involving failure to initiate cardiopulmonary resuscitation (CPR) in accordance with certification training and the resident's advance directives. A plan of correction was provided.
Deficiencies (1)
A.R.S. § 36-420.B.1. — The facility failed to initiate CPR according to certification training and the resident's advance directives before emergency medical services arrived, posing a risk to resident safety.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 12, 2025
Complaint Investigation
Date: Jun 12, 2025
Visit Reason
On-site complaint investigation of complaint 00133139 at an Assisted Living Center, conducted 12 June 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00133139 conducted on June 12, 2025.
Findings
No deficiencies were found during the on-site investigation.
Report Facts
Complaints investigated: 1
Inspection Report — May 20, 2025
Complaint Investigation
Date: May 20, 2025
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On-site complaint investigation of complaint 00127968 at an Assisted Living Center, conducted 20 May 2025.
Complaint Details
The following deficiencies were found during the on-site investigation of complaint 00127968 conducted on May 20, 2025.
Findings
The inspection found two deficiencies related to caregiver competency verification and medication administration compliance. Both deficiencies were repeats from prior complaint inspections and posed risks to resident care.
Deficiencies (2)
R9-10-806 — The manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services for four sampled caregivers. This deficiency was a repeat citation from a prior inspection.
R9-10-816 — The manager failed to ensure medication was administered in compliance with medication orders for two of three sampled residents. Medications were missed due to unavailability, and this was an uncorrected repeat deficiency.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 10, 2025
Complaint Investigation
Date: Apr 10, 2025
Visit Reason
On-site complaint investigation at an Assisted Living Center, conducted 10 April 2025.
Findings
One deficiency was found related to the designation of a qualified manager. No evidence text was provided for the deficiency.
Deficiencies (1)
The facility failed to provide evidence that a manager was designated in writing who holds the required certificate as an assisted living facility manager or a temporary certificate.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 1, 2025
Complaint Investigation
Date: Apr 1, 2025
Visit Reason
On-site complaint investigation of complaint 00124918 at an Assisted Living Center, conducted 1 April 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00124918 conducted on April 1, 2025.
Findings
No deficiencies were found during the inspection.
Inspection Report — Feb 25, 2025
Enforcement
Date: Feb 25, 2025
Visit Reason
Civil monetary penalty, action 00121431 (invoice INV-265341), assessed 25 February 2025.
Findings
A $2,900.00 penalty was assessed and paid in full on 10 April 2025.
Report Facts
Penalty amount: 2900
Amount paid: 2900
Amount remaining: 0
Inspection Report — Feb 6, 2025
Complaint Investigation
Date: Feb 6, 2025
Visit Reason
On-site complaint investigation of complaint AZ00223089 at an Assisted Living Center, conducted 6 February 2025.
Complaint Details
An on-site investigation of complaint AZ00223089 was conducted on February 06, 2025, and the following deficiency was cited.
Findings
The inspection found one deficiency related to the facility's failure to designate a certified or temporary certified assisted living facility manager in writing.
Deficiencies (1)
The governing authority failed to designate in writing a manager who holds either a certificate or temporary certificate as an assisted living facility manager. The facility has had no certified manager since January 8, 2024, and no certificate was posted during the investigation.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 25, 2024
Complaint Investigation
Date: Nov 25, 2024
Visit Reason
On-site complaint investigation of complaints AZ00217436, AZ00218673, AZ00218966, and AZ00218983 at an Assisted Living Center, conducted 22 and 25 November 2024.
Complaint Details
An on-site investigation of complaints AZ00217436, AZ00218673, AZ00218966, and AZ00218983 was conducted on November 22, 2024, and November 25, 2024, resulting in two deficiencies cited.
Findings
The inspection found two deficiencies related to medication administration not complying with orders and garbage being stored in uncovered containers. These deficiencies posed risks to resident health and safety.
Deficiencies (2)
The manager failed to ensure medication administered to residents was in compliance with medication orders for three of four sampled residents, including missed doses and administration without orders.
The manager failed to ensure garbage and refuse were stored in covered containers, with uncovered garbage observed in multiple facility locations, posing a risk of infection.
Report Facts
Deficiencies cited: 2
Inspection Report — Sep 26, 2024
Complaint Investigation
Date: Sep 26, 2024
Visit Reason
On-site complaint investigation of complaint AZ00216585 at an Assisted Living Center, conducted 26 September 2024.
Complaint Details
An on-site investigation of complaint AZ00216585 was conducted on September 26, 2024, and no deficiencies were cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Sep 24, 2024
Enforcement
Date: Sep 24, 2024
Visit Reason
Civil monetary penalty, action 00109639 (invoice INV-256948), assessed 24 September 2024.
Findings
A $1,000.00 penalty was assessed and paid in full on 15 November 2024.
Report Facts
Penalty amount: 1000
Amount paid: 1000
Amount remaining: 0
Inspection Report — Sep 13, 2024
Complaint Investigation
Date: Sep 13, 2024
Visit Reason
On-site complaint investigation of complaints AZ00214794, AZ00215256, and AZ00215742 at an Assisted Living Center, conducted 13 September 2024.
Complaint Details
An on-site investigation of complaints AZ00214794, AZ00215256, and AZ00215742 was conducted on September 13, 2024, and the following deficiency was cited.
Findings
The inspection found one deficiency related to medication administration not being in compliance with medication orders for one resident. The deficient practice posed a risk of harm due to improper medication administration.
Deficiencies (1)
Medication administration — The manager failed to ensure medication was administered in compliance with a medication order for one of four sampled residents, resulting in missed doses due to medication unavailability.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 6, 2024
Annual Inspection
Date: Aug 6, 2024
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints AZ00201825, AZ00204181, AZ00204835, AZ00209668, AZ00210570, AZ00213450, and AZ00214009 at an Assisted Living Center, conducted 5-6 August 2024.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00201825, AZ00204181, AZ00204835, AZ00209668, AZ00210570, AZ00213450, and AZ00214009 conducted on August 5-6, 2024.
Findings
The inspection found five deficiencies related to documentation delays, failure to immediately report suspected abuse, inadequate verification of caregiver skills, lack of first aid certification documentation, and improper medication storage. No plan of correction was provided for any deficiency.
Deficiencies (5)
E — The manager failed to provide requested personnel schedules within two hours after a Department request, with multiple date ranges missing. This was a repeat citation from a prior inspection.
J — The manager failed to immediately report suspected abuse, neglect, or exploitation incidents to Adult Protective Services as required, causing risk to resident health and safety.
The manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, with one caregiver providing services for two months before verification.
The manager failed to ensure a caregiver provided current first aid training certification specific to adults before providing assisted living services, with one caregiver lacking such documentation.
F — The manager failed to ensure medication was stored in a separate locked area, as an office in the memory care section was found unlocked with resident medication accessible.
Report Facts
Deficiencies cited: 5
Complaints investigated: 7
Inspection Report — Apr 24, 2024
Complaint Investigation
Date: Apr 24, 2024
Visit Reason
On-site complaint investigation of complaints AZ00208808 and AZ00208917 at an Assisted Living Center, conducted 24 April 2024.
Complaint Details
An on-site investigation of complaints AZ00208808 and AZ00208917 was conducted on April 24, 2024, and no deficiencies were cited.
Findings
No deficiencies were cited during this inspection.
Report Facts
Complaints investigated: 2
Inspection Report — May 30, 2023
Enforcement
Date: May 30, 2023
Visit Reason
Civil monetary penalty, action 00109756 (invoice INV-257061), assessed 30 May 2023.
Findings
A $1,250.00 penalty was assessed and paid in full on 15 July 2023.
Report Facts
Penalty amount: 1250
Amount paid: 1250
Amount remaining: 0
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