Inspection Reports for
The Citadel Senior Living Community
520 S Higley Rd, Mesa, AZ 85206, United States, AZ, 85206
Back to Facility Profile42 Reports
Inspection Report — Apr 3, 2026
Complaint Investigation
Date: Apr 3, 2026
Visit Reason
On-site complaint investigation of complaints 00163135, 00164129, and 00164323 at an Assisted Living Center, conducted 3 April 2026.
Complaint Details
On March 4, 2024, the Department issued a Notice of Intent to Revoke for license AL12140C. The Licensee and the Department entered into a Settlement Agreement executed July 8, 2024. On April 3, 2026, the Department conducted an on-site complaint inspection for license AL12140C and found the Licensee out of compliance with Terms #17 and #18 of the Agreement. The licensee failed to meet the requirements of the Settlement Agreement as indicated in the deficiencies found during the investigation of complaints 00163135, 00164129, and 00164323.
Findings
The inspection found two deficiencies related to the failure to ensure that residents receiving personal care and directed care services had accessible means to alert staff in emergencies. These deficiencies posed risks to resident safety and included a repeat citation from a prior inspection.
Deficiencies (2)
R9-10-814 — The manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom or residential unit used by a resident receiving personal care services. The pendant device observed was not working and staff were unaware it needed a new battery.
R9-10-815 — The manager failed to ensure that a bell, intercom, or other mechanical means to alert employees was available in bedrooms used by residents receiving directed care services. One resident had a bell across the room and another had no alert device, posing a risk to their physical health and safety.
Report Facts
Deficiencies cited: 2
Complaints investigated: 3
Inspection Report — Mar 19, 2026
Complaint Investigation
Date: Mar 19, 2026
Visit Reason
On-site complaint investigation of complaints 00161685, 00161598, and 00161197 at an Assisted Living Center, conducted 19 March 2026.
Complaint Details
This revised Statement of Deficiencies supersedes the previous SOD sent on April 28, 2026, for INSP-0170434. On March 4, 2024, the Department issued a Notice of Intent to Revoke for license AL12140C. The Licensee and the Department entered into a Settlement Agreement executed July 8, 2024. On March 19, 2026, the Department conducted an on-site complaint inspection for license AL12140C and found the Licensee out of compliance with Term #17 of the agreement. The inspection investigated complaints 00161685, 00161598, and 00161197.
Findings
The inspection found two deficiencies related to medication documentation and administration compliance. The facility failed to document residents' medication refusals and administered medication inconsistently with physician orders.
Deficiencies (2)
R9-10-811 — The manager failed to ensure that residents' medical records contained documentation of medication refusals despite multiple instances of refused medications without proper follow-up documentation.
R9-10-817 — The manager failed to ensure that medication was administered in compliance with the medication order, as a resident received two tablets daily when the MAR indicated one tablet, and no documentation showed notification of this discrepancy.
Report Facts
Deficiencies cited: 2
Complaints investigated: 3
Inspection Report — Mar 3, 2026
Complaint Investigation
Date: Mar 3, 2026
Visit Reason
On-site complaint investigation of complaints 00121903, 00152394, 00152395, 00154206, 00154904, 00158397, 00158889, 00158926, 00159227, 00159940, 00160112, 00160221, and 00160505 at an Assisted Living Center, conducted 3 March 2026.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00121903, 00152394, 00152395, 00154206, 00154904, 00158397, 00158889, 00158926, 00159227, 00159940, 00160112, 00160221, and 00160505 conducted on March 2, 2026, and March 3, 2026.
Findings
No deficiencies were found during the on-site investigation of the complaints.
Report Facts
Complaints investigated: 13
Inspection Report — Feb 6, 2026
Date: Feb 6, 2026
Visit Reason
On-site review of the plan of correction at an Assisted Living Center conducted 6 February 2026.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Feb 3, 2026
Complaint Investigation
Date: Feb 3, 2026
Visit Reason
On-site complaint investigation of complaints 00155806, 00155829, 00156816, and 00157354 at an Assisted Living Center, conducted 3 February 2026.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00155806, 00155829, 00156816, and 00157354 conducted on February 2, 2026.
Findings
No deficiencies were found during the complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Jan 9, 2026
Complaint Investigation
Date: Jan 9, 2026
Visit Reason
On-site complaint investigation of complaint 00155533 at an Assisted Living Center, conducted 9 January 2026.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00155533 conducted on January 9, 2026.
Findings
No deficiencies were found during the inspection.
Report Facts
Complaints investigated: 1
Inspection Report — Dec 10, 2025
Date: Dec 10, 2025
Visit Reason
On-site inspection of The Citadel Assisted Living Facility conducted 10 December 2025 as a follow-up to a prior complaint inspection and Settlement Agreement compliance review.
Complaint Details
On March 4, 2024, the Department issued a Notice of Intent to Revoke for license AL12140C. The Licensee and Department entered into a Settlement Agreement executed July 8, 2024. On April 21, 2025, an on-site complaint inspection found the Licensee out of compliance with Term #17 of the agreement. The licensee failed to meet the requirements as indicated in deficiencies found during the December 10, 2025 plan of correction review.
Findings
The inspection found two deficiencies: failure to ensure residents provided evidence of freedom from infectious tuberculosis as required, and failure to maintain clean and pest-free premises due to cockroach presence in a resident's room. Both deficiencies were repeat or uncorrected from prior inspections.
Deficiencies (2)
R9-10-807 — The manager failed to ensure three of four residents provided evidence of freedom from infectious tuberculosis signed by an authorized professional within the required timeframe, posing a TB exposure risk.
R9-10-820 — The manager failed to ensure the facility premises were cleaned and disinfected, as evidenced by live and dead cockroaches found in a resident's room, posing a health risk.
Report Facts
Deficiencies cited: 2
Inspection Report — Dec 2, 2025
Complaint Investigation
Date: Dec 2, 2025
Visit Reason
On-site complaint investigation of complaints 00151099, 00151145, 00151082, and 00150629 at an Assisted Living Center, conducted 2 December 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00151099, 00151145, 00151082, and 00150629 conducted on December 1, 2025.
Findings
No deficiencies were found during the complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Nov 17, 2025
Complaint Investigation
Date: Nov 17, 2025
Visit Reason
On-site complaint investigation of complaints 00149061, 00146659, and 00147847 at an Assisted Living Center, conducted 17 November 2025.
Complaint Details
On March 4, 2024, a Notice of Intent to Revoke was issued. A Settlement Agreement was executed July 8, 2024. On April 21, 2025, an on-site complaint inspection found noncompliance with the agreement. On September 18, 2025, a compliance and complaint inspection found continued noncompliance with Term #17 of the agreement. On October 31, 2025, a Notice of Non-Compliance was issued. The licensee failed to meet Settlement Agreement requirements as indicated in deficiencies found during the investigation of complaints 00149061, 00146659, and 00147847 conducted on November 17, 2025.
Findings
The inspection found six deficiencies related to caregiver training, incomplete service plans, failure to provide services as planned, lack of resident dignity and respect, medication administration errors, and unclean premises. Several deficiencies were repeats from prior inspections.
Deficiencies (6)
R9-10-806 — The manager failed to ensure a caregiver provided valid adult CPR training certification before providing assisted living services, as one caregiver's certification was from an online-only course without a return demonstration.
R9-10-808 — The manager failed to ensure a resident's service plan included the amount, type, and frequency of assisted living services provided, as these details were missing from the plan reviewed.
R9-10-808 — The manager failed to ensure a caregiver provided services according to the resident’s service plan, resulting in the resident lying in feces for hours, going weeks without showers, and not receiving meal assistance as required.
R9-10-810 — The manager failed to ensure a resident was treated with dignity, respect, and consideration, as evidenced by the resident’s soiled condition, lack of assistance, and unclean environment.
R9-10-817 — The manager failed to ensure medication was administered in compliance with orders, including administering medications that were out of stock and lacking documentation for withheld medications.
R9-10-820 — The manager failed to ensure the premises were cleaned, with heavily soiled flooring, grime in the shower area, unclean toilets, and scattered trash observed throughout the residential unit.
Report Facts
Deficiencies cited: 6
Complaints investigated: 3
Inspection Report — Nov 4, 2025
Date: Nov 4, 2025
Visit Reason
Off-site desktop review conducted on 4 November 2025 to modify the licensed capacity from 150 directed care beds to 36 directed care beds and 114 personal care beds at an Assisted Living Center.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Sep 24, 2025
Enforcement
Date: Sep 24, 2025
Visit Reason
Civil monetary penalty, action 00139163 (invoice INV-298673), assessed 24 September 2025.
Findings
A $1,250.00 penalty was assessed and paid in full on 24 September 2025.
Report Facts
Penalty amount: 1250
Amount paid: 1250
Amount remaining: 0
Inspection Report — Sep 18, 2025
Annual Inspection
Date: Sep 18, 2025
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints 00145071 and 00138655 at The Citadel Assisted Living Facility, conducted 18 September 2025.
Complaint Details
On March 4, 2024, the Department issued a Notice of Intent to Revoke for license AL12140C. The Licensee and the Department entered into a Settlement Agreement executed July 8, 2024. On April 21, 2025, an on-site complaint inspection found the Licensee out of compliance with Term #17 of the agreement. This inspection investigated complaints 00145071 and 00138655 conducted on September 18, 2025.
Findings
The inspection found nine deficiencies related to personnel tuberculosis documentation, CPR training, resident tuberculosis evidence, medication storage plans, resident dignity and respect, cognitive stimulation in service plans, medication administration compliance and documentation, and bathroom privacy. Several deficiencies posed risks to resident health, safety, and rights.
Deficiencies (9)
R9-10-806 — The manager failed to ensure personnel records included documentation of evidence of freedom from infectious tuberculosis for one of ten personnel sampled, posing a potential TB exposure risk to residents.
R9-10-806 — The manager failed to ensure personnel records included documentation of current CPR training for three of ten employees sampled, posing a risk if an employee was unable to meet resident needs.
R9-10-807 — The manager failed to ensure two residents provided evidence of freedom from infectious tuberculosis, posing a TB exposure risk and preventing determination of substantial compliance.
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.
R9-10-810 — The manager failed to ensure a resident was treated with dignity, respect, and consideration after allegations of sexual abuse by a caregiver, posing a risk to resident health and safety.
R9-10-815 — The manager failed to ensure service plans for four residents receiving directed care included specific cognitive stimulation and activities to maximize functioning, risking unclear service provision.
R9-10-817 — The manager failed to ensure medication administration complied with orders for two residents, including missing blood pressure documentation and improper administration when parameters were not met.
R9-10-817 — The manager failed to ensure medication administration was accurately documented for one resident, with duplicate orders and incorrect transcription leading to inaccurate eMAR documentation.
R9-10-821 — The manager failed to ensure a shared resident bathroom provided privacy, as no door or curtain was in place, risking the resident's right to privacy.
Report Facts
Deficiencies cited: 9
Complaints investigated: 2
Inspection Report — Aug 5, 2025
Complaint Investigation
Date: Aug 5, 2025
Visit Reason
On-site complaint investigation of complaints 00138244 and 00138238 at an Assisted Living Center, conducted 5 August 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00138244 and 00138238 conducted on August 5, 2025.
Findings
No deficiencies were found during the inspection.
Inspection Report — Jul 21, 2025
Complaint Investigation
Date: Jul 21, 2025
Visit Reason
On-site complaint investigation of complaint 00131968 at an Assisted Living Center, conducted 21 July 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00131968 conducted on July 21, 2025.
Findings
No deficiencies were found during the inspection.
Inspection Report — Jul 15, 2025
Complaint Investigation
Date: Jul 15, 2025
Visit Reason
On-site complaint investigation of complaint 00136293 at an Assisted Living Center, conducted 15 July 2025.
Complaint Details
No deficiencies were found during the investigation of complaint number 00136293 conducted on July 15, 2025.
Findings
No deficiencies were found during the investigation.
Report Facts
Complaints investigated: 1
Inspection Report — Jul 1, 2025
Complaint Investigation
Date: Jul 1, 2025
Visit Reason
On-site complaint investigation of complaints 00135153, 00134921, and 00134454 at an Assisted Living Center, conducted 1 July 2025.
Complaint Details
On March 4, 2024, the Department issued a Notice of Intent to Revoke for license AL12140C. The Licensee and the Department entered into a Settlement Agreement executed July 8, 2024. On April 21, 2025, an on-site complaint inspection found the Licensee out of compliance with Term #17 of the agreement. The deficiencies were found during the investigation of complaints 00135153, 00134921, and 00134454 conducted on July 1, 2025.
Findings
The inspection found three deficiencies related to emergency notification, documentation of preventive actions after incidents, and environmental cleanliness. The facility failed to immediately notify emergency contacts and primary care providers, document preventive actions after incidents, and maintain clean premises in some resident rooms.
Deficiencies (3)
R9-10-819 — The manager failed to ensure that when a resident had an incident requiring medical services, the resident's emergency contact and primary care provider were immediately notified, as documented in one of two residents' records reviewed.
R9-10-819 — The manager failed to ensure that caregivers documented any action taken to prevent incidents from occurring in the future for two of four residents reviewed, with no such documentation found in the incident reports.
R9-10-820 — The manager failed to ensure the facility premises were cleaned and disinfected, as evidenced by feces and urine odors and residues in two residents' rooms, posing a health risk.
Report Facts
Deficiencies cited: 3
Complaints investigated: 3
Inspection Report — Jun 18, 2025
Complaint Investigation
Date: Jun 18, 2025
Visit Reason
On-site complaint investigation of complaint 00133779 at an Assisted Living Center, conducted 18 June 2025.
Complaint Details
An on-site complaint investigation for 00133779 was conducted on June 18, 2025 and no deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jun 16, 2025
Date: Jun 16, 2025
Visit Reason
On-site review of the plan of correction at an Assisted Living Center conducted 16 June 2025.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Jun 5, 2025
Complaint Investigation
Date: Jun 5, 2025
Visit Reason
On-site complaint investigation at an Assisted Living Center, conducted 5 June 2025.
Findings
One deficiency was found related to medication administration compliance. No evidence text was provided for the deficiency.
Deficiencies (1)
The facility failed to ensure that medication administered to a resident was in compliance with a medication order.
Report Facts
Deficiencies cited: 1
Inspection Report — May 19, 2025
Complaint Investigation
Date: May 19, 2025
Visit Reason
On-site complaint investigation of complaint 00129688 at an Assisted Living Center, conducted 19 May 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00129688 conducted on May 19, 2025.
Findings
No deficiencies were found during the inspection.
Inspection Report — May 2, 2025
Complaint Investigation
Date: May 2, 2025
Visit Reason
On-site complaint investigation of complaint 00129393 at an Assisted Living Center, conducted 2 May 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00129393 conducted on May 2, 2025.
Findings
No deficiencies were found during this inspection.
Inspection Report — Apr 21, 2025
Complaint Investigation
Date: Apr 21, 2025
Visit Reason
On-site complaint investigation of complaints 00127292, 00125166, 00122165, and 00120770 at an Assisted Living Center, conducted 21 April 2025.
Complaint Details
On March 4, 2024, the Department issued a Notice of Intent to Revoke for license AL12140C. The Licensee and the Department entered into a Settlement Agreement executed July 8, 2024. The inspection on April 21, 2025, investigated complaints 00127292, 00125166, 00122165, and 00120770 and found noncompliance with Term #17 of the Settlement Agreement regarding substantial compliance.
Findings
The inspection found the facility out of compliance with the Settlement Agreement terms, identifying eight deficiencies related to opioid medication documentation, investigation of suspected exploitation, incomplete service plans, unsecured exits, food menu posting, incident documentation, storage of toxic materials, and bathroom privacy.
Deficiencies (8)
R9-10-120 — The manager failed to ensure authorized individuals documented the resident's need for opioids before administration and the effect afterward for two residents receiving opioids.
R9-10-803 — The manager failed to initiate and document an investigation of suspected exploitation within five working days after having a reasonable basis to believe exploitation occurred.
R9-10-808 — The manager failed to ensure residents' written service plans included the amount, type, and frequency of assisted living services provided, including medication assistance, for two nonambulatory residents.
R9-10-815 — The manager failed to ensure there was a means of exiting the facility that provided access to an outside area at least 30 feet away and alerted employees of resident egress.
R9-10-817 — The manager failed to ensure a food menu was prepared at least one week in advance, conspicuously posted at least one calendar day before the first meal, and included any food substitutions timely.
R9-10-818 — The manager failed to ensure caregivers documented any action taken to prevent incidents resulting in medical services for two residents.
R9-10-819 — The manager failed to ensure poisonous or toxic materials were stored in locked, labeled containers inaccessible to residents.
R9-10-820 — The manager failed to ensure residents' bathrooms provided privacy when in use, as shared bathrooms lacked doors or curtains for privacy.
Report Facts
Deficiencies cited: 8
Complaints investigated: 4
Inspection Report — Mar 4, 2025
Enforcement
Date: Mar 4, 2025
Visit Reason
Civil monetary penalty, action 00122741 (invoice INV-267787), assessed 4 March 2025.
Findings
A $250.00 penalty was assessed and paid in full on 25 April 2025.
Report Facts
Penalty amount: 250
Amount paid: 250
Amount remaining: 0
Inspection Report — Feb 24, 2025
Complaint Investigation
Date: Feb 24, 2025
Visit Reason
On-site complaint investigation of complaints AZ00108812, AZ00223388, and 00116048 at an Assisted Living Center, conducted 24 February 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint AZ00108812 and AZ00223388 / 00116048 conducted on February 24, 2025.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Dec 24, 2024
Complaint Investigation
Date: Dec 24, 2024
Visit Reason
On-site complaint investigation of complaints AZ00218254 and AZ00220351 at an Assisted Living Center, conducted 24 December 2024.
Complaint Details
An on-site investigation of complaints AZ00218254 and AZ00220351 was conducted on December 24, 2024 and no deficiencies were cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Dec 18, 2024
Complaint Investigation
Date: Dec 18, 2024
Visit Reason
On-site complaint investigation at The Citadel Assisted Living Facility, conducted 18 December 2024, regarding medication administration and care documentation.
Complaint Details
On December 18, 2024, an on-site review of the plan of correction was conducted and the following deficiency was cited.
Findings
Three deficiencies were found, including failure to ensure medication administration compliance with orders for multiple residents. Two deficiencies had plans of correction provided, while one medication administration deficiency did not have a plan of correction.
Deficiencies (3)
Documentation submission — No evidence was provided regarding documentation of required medical information before or at acceptance of individuals.
Care documentation — No evidence was provided that caregivers documented services provided in residents' medical records as required.
Medication administration — The manager failed to ensure medications were administered in compliance with orders for four of seven residents sampled, including administration of discontinued medications and lack of signed orders for some medications.
Report Facts
Deficiencies cited: 3
Inspection Report — Nov 4, 2024
Complaint Investigation
Date: Nov 4, 2024
Visit Reason
On-site complaint investigation of complaints AZ00217889, AZ00218093, AZ00218094, and AZ00218110 at an Assisted Living Center, conducted 4 November 2024.
Complaint Details
An on-site investigation of complaint AZ00217889, AZ00218093, AZ00218094, and AZ00218110 was conducted on November 4, 2024, and no deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Oct 21, 2024
Annual Inspection
Date: Oct 21, 2024
Visit Reason
On-site complaint and annual compliance inspection of license AL12140C at The Citadel Assisted Living Facility, conducted 21 October 2024, investigating complaints AZ00212178, AZ00216082, AZ00216389, AZ00217005, AZ00217416, AZ00217584, and AZ00217557.
Complaint Details
On March 4, 2024, the Department issued a Notice of Intent to Revoke for license AL12140C. The Licensee and the Department entered into a Settlement Agreement executed July 8, 2024. The inspection on October 21, 2024, found the Licensee out of compliance with Term #17 of the agreement. Complaints investigated include AZ00212178, AZ00216082, AZ00216389, AZ00217005, AZ00217416, AZ00217584, and AZ00217557.
Findings
The inspection found three deficiencies related to incomplete or missing documentation for resident acceptance, inadequate documentation of services provided by caregivers, and medication administration not in compliance with orders. Two deficiencies had plans of correction provided; one deficiency had no plan provided.
Deficiencies (3)
The manager failed to ensure that documentation dated within 90 calendar days before acceptance included whether residents required continuous medical services, nursing services, or restraints, and was signed by an authorized medical practitioner for three of ten residents reviewed.
The manager failed to ensure caregivers documented the services provided in residents' medical records, resulting in incomplete verification of services against service plans for multiple residents.
The manager failed to ensure medication administered to residents was in compliance with a verified medication order; verbal orders were not verified and medication lists were unsigned for two residents.
Report Facts
Deficiencies cited: 3
Complaints investigated: 7
Inspection Report — May 9, 2024
Complaint Investigation
Date: May 9, 2024
Visit Reason
On-site complaint investigation of complaints AZ00208644, AZ00208649, AZ00209675, AZ00209760, and AZ00209791 at an Assisted Living Center, conducted 9 May 2024.
Complaint Details
An on-site investigation of complaints AZ00208644, AZ00208649, AZ00209675, AZ00209760, and AZ00209791 was conducted on May 9, 2024, and no deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 5
Inspection Report — Mar 29, 2024
Complaint Investigation
Date: Mar 29, 2024
Visit Reason
On-site complaint investigation of complaints AZ00207178, AZ00207180, AZ00207703, AZ00207829, and AZ00208255 at an Assisted Living Center, conducted 29 March 2024.
Complaint Details
An on-site investigation of complaints AZ00207178, AZ00207180, AZ00207703, AZ00207829, and AZ00208255 was conducted on March 29, 2024, and no deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Feb 6, 2024
Complaint Investigation
Date: Feb 6, 2024
Visit Reason
On-site complaint investigation of complaints AZ00205937 and AZ00206010 at an Assisted Living Center, conducted 6 February 2024.
Complaint Details
An on-site investigation of complaint AZ00205937 and AZ00206010 was conducted on February 6, 2024, and the following deficiency was cited:
Findings
The inspection found one deficiency related to the lack of a mechanical alert system in a resident's bedroom, posing a risk to resident safety.
Deficiencies (1)
The manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom used by a resident receiving personal care services. This failure resulted in a resident sitting on the toilet for hours after pushing a pendant without staff response.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 19, 2024
Complaint Investigation
Date: Jan 19, 2024
Visit Reason
On-site complaint investigation of complaints AZ00201805, AZ00201866, AZ00203201, AZ00203413, AZ00205321, AZ00205232 and AZ000205329 at an Assisted Living Center, conducted 19 January 2024.
Complaint Details
An on-site investigation of complaints AZ00201805, AZ00201866, AZ00203201, AZ00203413, AZ00205321, AZ00205232 and AZ000205329 was conducted on January 19, 2024 and the following deficiencies were cited:
Findings
The inspection found four deficiencies related to incomplete service plans, undocumented services, unsecured memory care area leading to resident elopement, and uncovered garbage containers. Plans of correction were provided for all deficiencies.
Deficiencies (4)
The manager failed to ensure a resident had a written service plan including the frequency of assisted living services for three of seven residents sampled.
The manager failed to ensure a caregiver documented the services provided in the resident's medical record for three of seven residents sampled, posing a risk as services could not be verified.
The manager failed to ensure the premises were free from a condition that may cause physical injury; the memory care door was unsecured on one side, allowing a resident to elope.
The manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags; uncovered garbage containers were observed in two resident rooms.
Report Facts
Deficiencies cited: 4
Inspection Report — Oct 3, 2023
Complaint Investigation
Date: Oct 3, 2023
Visit Reason
On-site complaint investigation of complaints AZ00199277, AZ00199342, and AZ00199352 at an Assisted Living Center, conducted 23 August 2023 with off-site documentation review completed 3 October 2023.
Complaint Details
An on-site investigation of complaints AZ00199277, AZ00199342, and AZ00199352 was conducted on August 23, 2023, with an off-site documentation review completed on October 3, 2023.
Findings
The inspection found one deficiency related to the manager's failure to document suspected abuse or neglect and related actions, posing a risk due to inadequate investigation and documentation.
Deficiencies (1)
The manager failed to document suspected abuse or neglect, any action taken, and the required report, despite multiple incident reports of resident falls and referral to police for elder abuse. This failure posed a risk as the facility did not properly investigate or document the suspected abuse or neglect.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 30, 2023
Complaint Investigation
Date: Aug 30, 2023
Visit Reason
On-site complaint investigation of complaints AZ00199828, AZ00199862, and AZ00199929 at an Assisted Living Center, conducted 30 August 2023.
Complaint Details
An on-site investigation of complaint AZ00199828, AZ00199862, and AZ00199929 was conducted on August 30, 2023 and the following deficiencies were cited.
Findings
The inspection found ten deficiencies related to staff training, policies and procedures, service plans, medication administration, cleanliness, safety hazards, and garbage storage. All deficiencies were cited and plans of correction were provided.
Deficiencies (10)
36-420.01 — The facility failed to administer initial and continued competency training on fall prevention and fall recovery to all staff, including employees E5 and E6, posing a risk to resident care and safety.
Policies and procedures — The manager failed to establish and document policies and procedures covering methods to be aware of residents' general or specific whereabouts based on their level of assisted living services.
Written service plan — The manager failed to ensure residents had written service plans that included medication administration and how medication stored in residents' rooms would be stored and controlled, for residents R6 and R7.
Written service plan review — The manager failed to ensure written service plans were reviewed and updated at least once every three months for residents R1 and R2 receiving directed care services.
Written service plan signatures — The manager failed to ensure service plans were signed and dated by the resident or representative, the manager, and the nurse or medical practitioner for residents R2 and R5 receiving medication administration.
Policies and procedures — The manager failed to establish and document policies and procedures to ensure the safety of residents who may wander.
R9-10-816.B.3 — The manager failed to ensure medication administered to resident R5 was in compliance with medication orders, with multiple medications not documented as administered or lacking nurse notes.
Cleanliness — The manager failed to ensure the premises were cleaned and disinfected to prevent, minimize, and control illness or infection, with soiled bedding, clutter, and cleaning supplies stored near food in residents R6 and R7's unit.
Premises safety — The manager failed to ensure the premises were free from conditions that could cause physical injury, including clutter, exposed cords, accessible opioid medication, and other hazards in residents R6 and R7's unit.
Garbage storage — The manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags, with an uncovered can observed in residents R6 and R7's unit.
Report Facts
Deficiencies cited: 10
Inspection Report — Aug 29, 2023
Enforcement
Date: Aug 29, 2023
Visit Reason
Civil monetary penalty, action 00112637 (invoice INV-259094), assessed 29 August 2023.
Findings
A $5,250.00 penalty was assessed and paid in full on 8 August 2024.
Report Facts
Penalty amount: 5250
Amount paid: 5250
Amount remaining: 0
Inspection Report — Aug 7, 2023
Complaint Investigation
Date: Aug 7, 2023
Visit Reason
On-site complaint investigation of complaints AZ00195560, AZ00195561, AZ00196631, AZ00196635, AZ00197535, AZ00197537, AZ00198293 and AZ00198600 at an Assisted Living Center, conducted 7 August 2023.
Complaint Details
An on-site investigation of complaints AZ00195560, AZ00195561, AZ00196631, AZ00196635, AZ00197535, AZ00197537, AZ00198293 and AZ00198600 was conducted on August 7, 2023 and the following deficiencies were cited.
Findings
The inspection found five deficiencies related to staff training on fall prevention, timely updating of resident service plans, documentation of services provided, medication orders, and compliance with medication administration and documentation requirements.
Deficiencies (5)
36-420.01 — The facility failed to administer a training program for all staff regarding fall prevention and fall recovery, including initial and continued competency training.
The manager failed to ensure a resident had a written service plan updated within 14 calendar days after a significant change in condition for two of twelve residents sampled.
The manager failed to ensure caregivers documented the services provided in the residents' medical records for five of six residents sampled, posing a risk as services could not be verified.
The manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for one of six residents sampled, posing a risk of improper medication administration.
The manager failed to ensure medications were administered in compliance with medication orders and documented in the residents' medical records for four of six residents sampled, including instances of medication administration without valid orders and missing documentation.
Report Facts
Deficiencies cited: 5
Inspection Report — Jun 6, 2023
Enforcement
Date: Jun 6, 2023
Visit Reason
Civil monetary penalty, action 00113243 (invoice INV-259597), assessed 6 June 2023.
Findings
A $2,000.00 penalty was assessed and paid in full on 15 July 2023.
Report Facts
Penalty amount: 2000
Amount paid: 2000
Amount remaining: 0
Inspection Report — 500cs00001LtzT4AAJ
Enforcement
Date: 500cs00001LtzT4AAJ
Visit Reason
Enforcement action for THE CITADEL ASSISTED LIVING FACILITY, identified as 500cs00001LtzT4AAJ, status Closed (Complete).
Findings
No penalty amount or payment information was provided in the document.
Report
Report
Report
Report
Viewing
Loading inspection reports...
