7 Reports
Inspection Report — Sep 26, 2025
Complaint Investigation State
Date: Sep 26, 2025
Visit Reason
On-site complaint investigation of complaint 00142023 at an Assisted Living Center, conducted 26 September 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00142023 conducted on September 26, 2025.
Findings
No deficiencies were found during the inspection.
Inspection Report — Jun 23, 2025
State
Date: Jun 23, 2025
Visit Reason
Off-site desktop review conducted on 23 June 2025 to modify the licensed capacity from 84 directed care to 28 directed care and 56 personal care at an Assisted Living Center.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Jan 16, 2025
Annual Inspection State
Date: Jan 16, 2025
Visit Reason
On-site complaint investigation of complaint AZ00212883 combined with an annual compliance inspection at an Assisted Living Center, conducted 16 January 2025.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00212883 conducted on January 16, 2025.
Findings
The inspection found four deficiencies related to incomplete service plans, missing vaccination notification documentation, delayed resident orientation to emergency exits, and lack of tuberculosis baseline screening documentation.
Deficiencies (4)
The manager failed to ensure a resident had a written service plan completed within 14 calendar days after acceptance for four of six residents sampled, posing a risk due to lack of service direction.
The manager failed to ensure resident medical records contained documentation of notification of the availability of influenza and pneumonia vaccinations for three of six residents, posing a potential illness risk.
The manager failed to ensure residents received orientation to the facility exits and evacuation routes within 24 hours after acceptance for four of six residents sampled.
R9-10-113 — The chief administrative officer failed to implement tuberculosis infection control activities including baseline screening for two of six residents, posing a potential TB exposure risk.
Report Facts
Deficiencies cited: 4
Inspection Report — Apr 11, 2024
Complaint Investigation State
Date: Apr 11, 2024
Visit Reason
On-site complaint investigation of complaint AZ00208842 at an Assisted Living Center, conducted 11 April 2024.
Complaint Details
An on-site investigation of complaint AZ00208842 was conducted on April 11, 2024, and no deficiencies were cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Dec 12, 2023
Enforcement State
Date: Dec 12, 2023
Visit Reason
Civil monetary penalty, action 00112069 (invoice INV-258654), assessed 12 December 2023.
Findings
A $3,500.00 penalty was assessed and paid in full on 8 February 2024.
Report Facts
Penalty amount: 3500
Amount paid: 3500
Amount remaining: 0
Inspection Report — Oct 27, 2023
Annual Inspection State
Date: Oct 27, 2023
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints AZ00184589, AZ00185627, AZ00185823, AZ00186256, AZ00186285, AZ00191929, AZ00193046, AZ00193551, AZ00193822, AZ00195773, AZ00198181, AZ00198620, AZ00200737, AZ00201942, and AZ00202230 at an Assisted Living Center, conducted October 25-27, 2023.
Complaint Details
The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00184589, AZ00185627, AZ00185823, AZ00186256, AZ00186285, AZ00191929, AZ00193046, AZ00193551, AZ00193822, AZ00195773, AZ00198181, AZ00198620, AZ00200737, AZ00201942, and AZ00202230 conducted on October 25-27, 2023.
Findings
This inspection found sixteen deficiencies related to staff training, documentation, resident care, and policy implementation. The facility failed to ensure adequate training, documentation of fingerprint clearance, verification of caregiver skills, tuberculosis clearance, orientation, medication administration, evacuation drills, and resident dignity among other issues.
Deficiencies (16)
36-420.01 — The governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, lacking coverage of fall recovery and documentation for several personnel.
The governing authority failed to ensure documented, good faith efforts to contact previous employers and verify fingerprint clearance card status for five personnel members, with one lacking a valid fingerprint clearance card.
Policies and procedures were not established or documented to protect resident health and safety covering job descriptions, duties, and qualifications including required skills and knowledge for employees and volunteers.
The manager failed to comply with abuse, neglect, and exploitation reporting requirements, including incomplete incident reports and failure to contact local police and Adult Protective Services as required.
The manager failed to verify and document caregiver and assistant caregiver skills and knowledge before providing physical health services, with no policy covering this verification.
R9-10-113 — The manager failed to ensure evidence of freedom from infectious tuberculosis was provided on or before the date personnel began providing services for two of four sampled personnel.
The manager failed to ensure caregivers received orientation specific to their duties before providing assisted living services, with missing documentation for three of four personnel sampled.
The manager failed to ensure current documentation of first aid and adult CPR training certification was provided before caregivers provided assisted living services, with expired or missing certifications for four personnel.
The manager failed to ensure a resident's written service plan was signed and dated by the manager and medical practitioner when initially developed and updated for one of eight residents sampled.
The manager failed to ensure caregivers provided assisted living services as specified in residents' service plans and documented the services provided for two of eight residents sampled.
The manager failed to ensure residents were treated with dignity, respect, and consideration, as evidenced by incomplete incident reports and acknowledged deficiencies in resident treatment.
The manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered, with one resident receiving medication without a signed order.
The manager failed to ensure medication administration policies included a process for documenting individuals authorized by a medical practitioner to administer medication.
The manager failed to ensure medications were administered in compliance with medication orders for two residents, with multiple instances of medications not given or unavailable as documented in records.
The manager failed to ensure evacuation drills for employees and residents were conducted at least once every six months, with no documentation of evacuation drills found.
The manager failed to ensure caregivers documented actions taken to prevent accidents, emergencies, or injuries from recurring, with multiple incident reports lacking such documentation.
Report Facts
Deficiencies cited: 16
Complaints investigated: 15
Report
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