The most recent inspection on March 11, 2025, identified a deficiency related to the facility manager’s failure to ensure a means of exiting the facility that provided access to an outside area and alerted staff to a resident’s egress, resulting in a civil fine. Earlier inspections showed a pattern of deficiencies involving quality management, caregiver designation, resident service plans, medication policies, toxic materials storage, and medical record maintenance, with enforcement actions including fines of $1,500 and $500 that were paid in full. Complaint investigations mostly found deficiencies related to medical record keeping and compliance with care and safety regulations, with one substantiated complaint involving multiple quality and medication management issues. Enforcement actions were taken due to health and safety risks, but license suspensions or revocations were not listed in the available reports. The facility’s inspection history shows recurring issues with documentation and safety protocols, with no clear trend of improvement or worsening over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The deficient practice posed a health and safety risk because the facility was unaware of the general or specific whereabouts of a resident, resulting in a civil fine.
Fines & Penalties (1)
Amount
Reason
Status
$500.00
Failure to ensure a means of exiting the facility that alerts employees of resident egress, posing a health and safety risk.
Eleven deficiencies found related to quality management, caregiver designation, resident service plans, medication policies, toxic materials storage, and opioid prescribing during complaint and compliance inspection.
Findings
Eleven deficiencies found related to quality management, caregiver designation, resident service plans, medication policies, toxic materials storage, and opioid prescribing during complaint and compliance inspection.
Complaint Details
Complaint AZ00215298 investigated
Deficiencies (11)
Description
A. A governing authority shall: 5. Review and evaluate the effectiveness of the quality management program at least once every 12 months;
B. A manager: 3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is: a. At least 21 years of age, and b. Present on the premises
A. A manager shall ensure that: 2. An assistant caregiver: b. Interacts with residents under the supervision of a manager or caregiver;
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: a. A description
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated includes signatures
B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided
F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility
D. A manager shall ensure that: 2. A current toxicology reference guide is available for use by personnel members.
F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented
A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area
R9-10-120. Opioid Prescribing and Treatment F. For a health care institution where opioids are administered as part of treatment or where a patient is
The facility was found deficient in maintaining required medical records for three residents, posing a health and safety risk due to unverifiable required information.
Fines & Penalties (1)
Amount
Reason
Status
$1,500.00
Failure to maintain medical records for each resident as required by state regulations.
One deficiency found related to failure to maintain medical records for each resident according to statutory requirements during complaint investigation.
Findings
One deficiency found related to failure to maintain medical records for each resident according to statutory requirements during complaint investigation.
Complaint Details
Complaints AZ00212960, AZ00205363, and AZ00212996 investigated
Deficiencies (1)
Description
A. A manager shall ensure that: 1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1.
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