Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 9
Oct 1, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2022-12 to 2025-10 with deficiency history and complaint investigations.
Findings
Across nine inspections, including seven complaint investigations and two annual compliance inspections, the facility had nine deficiencies found during the two annual compliance inspections in 2022 and 2023. The complaint investigations found no deficiencies. Deficiencies involved training, documentation, service plans, and policy reviews.
Complaint Details
Seven complaint investigations were conducted between 2023 and 2025 with no deficiencies cited during any of these investigations.
Deficiencies (9)
| Description |
|---|
| A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. Based on record review, documentation review, and interview, the manager failed to ensure, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training for two of four caregivers sampled. |
| C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d); Based on record review, documentation review, observation, and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for pneumonia for five of seven residents sampled. |
| F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 1. Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; 2. Offering sufficient fluids to maintain hydration; 3. Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; and 4. If applicable, the determination in subsection (B)(2)(b)(iii). Based on record review, documentation review, and interview, the manager failed to ensure a service plan for a resident receiving personal care services included required elements for three of three residents sampled. |
| C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 1. The requirements in R9-10-814(F)(1) through (3); 2. If applicable, the determination in R9-10-814(B)(2)(b)(iii); 3. Cognitive stimulation and activities to maximize functioning; 4. Strategies to ensure a resident's personal safety; 5. Encouragement to eat meals and snacks; 6. Documentation: a. Of the resident's weight, or b. From a medical practitioner stating that weighing the resident is contraindicated; and 7. Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan. Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included required elements for four of four sampled residents. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. |
| C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed. Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. |
| E. A manager shall ensure that, unless otherwise stated: 1. Documentation required by this Article is provided to the Department within two hours after a Department request; and Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. |
| B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and Based on record review, documentation review, and interview, the manager failed to ensure required documentation was submitted for four of seven residents sampled. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 2. Policies and procedures for medication administration: a. Are reviewed and approved by a medical practitioner, registered nurse, or pharmacist; Based on documention review and interview, the manager failed to ensure the facility's policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse (RN), or pharmacist. |
Report Facts
Inspections on page: 9
Total deficiencies: 9
Complaint inspections: 7
Total capacity: 100
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