Inspection Report Summary
The most recent inspection on November 6, 2025, included enforcement action with a $1,500 fine that has been paid in full. Earlier inspections showed a pattern of deficiencies related mainly to medical record documentation, timely notification of primary care providers after incidents, medication services compliance, and emergency and safety standards. Several enforcement actions with fines, including a $25,000 penalty in May 2025 and smaller fines in late 2023, were issued for issues such as employee training, abuse reporting, and documentation failures. Complaint investigations were mostly unsubstantiated, though some inspections did identify deficiencies tied to service plans, resident rights, and staff qualifications. The facility’s record shows ongoing challenges with regulatory compliance, particularly around documentation and notification procedures, with enforcement actions continuing into late 2025.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
314% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
32
24
16
8
0
Enforcement Action
Enforcement
Fines: 1
Total: $1,500.00
Date: Nov 6, 2025
Summary
The facility was fined $1,500.00 which has been paid in full as of the completion date.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,500.00 | Enforcement action fine against the facility | Paid |
Enforcement Action
Enforcement
Fines: 2
Total: $1,500.00
Date: Sep 30, 2025
Summary
The facility was found to have deficient practices posing risks to health and safety, including incomplete medication records and failure to notify the primary care provider promptly, resulting in civil fines.
Fines & Penalties (2)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to ensure a resident's medical record contained documentation of medication administration including date, time, dosage, and signature. | — |
| $1,000.00 | Failure to ensure a caregiver immediately notified the resident's primary care provider after an accident, emergency, or injury. | — |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Sep 16, 2025
Visit Reason
No deficiencies were found during the on-site investigation of multiple complaints.
Complaint Details
Investigation of complaints 00143040, 00144184, 00144623, and 00144713
Findings
No deficiencies were found during the on-site investigation of multiple complaints.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 4
Date: Jul 30, 2025
Visit Reason
Four deficiencies found related to administration notification, medical records documentation, medication services compliance, and emergency and safety standards notification.
Complaint Details
Investigation of complaint 0000136637
Findings
Four deficiencies found related to administration notification, medical records documentation, medication services compliance, and emergency and safety standards notification.
Deficiencies (4)
R9-10-803.K.2. — Administration
R9-10-811.C.13.a-d. — Medical Records
R9-10-817.B.3.b. — Medication Services
R9-10-819.D.1. — Emergency and Safety Standards
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 2
Date: Jul 7, 2025
Visit Reason
Two deficiencies found related to service plans and resident rights.
Complaint Details
Investigation of complaints 00135347 and 00122654
Findings
Two deficiencies found related to service plans and resident rights.
Deficiencies (2)
R9-10-808.C.1.a. — Service Plans
R9-10-810.B.1. — Resident Rights
Enforcement Action
Enforcement
Fines: 1
Total: $25,000.00
Date: May 14, 2025
Summary
The facility was fined $25,000.00 which has been fully paid and the enforcement action is complete.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $25,000.00 | Fine related to enforcement action against the facility | Paid |
Enforcement Action
Enforcement
Fines: 1
Total: $100,000.00
Date: Mar 31, 2025
Summary
The Department documented violations across several Brookdale facilities, issued Statements of Deficiencies, and assessed civil fines. Brookdale disputed some fines but ultimately entered into a settlement agreement to resolve enforcement actions and comply with corrective measures.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $100,000.00 | Settlement amount to resolve outstanding enforcement actions and notices for four Brookdale facilities. | — |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
No deficiencies were cited during the on-site investigation of complaint AZ00221178.
Complaint Details
Investigation of complaint AZ00221178
Findings
No deficiencies were cited during the on-site investigation of complaint AZ00221178.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Oct 22, 2024
Visit Reason
No deficiencies were cited during the on-site investigation of complaint AZ00217685.
Complaint Details
Investigation of complaint AZ00217685
Findings
No deficiencies were cited during the on-site investigation of complaint AZ00217685.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
No deficiencies were cited during the on-site investigation of complaint AZ00216370.
Complaint Details
Investigation of complaint AZ00216370
Findings
No deficiencies were cited during the on-site investigation of complaint AZ00216370.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
No deficiencies were cited during the on-site investigation of complaint AZ00214769.
Complaint Details
Investigation of complaint AZ00214769
Findings
No deficiencies were cited during the on-site investigation of complaint AZ00214769.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 1
Date: Aug 9, 2024
Visit Reason
One deficiency cited related to resident written service plan.
Complaint Details
Investigation of complaint AZ00214294
Findings
One deficiency cited related to resident written service plan.
Deficiencies (1)
A. Except as required in subsection (B) — Resident written service plan
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 2
Date: Aug 7, 2024
Visit Reason
Two deficiencies cited related to policies and procedures and abuse reporting.
Complaint Details
Investigation of complaints AZ00214162 and AZ00214166
Findings
Two deficiencies cited related to policies and procedures and abuse reporting.
Deficiencies (2)
C. A manager shall ensure that policies and procedures are established and implemented
J. If a manager has a reasonable basis to believe abuse, neglect or exploitation occurred
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 30
Date: Jul 29, 2024
Visit Reason
Thirty deficiencies cited covering a wide range of issues including first aid, fall prevention, quality management, compliance with statutes, staff qualifications, documentation, resident service plans, food safety, evacuation drills, incident notifications, premises cleanliness, and toxic material storage.
Complaint Details
Investigation of complaints AZ00213809, AZ00213769, AZ00212955, AZ00212741, AZ00211631, AZ00210962, AZ00201232, and AZ00201117
Findings
Thirty deficiencies cited covering a wide range of issues including first aid, fall prevention, quality management, compliance with statutes, staff qualifications, documentation, resident service plans, food safety, evacuation drills, incident notifications, premises cleanliness, and toxic material storage.
Deficiencies (30)
36-420. — Health care institutions first aid
36-420.01. — Fall prevention training programs
A. A governing authority shall review and evaluate quality management
A. A governing authority shall ensure compliance with A.R.S. § 36-411
J. If a manager has a reasonable basis to believe abuse, neglect or exploitation occurred
A. A manager shall ensure caregiver skills and knowledge verification
A. A manager shall ensure qualifications, experience, skills, and knowledge of staff
A. A manager shall ensure documentation maintenance
A. A manager shall ensure employee documentation of freedom from infectious tuberculosis
A. A manager shall ensure orientation for caregivers
A. Except as provided in R9-10-808(B)(2), a manager shall ensure resident provides evidence of freedom from tuberculosis
A. Except as required in subsection (B), a manager shall ensure resident has a written service plan including description
A. Except as required in subsection (B), a manager shall ensure resident service plan is reviewed and updated
A. Except as required in subsection (B), a manager shall ensure resident service plan is signed and dated
C. A manager shall ensure caregiver documents services provided in medical record
B. A manager shall ensure resident is treated with dignity, respect, and consideration
C. A manager shall ensure resident medical record contains vaccination notification documentation
F. A manager shall ensure service plan for personal care services includes required elements
B. A manager shall ensure facility does not accept or retain resident confined to bed or chair
C. A manager shall ensure service plan for directed care services includes coordination of communications
C. A manager shall ensure food is obtained, prepared, served, and stored properly including refrigerator thermometer
C. A manager shall ensure facility equipment and food contact surfaces are clean
A. A manager shall ensure evacuation drill for employees and residents conducted at least every six months
D. When resident has accident or injury needing medical services, caregiver immediately notifies required parties
D. When resident has accident or injury needing medical services, caregiver documents actions taken
A. A manager shall ensure premises and equipment are cleaned and disinfected
A. A manager shall ensure garbage and refuse are stored in covered containers lined with plastic bags
A. A manager shall ensure poisonous or toxic materials are stored in labeled containers in locked areas
R9-10-113. — Tuberculosis Screening
R9-10-120. — Opioid Prescribing and Treatment
Enforcement Action
Enforcement
Fines: 3
Total: $1,250.00
Date: Nov 27, 2023
Summary
The enforcement resulted in civil fines totaling $1250.00 for multiple violations related to employee training and abuse reporting requirements.
Fines & Penalties (3)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to report suspected abuse of a resident according to A.R.S. § 46-454. | — |
| $250.00 | Failure to ensure the skills and knowledge of five employees were verified and documented before providing physical health services. | — |
| $500.00 | Failure to ensure one employee provided documentation of CPR and first aid training. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $1,250.00
Date: Oct 31, 2023
Summary
The enforcement resulted in a fine of $1,250.00 which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,250.00 | Fine related to enforcement action | Paid |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 7
Date: Aug 23, 2023
Visit Reason
Seven deficiencies cited related to compliance with statutes, abuse reporting, caregiver skills verification, first aid and CPR documentation, service documentation, disaster drills, and accident notifications.
Complaint Details
Investigation of complaints AZ00188259, AZ00190508, AZ00191312, AZ00192889, and AZ00193010
Findings
Seven deficiencies cited related to compliance with statutes, abuse reporting, caregiver skills verification, first aid and CPR documentation, service documentation, disaster drills, and accident notifications.
Deficiencies (7)
A. A governing authority shall ensure compliance with A.R.S. § 36-411
J. If a manager has a reasonable basis to believe abuse, neglect or exploitation occurred
A. A manager shall ensure caregiver skills and knowledge verification
A. A manager shall ensure caregiver provides current documentation of first aid and CPR training
C. A manager shall ensure caregiver documents services provided in medical record
A. A manager shall ensure disaster drill for employees conducted on each shift quarterly
D. When resident has accident or injury needing medical services, caregiver immediately notifies required parties
Enforcement Action
Enforcement
Total: $0.00
Date: Nodate Enforcement
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