Inspection Report
Capacity: 60
Deficiencies: 16
Oct 9, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2024-03 to 2025-10 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies primarily involved failure to provide required documentation, inadequate investigation and reporting of suspected abuse, incomplete service plans, lack of verification of caregiver skills, and failure to ensure residents were treated with dignity and respect. Some inspections found no deficiencies.
Complaint Details
Multiple on-site complaint investigations were conducted between July 22, 2024 and December 11, 2024, involving allegations of abuse, neglect, failure to provide documentation, and resident rights violations.
Deficiencies (16)
| Description |
|---|
| 36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to provide required documentation to an emergency responder for one of two sampled residents. |
| A.R.S. § 36-424. Inspections; suspension or revocation of license; report to board of examiners of nursing care institution administrators and assisted living facility managers: Failed to provide complete acquiescence in an inspection by refusing to produce requested documents. |
| 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: Failed to provide required documentation within two hours after Department request. |
| E. A manager shall ensure that, unless otherwise stated: 2. When documentation or information is required by this Chapter to be submitted on behalf of an assisted living facility, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the assisted living facility.: Failed to provide required documentation to the Bureau of Assisted Living Facilities Licensing after Department request. |
| J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall: Failed to report suspected abuse, document the report, initiate investigation, and document required information. |
| A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that includes identification, documentation, evaluation of incidents, data collection, evaluation, and action: Failed to ensure a plan was implemented for an ongoing quality management program. |
| A manager shall ensure that: 3. The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority.: Failed to maintain quality management report and supporting documentation for at least 12 months. |
| A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented before providing physical health services and according to policies and procedures: Failed to verify and document caregiver's skills and knowledge before providing physical health services. |
| A manager shall ensure that: 5. An assisted living facility has a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to provide services, meet resident needs, and ensure health and safety: Failed to ensure caregivers had necessary qualifications, experience, skills, and knowledge. |
| B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;: Failed to ensure a resident was treated with dignity, respect, and consideration; repeat deficiency. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that is signed and dated by the resident or representative, manager, and nurse or medical practitioner when developed and updated: Failed to ensure service plans were signed and dated by required parties for three of five residents. |
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver documents the services provided in the resident's medical record;: Failed to ensure caregivers documented services provided in medical records for five residents. |
| B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;: Failed to ensure a resident was treated with dignity, respect, and consideration; repeat deficiency involving verbal abuse and theft by staff. |
| 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.: Failed to ensure caregiver had current CPR training documentation before providing services. |
| 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 skin maintenance, hydration, and incontinence care: Failed to ensure service plans included required elements for five residents. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident is documented in the resident's medical record.: Failed to ensure medication administered was documented for one resident. |
Report Facts
Inspections on page: 7
Total deficiencies: 17
Complaint inspections: 4
Total capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director / Licensed Manager | Named in multiple findings related to refusal to provide documentation, failure to report abuse, and acknowledgment of deficient practices |
| E2 | Caregiver / Medication Technician | Named in findings related to improper resident handling, lack of verified skills, and corrective action |
| E4 | Assistant Caregiver | Named in verbal abuse and termination finding |
| E5 | Caregiver | Named in verbal abuse complaint and termination |
| E8 | Acknowledged failure to provide documentation within two hours |
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