Inspection Reports for Canyon Valley Memory Care
2985 S Camino Del Sol, Green Valley, AZ 85622, AZ, 85622
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Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 32
Jul 15, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-02 to 2025-07 with deficiency history and complaint investigations.
Findings
Across multiple complaint and compliance inspections, numerous deficiencies were identified including failures in service plan documentation, medication administration and storage, personnel records, emergency preparedness, and environmental safety. Several inspections found no deficiencies, but the majority revealed significant compliance issues.
Complaint Details
Multiple complaint investigations were conducted, including complaint numbers 00136435, 00133960, 00133239, 00133290, 00133278, 00127983, AZ00216229, 00115491, AZ00214007, AZ00210553, AZ00205174, AZ00197792, AZ00197910, AZ00199639, AZ00199658, AZ00188176, and AZ00190656. Several inspections found no deficiencies, while others cited numerous deficiencies.
Deficiencies (32)
| Description |
|---|
| R9-10-808.A.3.b. Service Plans; Failed to ensure a resident's written service plan included the level of service the resident was expected to receive. |
| R9-10-815.C.1-7. Directed Care Services; Failed to ensure service plans for residents receiving directed care included documentation of weight and coordination of communications with representatives. |
| R9-10-808.A.5.a-d. Service Plans; Failed to ensure service plans were signed and dated by required parties when initially developed and updated. |
| R9-10-113.A.2.a-f. Tuberculosis Screening; Failed to document and implement required tuberculosis infection control activities. |
| R9-10-804.2.a-b. Quality Management; Failed to submit documented reports to governing authority identifying concerns and actions taken related to resident care. |
| R9-10-808.A.4.a. Service Plans; Failed to review and update service plans within 14 days after significant change in resident condition. |
| R9-10-808.A.4.b.i-iii. Service Plans; Failed to update service plans at required intervals for residents receiving directed care services. |
| R9-10-808.C.1.g. Service Plans; Failed to ensure caregivers documented services provided in residents' medical records. |
| R9-10-814.B.1-2. Personal Care Services; Failed to meet requirements for residents confined to bed or chair including documentation and practitioner review. |
| R9-10-816.B.3.b. Medication Services; Failed to administer medication in compliance with medication orders. |
| R9-10-816.B.3.c. Medication Services; Failed to document medication administration in resident medical records. |
| R9-10-816.F.1. Medication Services; Failed to store medication in a separate locked area used only for medication storage. |
| R9-10-816.F.3.d. Medication Services; Failed to establish and implement policies for storing, inventorying, and dispensing controlled substances. |
| R9-10-817.A.1.a-e. Food Services; Failed to document food substitutions timely and maintain food menus for required period. |
| R9-10-817.C.5. Food Services; Failed to ensure refrigerators used for food or medication storage contained accurate thermometers. |
| R9-10-817.C.6. Food Services; Failed to store frozen foods at 0° F or below. |
| R9-10-818.A.4. Emergency and Safety Standards; Failed to conduct and document disaster drills on each shift at least quarterly. |
| R9-10-819.A.12. Environmental Standards; Failed to store combustible or flammable liquids and hazardous materials in locked areas inaccessible to residents. |
| A.R.S. § 36-420.B.1. Health care institutions; Failed to initiate CPR in accordance with certification training and resident directives. |
| E. Documentation required by this Article; Failed to provide required documentation to the Department within two hours of request. |
| A.10. Manager shall ensure caregivers provide current CPR and first aid training documentation before providing services; Failed to ensure caregiver had valid CPR certification. |
| C. Personnel records; Failed to maintain complete personnel records including qualifications, education, and TB documentation for sampled employees. |
| B.1. Documentation dated within 90 days before acceptance; Failed to ensure residents submitted required documentation signed and dated by authorized medical practitioners. |
| A.5. Service Plans; Failed to ensure service plans were signed and dated by manager when initially developed and updated. |
| C. Medical records; Failed to ensure resident medical records contained required documentation including needs, agreements, medication orders, and administration documentation. |
| C. Policies and procedures; Failed to implement policies covering methods to be aware of resident whereabouts based on level of care. |
| A.5. Service Plans; Failed to ensure service plans were signed and dated by resident, manager, nurse, and medical practitioner as required. |
| C. Caregiver services; Failed to ensure caregivers provided services as per service plan and documented services provided. |
| E. Mechanical alert systems; Failed to ensure call light or other alert system was available and functional in resident bedrooms receiving directed care. |
| B.2. Medication administration policies; Failed to include process for documenting authorized individuals administering medication under medical direction. |
| A.1.b. Premises and equipment; Failed to maintain premises free from conditions causing physical injury including roof leaks, mold, and unsafe conditions. |
| F.1. Medication storage; Failed to store medication in a separate locked room or cabinet used only for medication storage. |
Report Facts
Inspections on page: 10
Total deficiencies: 32
Complaint inspections: 10
Facility capacity: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Health Services Director | Named in multiple findings related to service plans, medication administration, and documentation |
| E2 | Resident Care Coordinator | Named in findings related to medication administration, documentation, and policies |
| E3 | Mentioned in personnel record deficiencies and interviews | |
| E4 | Caregiver | Named in findings related to tuberculosis screening and CPR certification |
| E5 | Named in tuberculosis screening and personnel record deficiencies | |
| Executive Director | Executive Director | Named in findings related to quality management, service plans, and environmental safety |
| Executive Chef | Executive Chef | Named in findings related to food service deficiencies |
| Environmental Services Director | Environmental Services Director | Named in findings related to environmental safety and disaster drills |
| Resident Care Coordinator | Resident Care Coordinator | Named in medication administration and documentation deficiencies |
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