Inspection Reports for
Immanuel Campus of Care

The facility failed to ensure timely notification of the resident's representative regarding an injury sustained by resident #222 after an unwitnessed fall. Staff did not promptly report the incident to family or supervisors, which was a violation of facility policy and expectations.

The complaint investigation found that Resident #222 experienced an unwitnessed fall on October 17, 2025, with bruising noted later, but the family was not notified promptly. The resident's representative confirmed no notification from the facility until hospice staff informed them on October 20, 2025. Staff acknowledged delayed reporting and were reeducated on timely communication.

The facility failed to ensure timely notification to the resident's representative about an injury sustained by Resident #222 following an unwitnessed fall. Staff interviews and record reviews confirmed delayed communication and incomplete documentation of the incident.

Investigation of complaints #2243368, 2243339.

Risk-Based Complaint survey conducted with one deficiency cited related to abuse prevention.

The complaint involved Resident #16 reporting that Resident #3 struck him in the face and attempted to choke him. The incident occurred on July 3, 2025. Witnesses included a Life Enrichment Associate who saw the incident but was not interviewed. The facility failed to report the abuse to the State Agency and Adult Protective Services within the required two-hour timeframe and did not conduct a thorough investigation as required by policy.

The facility failed to protect a resident from abuse by another resident, failed to timely investigate and report the alleged abuse within the mandatory two-hour timeframe, and did not follow proper procedures for interviewing witnesses and staff. The Executive Director confirmed gaps in the investigation and reporting process despite staff training on abuse reporting.

Investigation of complaints 00135689, 00136012, 00136014.

Complaint survey conducted with census 159 and six deficiencies cited related to abuse reporting and resident rights.

The complaint investigation was triggered by Resident #16 reporting to his insurance case manager that Resident #3 struck him in the face and attempted to choke him. Witness testimony from a Life Enrichment Associate confirmed the assault. The facility failed to report the abuse within the mandatory two-hour timeframe and did not fully investigate by interviewing all witnesses. The Executive Director acknowledged the failures in reporting and investigation.

The facility failed to protect Resident #16 from abuse by Resident #3, with evidence of physical assault witnessed by staff. The facility also failed to develop and implement adequate policies and procedures for timely reporting and investigation of abuse allegations, resulting in delayed reporting to appropriate authorities and incomplete investigations.

The complaint investigation substantiated that Resident #222 was physically abused by Resident #333 in a common area. The facility's investigation included interviews with staff and residents, confirming the incident and resulting in separation and assessment of both residents.

The facility failed to protect Resident #222 from abuse by Resident #333, resulting in physical harm evidenced by mild redness on Resident #222's face. Multiple staff interviews and resident assessments confirmed the incident occurred in a designated smoking area, and both residents were separated and assessed following the event.

Investigation of complaints AZ00225062, SF00135196, AZ00209074, AZ00210557.

Complaint survey conducted with two deficiencies cited related to abuse prevention.

The complaint investigation substantiated that Resident #333 physically abused Resident #222 by hitting them in the face, causing mild redness. Multiple staff interviews confirmed the incident and the facility's failure to prevent the abuse.

The facility failed to protect Resident #222 from abuse by Resident #333, resulting in mild redness on Resident #222's face. Both residents were separated and assessed for injuries. Interviews with staff and witnesses confirmed the incident occurred as described.

The facility substantiated resident-to-resident abuse after an investigation revealed Resident #32 grabbed Resident #121's leg and pulled him to the ground. The incident was witnessed by staff and resulted in 1:1 supervision and unit change for Resident #32.

The facility substantiated that Resident #32 grabbed Resident #121's leg and pulled him to the ground, resulting in physical aggression. The facility implemented interventions including 1:1 supervision and unit change for Resident #32. Policies on resident rights and abuse prevention were reviewed.

Investigation of intake #00130912, 00131147, 00131585, 00131826, AZ00211290, AZ00211249, AZ00212102.

Onsite complaint survey conducted with one deficiency cited related to abuse prevention.

The facility substantiated resident-to-resident abuse after an incident where Resident #32 grabbed Resident #121's leg and pulled him to the ground. The investigation included staff interviews and review of clinical records and policies.

The facility failed to prevent resident #32 from physically abusing resident #121, resulting in minimal harm or potential for actual harm. The investigation substantiated the abuse, and interventions included separating the residents, placing resident #32 on 1:1 supervision, and completing a unit change.

The investigation was complaint-related, focusing on a suspected overdose incident involving Resident #12. The complaint was substantiated as the resident overdosed on fentanyl obtained from outside the facility, with no staff involvement in providing the substance.

The facility failed to ensure adequate supervision to prevent a non-prescribed medication overdose for Resident #12, who was found unresponsive and hospitalized after overdosing on fentanyl obtained from outside the facility. Interviews and documentation revealed gaps in preventing residents from obtaining or sharing illicit or non-prescribed substances.

Investigation of complaints 00123323 and 00123532.

Complaint investigation conducted with one deficiency cited related to facility premises and equipment safety.

The investigation was complaint-driven, focusing on a suspected overdose incident involving Resident #12. The complaint was substantiated as the resident was found unresponsive due to fentanyl overdose, which was not prescribed and obtained from outside the facility. Resident #24 admitted to giving fentanyl to Resident #12.

The facility failed to ensure adequate supervision to prevent a non-prescribed medication overdose for Resident #12. Interviews and documentation revealed that Resident #24 gave fentanyl to Resident #12, resulting in an overdose and hospital admission. The facility's interventions to prevent illicit substances were insufficient.

The complaint investigation substantiated abuse by staff towards residents #1 and #2. Staff #5 was found to have physically abused resident #1 and was terminated. Staff #7 was found to have verbally abused resident #2 and was also terminated. Both incidents were reported to the State Board of Nursing.

The facility failed to ensure residents #1 and #2 were free from physical abuse by staff. Resident #1 was pushed roughly and had a desk chair aggressively pushed against his wheelchair by CNA #5, who was subsequently terminated. Resident #2 experienced verbal abuse and aggressive behavior from staff #7, who was also terminated. The facility substantiated both abuse allegations and reported the involved staff to the State Board of Nursing.

Investigation of intake #001211966, 00122041, 00123184.

Complaint survey conducted with one deficiency cited related to abuse prevention.

The complaint investigation substantiated abuse allegations against CNA #5 for physical abuse of resident #1 and CNA #7 for verbal abuse of resident #2. Both staff were terminated and reported to the State Board of Nursing.

The facility failed to ensure residents #1 and #2 were free from physical and verbal abuse by staff. Staff #5 was found to have physically abused resident #1 and was terminated. Staff #7 was found to have verbally abused resident #2 and was also terminated. Both cases were substantiated by the facility.

Recertification survey for Medicare under Life Safety Code 2012 with five deficiencies cited related to fire safety and electrical systems.

The complaint investigation substantiated allegations of resident-to-resident physical abuse involving residents #12 and #400, as well as residents #137 and #105. The abuse was witnessed by staff and admitted by residents. No injuries were noted in the incidents involving residents #12 and #400. Resident #105 was placed on one-on-one supervision and moved to another unit after hitting resident #137. The facility followed reporting procedures and provided staff education on abuse prevention.

The facility failed to ensure residents were free from abuse, substantiating multiple incidents of resident-to-resident physical abuse. Staff intervened during altercations, provided assessments and notifications, and implemented one-on-one supervision and unit transfers to prevent further incidents.

The complaint investigation included substantiated allegations of resident-to-resident physical abuse involving residents #12 and #400, and residents #137 and #105. The facility was found to have failed in preventing and properly reporting these incidents.

The facility failed to ensure resident dignity and respect for Resident #64, failed to protect residents (#12, #400, #137, #105) from abuse including physical altercations, and failed to monitor behaviors as specified in medication orders for residents (#118, #123). The deficiencies posed minimal harm or potential for actual harm to residents.

The complaint investigation substantiated allegations of resident-to-resident physical abuse. The administrator confirmed the allegation based on staff witnessing the incidents and admissions by residents. Notifications were made to appropriate parties within required timeframes.

The facility failed to ensure that residents were free from abuse, with substantiated incidents of resident-to-resident physical altercations involving residents #12, #400, #137, and #105. Staff intervened, provided care, and reported incidents as required, but the incidents posed risks of harm.

The complaint investigation substantiated multiple incidents including resident #64 exposing herself in public areas, resident-to-resident physical abuse involving residents #12 and #400, and residents #137 and #105. The facility failed to report and manage these incidents timely and appropriately. The allegation of resident-to-resident abuse was substantiated based on staff witnessing and resident admissions.

The facility failed to ensure residents were treated with dignity and respect, failed to protect residents from abuse including resident-to-resident physical altercations, and failed to properly monitor behaviors as specified in psychotropic medication orders. Several residents were involved in incidents of exposure and physical abuse with minimal harm noted. Medication administration records did not reflect required behavior monitoring for certain residents.

Investigation of complaints # AZ00222524, AZ00222616, AZ00219154, AZ00212847, AZ00212137, AZ00212282, AZ00215819, AZ00222617, AZ00213412, AZ00222759.

Recertification survey conducted with three deficiencies cited related to abuse prevention, resident rights, and medication administration.

The complaint investigation was substantiated, revealing that residents were improperly restricted to their rooms during COVID-19 quarantine and that one resident was inadequately supervised leading to a suicide attempt.

The facility failed to ensure residents (#55 and #33) were allowed to leave their rooms during COVID-19 quarantine, resulting in dignity and respect violations. Activities were not offered to COVID-19 positive residents, impacting their psychosocial well-being. Additionally, the facility failed to provide adequate supervision to resident #77, who attempted self-harm when left unsupervised.

The investigation was complaint-driven, focusing on residents being restricted from leaving rooms during COVID-19 quarantine, lack of activities for COVID-19 positive residents, and inadequate supervision of a suicidal resident. The complaint was substantiated based on interviews, observations, and documentation.

The facility failed to ensure residents (#55 and #33) were allowed to leave their rooms after quarantine during a COVID-19 outbreak, impacting their dignity and rights. The facility also failed to provide activities to COVID-19 positive residents, affecting their psychosocial well-being. Additionally, the facility failed to provide adequate supervision to resident #77 with suicidal history, resulting in a suicide attempt.

Investigation of complaints AZ00220766, AZ00219884, AZ00220880, AZ00220415.

Complaint survey conducted with three deficiencies cited related to resident dignity, activity choice, and care plan supervision.

Investigation of intake # AZ00217784, AZ00217843, AZ00217975, AZ00210040, AZ0017636.

Onsite complaint survey conducted with one deficiency cited related to failure to provide timely written notification of self-injury.

The complaint was substantiated based on clinical record reviews, staff interviews, and facility documentation confirming verbal abuse by staff member #4 towards resident #1.

The facility failed to ensure that a resident was free from verbal abuse by a staff member, who used inappropriate language and threats. The staff member was suspended and later terminated. The facility's investigation confirmed the unprofessional conduct and reviewed relevant policies and training records.

The complaint was substantiated based on clinical record reviews, staff interviews, and facility documentation. Staff member #4 admitted to verbal abuse and was terminated following investigation.

The facility failed to ensure a resident was free from verbal abuse by a staff member, who used inappropriate language and was subsequently terminated. The investigation confirmed unprofessional conduct and lack of behavior documentation in the resident's records.

The facility failed to ensure that skin assessments were complete and accurately documented for resident #43, who had multiple bruises and discolorations that were not properly recorded in weekly skin checks. Interviews with staff confirmed that bruising was noted but not documented as required by facility policy.

The facility failed to ensure that skin assessments were complete and accurately documented for resident #43, specifically missing documentation of bruising and discoloration noted during weekly skin checks and observations.

The complaint investigation was substantiated with findings that residents were physically abused by other residents, including incidents involving residents #34 and #190, #31 and #183, #164 and #185, #121 and #104, #128 and #167, #156 and #17, #168 and #169, #144 and #49, and #28 and #49. Police intervention and hospitalizations occurred in some cases.

The facility failed to protect the rights of 21 residents to be free from abuse by other residents, resulting in actual harm. Multiple incidents of physical aggression, hitting, punching, and altercations between residents were documented, with some residents requiring hospital visits and one resident being removed by police. The facility submitted several self-reports to the State Agency regarding these incidents.

The investigation was complaint-driven, focusing on multiple incidents of resident-to-resident abuse including hitting, punching, and physical altercations. The facility submitted several self-reports to the State Agency regarding these incidents. Police involvement and behavioral facility transfer occurred for one resident due to aggressive behavior.

The facility failed to protect residents from abuse by other residents, resulting in actual harm to several residents. Multiple incidents of physical aggression, hitting, and altercations among residents were documented, with some residents sustaining injuries such as fractures, lacerations, bruises, and abrasions.

The complaint investigation was substantiated with findings that staff #323 violated professional boundaries by engaging in an inappropriate relationship with resident #90. Additionally, the facility failed to prevent resident #90 from eloping and lacked an appropriate care plan for elopement risk.

The facility failed to ensure professional standards of care when staff engaged in an inappropriate relationship with a resident and failed to prevent a resident from eloping the facility without permission. The facility lacked a care plan for elopement risk despite the resident's history of leaving without a pass and becoming intoxicated.

The complaint involved allegations of inappropriate behavior by staff #323 with resident #90, which was substantiated as consensual but inappropriate and crossing professional boundaries. The complaint also involved resident #90 eloping twice without a pass, which was confirmed by staff interviews and progress notes.

The facility failed to ensure professional standards of care when a staff member engaged in an inappropriate relationship with a resident. Additionally, the facility failed to prevent a resident from eloping twice without a pass, despite known risks and lack of a care plan for elopement.

The complaint investigation substantiated staff physical abuse by CNA staff #305 against resident #53 and resident-to-resident abuse between residents #72 and #79. Verbal abuse by housekeeper staff #802 was also substantiated and resulted in termination.

The facility failed to ensure that residents were free from abuse, including verbal abuse by a housekeeper towards a resident's mother, physical abuse by a CNA towards a resident, and resident-to-resident altercations resulting in injury. Staff involved in abuse were terminated or suspended, and the facility substantiated the abuse incidents.

The complaint investigation focused on residents (#15, #165, #31, #418, #100, #35) who were restricted in phone access and privacy. The investigation also included review of care planning and PASARR referral compliance for residents with complex medical and psychiatric diagnoses.

The facility failed to ensure that residents had reasonable access to their personal phones and privacy during phone calls, with a blanket policy restricting phone use to specific hours and limiting calls to 15 minutes. Additionally, the facility failed to address certain medical needs in care plans and did not complete a required PASARR Level II referral for one resident.

The complaint investigation substantiated staff physical abuse by CNA staff #305 against resident #53, verbal abuse by housekeeper staff #802 against resident #27, and resident-to-resident abuse between residents #72 and #79. Staff #305 and staff #802 were terminated. Resident-to-resident altercation was substantiated with injuries noted.

The facility failed to ensure residents were free from abuse, including verbal abuse by staff, physical abuse by staff, and resident-to-resident altercations. Several incidents were substantiated, resulting in staff termination and implementation of monitoring and corrective actions.

The investigation was complaint-driven, focusing on residents' rights to phone access and privacy, adequacy of care planning for medical conditions, and compliance with PASARR requirements.

The facility failed to ensure reasonable access to personal phones and privacy for phone calls for multiple residents, imposed broad and non-individualized restrictions on phone use, and did not document or justify these restrictions in care plans. Additionally, the facility failed to address a resident's significant medical diagnoses in the care plan and did not complete a required PASARR Level II referral for a resident with a new mental health diagnosis.

The complaint investigation found that the resident experienced constipation without proper bowel care, resulting in abdominal pain and a suspected urinary tract infection. The resident was sent to the emergency room due to concerns about bowel obstruction. The facility failed to document constipation monitoring adequately and did not notify the physician timely.

The facility failed to provide adequate bowel care for one resident, resulting in constipation and related complications including abdominal pain and suspected urinary tract infection. Documentation and communication deficiencies were noted, including lack of timely physician notification and incomplete bowel movement records.

The complaint investigation found that the resident had not had a bowel movement for several days, was constipated, and had a urinary tract infection. The resident reported pain and requested hospital evaluation. The facility failed to adequately monitor and document bowel movements and notify physicians timely. The complaint was substantiated with findings of deficient care.

The facility failed to provide adequate bowel care for one resident, resulting in constipation and related complications including abdominal pain and urinary tract infection. Documentation and communication regarding bowel movements and physician notifications were inadequate, and the resident required emergency room visits due to unresolved symptoms.

The complaint investigation substantiated the allegation of resident-to-resident abuse involving resident #70 punching resident #176. The facility confirmed the incident through staff reports and documentation.

The facility substantiated the allegation that resident #70 physically abused resident #176 by punching him in the arms. The incident occurred on January 8, 2023, and resulted in minor physical injuries. Both residents were placed on one-on-one monitoring and resident #176 was transferred to another unit. Attempts to interview the CNA witness were unsuccessful, and both residents did not recall the incident during interviews.

The complaint investigation was substantiated. The incident occurred on January 8, 2023, when resident #70 punched resident #176. Staff intervened and separated the residents. Resident #176 had redness and discoloration on his hands. Attempts to interview the CNA witness were unsuccessful. Interviews with residents #70 and #176 found neither remembered the incident.

The facility substantiated the allegation that resident #70 physically abused resident #176 by punching him in the arms. The incident was witnessed by staff, and both residents were placed on one-on-one monitoring with resident #176 transferred to another unit. The facility failed to ensure resident #176 was free from physical abuse.

The complaint investigation involved multiple elopement incidents by resident #41, including leaving through windows on May 4, May 11, and August 13, 2023. The facility was unable to substantiate elopement for the last incident as the resident was alert and oriented. Interviews with staff revealed inconsistent monitoring and lack of specific interventions for the resident despite known elopement risk.

The facility failed to ensure adequate supervision to prevent elopement for resident #41, who eloped multiple times through windows despite being identified as an elopement risk. The facility lacked consistent interventions, such as frequent checks or secured windows, and did not have an elopement binder at nurses' stations. Staff interviews revealed gaps in communication and monitoring practices.

The complaint investigation focused on multiple elopement incidents involving resident #41. The facility was unable to substantiate elopement for the August 13, 2023 incident because the resident was alert and oriented. However, interviews and documentation revealed inadequate supervision and lack of proper interventions to prevent elopement.

The facility failed to ensure adequate supervision to prevent elopement for resident #41, who eloped multiple times through unsecured windows. Despite interventions and moving the resident to secured units, the resident was able to leave the facility unsupervised, indicating lapses in monitoring and safety measures.

The complaint investigation found substantiated incidents of resident-to-resident abuse including hitting, unwanted touching, biting, and pushing. The facility conducted interviews with residents and staff, and implemented monitoring and intervention strategies.

The facility failed to ensure that four residents (#1, #28, #5, #11) were free from abuse by other residents. Investigations revealed multiple incidents of physical and sexual abuse among residents, with staff interventions and monitoring procedures described.

The complaint investigation found substantiated incidents of resident-to-resident abuse including hitting, sexual touching without consent, biting, and pushing. The facility conducted interviews with involved residents and staff, and implemented interventions such as resident separation and one-to-one observation of alleged perpetrators.

The facility failed to ensure that four residents (#1, #28, #5, #11) were free from abuse by other residents. Investigations revealed incidents of physical hitting, sexual misconduct, biting, pushing, and verbal aggression among residents, with minimal harm or potential for actual harm noted.

The complaint involved resident-to-resident abuse allegations between resident #1 and resident #2. Resident #1 reported being startled by resident #2 touching her chest and later reported waking up to resident #2's hands around her neck. The facility failed to document the incident properly, failed to report it timely to the State Agency, and failed to investigate the allegation thoroughly. Resident #1 requested the incident not be reported. The facility moved resident #2 to a higher acuity behavioral unit but did not document the rationale or investigation details.

The facility failed to ensure that one resident was not abused by another resident, failed to report the abuse allegation to the State Agency within the required timeframe, and failed to thoroughly investigate the allegation of resident-to-resident abuse. The facility census was 185. Interviews, record reviews, and policy assessments revealed multiple deficiencies related to abuse prevention, reporting, and investigation.

The complaint involved allegations that resident #2 abused resident #1 by inappropriate physical contact and choking. The facility failed to document the incident properly, failed to report the allegation to the State Agency within the required timeframe, and failed to thoroughly investigate the allegation. Resident #1 reported the abuse to staff and a friend. Staff interviews revealed delays and omissions in reporting and investigation. The allegation was substantiated by interviews but lacked proper documentation and timely reporting.

The facility failed to ensure one resident was not abused by another resident, failed to report the abuse allegation to the State Agency within the required timeframe, and failed to thoroughly investigate the allegation of abuse. The facility census was 185. The deficient practices could result in further resident-to-resident abuse and unreported or uninvestigated abuse allegations.

The facility was able to substantiate the allegation of resident-to-resident abuse. Resident #50 hit resident #34 with a remote control causing a small scratch. Resident #50 was separated and transferred to another unit. Staff interviews confirmed the incident and the facility's response.

The facility substantiated the allegation that resident #50 struck resident #34 in the face causing a small scratch. Resident #50 was separated and transferred to another unit due to physical aggression and medication adjustments were made. Staff interviews and documentation confirmed the incident and the facility's policy on abuse was reviewed.

The facility was able to substantiate the allegation of resident-to-resident abuse. Resident #50 hit resident #34 with a remote control causing a small scratch. Resident #50 was separated and transferred to another unit. Medication adjustments were made and 1:1 monitoring was implemented. Interviews with nursing staff confirmed the incident and the facility's response.

The facility substantiated the allegation that resident #50 struck resident #34 in the face causing a small scratch. Resident #50 was separated and transferred to another unit for safety, and medication adjustments were made. The facility policy on abuse was reviewed and confirmed to prohibit all types of abuse and neglect.

The facility was found deficient in several areas including failure to timely address a resident's need for a specialized wheelchair, failure to ensure residents' access to personal trust funds, failure to protect a resident from abuse by another resident, failure to thoroughly investigate an abuse allegation, and failure to ensure medications were administered as ordered and by qualified personnel.

The complaint investigation was triggered by allegations including failure to provide a specialized wheelchair, restricted access to personal trust funds, resident-to-resident abuse, inadequate abuse investigation, and medication administration errors. The investigation included interviews with residents, staff, and review of policies and records. The abuse allegation was substantiated with findings of inadequate supervision and investigation.

The facility was found deficient in several areas including failure to timely provide a specialized wheelchair to a resident, restricting resident access to personal trust funds on weekends, failure to protect a resident from abuse by another resident, inadequate investigation of abuse allegations, and failure to administer medications as ordered or by qualified personnel.