The most recent inspection on August 9, 2025, included enforcement action resulting in a $2,250 fine that has been paid in full. Earlier inspections showed a pattern of deficiencies related primarily to medication administration, environmental standards, personnel documentation, service plan completion and updates, emergency drills, and safe storage of toxic materials. Complaint investigations generally found deficiencies in medication services, documentation, and fall prevention training, while most complaints were unsubstantiated. Enforcement actions with fines have been frequent, reflecting ongoing compliance challenges, but all fines have been paid in full as noted in the reports. The facility’s inspection history shows recurring issues with medication management and administrative compliance, with no clear trend of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The facility was found to have multiple repeat deficiencies from prior inspections and a complaint, resulting in civil fines totaling $2,250.00.
Fines & Penalties (5)
Amount
Reason
Status
$500.00
One employee permitted to work after fingerprint clearance card expired; repeat deficiency from May 8, 2024 compliance inspection.
—
$500.00
One employee's first aid and cardiopulmonary resuscitation (CPR) training expired.
—
$500.00
No evacuation drills conducted within the last 12 months; repeat deficiency from May 8, 2024 compliance inspection.
—
$250.00
Documentation of a current fire inspection was not available for review during the inspection; repeat deficiency from May 8, 2024 compliance inspection.
—
$500.00
Facility did not store poisonous or toxic materials in a locked area and inaccessible to residents; repeat deficiency from complaint inspection December 18, 2023 and compliance inspection May 8, 2024.
Fifteen deficiencies found during compliance inspection and complaint investigation covering tuberculosis screening, opioid prescribing, administration, personnel, service plans, medication storage, emergency standards, and environmental standards.
Findings
Fifteen deficiencies found during compliance inspection and complaint investigation covering tuberculosis screening, opioid prescribing, administration, personnel, service plans, medication storage, emergency standards, and environmental standards.
Deficiencies (15)
Description
R9-10-113.A.2.a-f. Tuberculosis Screening — Failure to document and implement TB screening
R9-10-120.F.4.a-c. Opioid Prescribing and Treatment — Inadequate opioid medication documentation
R9-10-803.A.9. Administration — Personnel records incomplete
R9-10-803.C.3. Administration — Policies and procedures not reviewed or updated timely
One deficiency cited related to failure to document witness names after suspected abuse.
Findings
One deficiency cited related to failure to document witness names after suspected abuse.
Deficiencies (1)
Description
J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation has occurred — Failure to document witness names
One deficiency cited related to failure to document abuse or neglect when manager had reasonable basis to believe it occurred.
Findings
One deficiency cited related to failure to document abuse or neglect when manager had reasonable basis to believe it occurred.
Deficiencies (1)
Description
J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation has occurred — Failure to document abuse or neglect
The enforcement resulted in multiple fines totaling $7,540.00 for repeated and new violations found during the compliance and complaint inspection conducted on May 8, 2024, including repeat citations from previous inspections.
Fines & Penalties (7)
Amount
Reason
Status
$1,000.00
Failure to ensure compliance with fingerprint clearance cards for two employees.
—
$500.00
Failure to ensure two assistant caregivers interacted with residents only under supervision.
—
$500.00
Failure to verify skills and knowledge of three assistant caregivers before providing physical health services (repeat citation).
—
$4,290.00
Failure to ensure a service plan was completed for one resident (triple-repeat citation) with daily penalties assessed for 143 days.
—
$500.00
Failure to update service plans for two residents at least every three months (double-repeat citation).
—
$500.00
Failure to conduct and document evacuation drills at least once every six months.
—
$250.00
Failure to store poisonous or toxic materials in a locked area inaccessible to residents (repeat citation).
Ten deficiencies cited during compliance inspection and complaint investigation related to personnel compliance, service plans, emergency drills, fire inspections, poisonous materials, opioid prescribing, and food service.
Findings
Ten deficiencies cited during compliance inspection and complaint investigation related to personnel compliance, service plans, emergency drills, fire inspections, poisonous materials, opioid prescribing, and food service.
Deficiencies (10)
Description
A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411 — Failure to ensure compliance with statute for employees
A. A manager shall ensure that: 2. An assistant caregiver: b. Interacts with residents under supervision — Failure to ensure supervision
A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented — Failure to verify caregiver skills
A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have mo... — Failure to document freedom from infectious tuberculosis
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 cale... — Failure to complete service plans timely
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on c... — Failure to review and update service plans timely
A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented; — Failure to conduct disaster drills quarterly
A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and — Failure to conduct evacuation drills biannually
E. A manager of an assisted living center shall ensure that: 3. A fire inspection is conducted by a local fire department or the State Fire Marshal be... — Failure to conduct fire inspections timely
A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a lock... — Failure to store poisonous materials securely
The facility was found to have no documented verification of skills and knowledge for two employees and a repeat citation for failure to notify emergency contacts promptly, resulting in civil fines.
Fines & Penalties (2)
Amount
Reason
Status
$250.00
Failure to ensure the skills and knowledge of two employees were verified and documented before providing physical health services.
—
$250.00
Failure to ensure a resident's emergency contact and primary care provider were immediately notified after an accident; repeat citation.
Five deficiencies cited related to fall prevention training, caregiver skills verification, diet provision, and documentation of medical services after incidents.
Findings
Five deficiencies cited related to fall prevention training, caregiver skills verification, diet provision, and documentation of medical services after incidents.
Deficiencies (5)
Description
36-420.01. Health care institutions; fall prevention and fall recovery; training programs — Failure to develop and administer fall prevention training
A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented — Failure to verify caregiver skills
A. A manager shall ensure that: 6. A resident is provided a diet that meets the resident's nutritional needs as specified in the resident's service pl... — Failure to provide appropriate diet
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services — Failure to document caregiver actions
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services — Failure to document caregiver actions
The facility was found deficient in multiple areas including CPR policy and training documentation, resident care documentation, medication administration records, and safety measures for resident egress. These deficiencies posed risks to resident health and safety and resulted in repeat violations.
Fines & Penalties (1)
Amount
Reason
Status
$1,500.00
Civil fines for multiple violations including failure to establish CPR policies, inadequate documentation of CPR training, failure to ensure proper resident care documentation, and repeat deficiencies related to resident safety and medication administration.
The facility failed to ensure timely completion of written service plans for residents and failed to prevent residents from being subjected to restraint, posing risks of physical injury or psychological distress. The Department was unable to determine substantial compliance during the inspection.
Fines & Penalties (2)
Amount
Reason
Status
$500.00
Failure to complete a resident's written service plan within 14 calendar days.
—
$500.00
Failure to ensure residents were not subjected to restraint, posing potential physical injury or psychological distress.
Eleven deficiencies cited related to policies and procedures, personnel documentation, service plans, documentation of services, restraint, medication orders, and hot water temperature.
Findings
Eleven deficiencies cited related to policies and procedures, personnel documentation, service plans, documentation of services, restraint, medication orders, and hot water temperature.
Deficiencies (11)
Description
C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident — Failure to establish and implement policies
A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of ... — Failure to provide current first aid and CPR documentation
C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: iii. The individual's completed or... — Personnel records incomplete
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on c... — Failure to review and update service plans timely
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on c... — Failure to review and update service plans timely
C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and — Failure to document services provided
B. A manager shall ensure that: 2. A resident is not subjected to: i. Restraint — Failure to prevent resident restraint
C. A manager shall ensure that a resident's medical record contains: 12. A medication order from a medical practitioner for each medication that is ad... — Medication orders missing
B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is a... — Medication administration compliance issues
A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by re... — Hot water temperature not maintained
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services — Failure to document caregiver actions
Ten deficiencies cited related to notification to Department, policies and procedures, documentation, service plans, restraint, medical records, and poisonous materials.
Findings
Ten deficiencies cited related to notification to Department, policies and procedures, documentation, service plans, restraint, medical records, and poisonous materials.
Deficiencies (10)
Description
A. A governing authority shall: 7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a cha... — Failure to notify Department of manager change
C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident... — Failure to implement policies and procedures
E. A manager shall ensure that, unless otherwise stated: 1. Documentation required by this Article is provided to the Department within two hours afte... — Failure to provide documentation timely
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 cale... — Failure to complete service plans timely
C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and — Failure to document services provided
B. A manager shall ensure that: 2. A resident is not subjected to: i. Restraint — Failure to prevent resident restraint
C. A manager shall ensure that a resident's medical record contains: 10. Resident's service plan and updates; — Service plan and updates missing
C. A manager shall ensure that a resident's medical record contains: 12. A medication order from a medical practitioner for each medication that is ad... — Medication orders missing
B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is a... — Medication administration compliance issues
A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by re... — Hot water temperature not maintained
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