Inspection Reports for The Citadel Senior Living Community
520 S Higley Rd, Mesa, AZ 85206, United States, AZ, 85206
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Inspection Report
Capacity: 150
Deficiencies: 31
Nov 4, 2025
Visit Reason
State-compiled facility profile showing 20 inspections from 2023-05 to 2025-11 with deficiency history and enforcement actions.
Findings
Multiple inspections revealed numerous deficiencies across various regulatory areas including personnel records, medication administration, resident safety, service plans, and environmental standards. Several repeat deficiencies and enforcement actions were noted, indicating ongoing compliance challenges.
Complaint Details
Multiple complaint investigations conducted between 2023 and 2025 revealed numerous deficiencies including failure to comply with settlement agreement terms, allegations of abuse, and failure to maintain substantial compliance.
Deficiencies (31)
| Description |
|---|
| R9-10-806.A.8.a-b. Personnel: Failed to ensure personnel records included documentation of freedom from infectious tuberculosis for employees and volunteers. |
| R9-10-806.A.10. Personnel: Failed to ensure personnel records included documentation of current CPR training for employees. |
| R9-10-807.A.1-2. Residency and Residency Agreements: Failed to ensure residents provided evidence of freedom from infectious tuberculosis as required. |
| R9-10-808.A.3.f. Service Plans: Failed to ensure service plans included how medication stored and controlled for residents storing medication in their units. |
| R9-10-810.B.1. Resident Rights: Failed to ensure a resident was treated with dignity, respect, and consideration; allegation of sexual abuse by caregiver. |
| R9-10-815.C.3. Directed Care Services: Failed to ensure service plans included cognitive stimulation and activities to maximize functioning. |
| R9-10-817.B.3.b. Medication Services: Failed to ensure medication administered in compliance with medication orders. |
| R9-10-817.B.3.c. Medication Services: Failed to ensure medication administration was accurately documented in resident medical records. |
| R9-10-821.C.3.a-g. Physical Plant Standards: Failed to ensure resident bathrooms provided privacy when in use. |
| R9-10-819.D.1. Emergency and Safety Standards: Failed to immediately notify resident's emergency contact and primary care provider after incidents requiring medical services. |
| R9-10-819.D.2.a-f. Emergency and Safety Standards: Failed to document actions taken to prevent future incidents after accidents or emergencies. |
| R9-10-820.A.1.a. Environmental Standards: Failed to ensure premises were cleaned and disinfected to prevent illness or infection. |
| R9-10-819.A.11. Environmental Standards: Failed to store poisonous or toxic materials in locked, labeled, and inaccessible areas. |
| R9-10-808.A.3.c. Service Plans: Failed to ensure service plans included amount, type, and frequency of assisted living services including medication administration. |
| R9-10-815.F.2.a-c. Directed Care Services: Failed to ensure means of exiting facility controlled or alerted employees of resident egress. |
| R9-10-817.A.1.a-e. Food Services: Failed to ensure food menu was prepared in advance, posted, and included substitutions. |
| R9-10-818.D.2.a-f. Emergency and Safety Standards: Failed to document actions taken to prevent future incidents after accidents or emergencies. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to administer fall prevention and recovery training to staff. |
| R9-10-803.J.1-6. Administration: Failed to initiate and document investigation of suspected exploitation within required timeframe. |
| R9-10-101.116. In-service education: Failed to document completed in-service education for personnel. |
| R9-10-120.F.4.a-c. Opioid Prescribing and Treatment: Failed to document resident's need for opioid and effect after administration. |
| R9-10-803.J. Documentation of suspected abuse, neglect, or exploitation: Failed to document suspected abuse or neglect and related actions. |
| R9-10-820.C.3.a-g. Physical Plant Standards: Failed to ensure resident bathrooms provided privacy when in use. |
| R9-10-816.B.3.a,b,c. Medication Administration: Failed to administer medication in compliance with orders and document administration accurately. |
| R9-10-814.B.2.b.i. Resident Care: Failed to obtain required medical practitioner examinations for non-ambulatory residents every six months. |
| R9-10-815.F.1. Directed Care Services: Failed to establish policies and procedures ensuring safety of residents who may wander. |
| R9-10-808.A.4.b.iii. Service Plans: Failed to review and update service plans at least every three months for residents receiving directed care. |
| R9-10-808.A.5.a-d. Service Plans: Failed to ensure service plans were signed and dated by required parties. |
| R9-10-819.C. Garbage and refuse: Failed to store garbage and refuse in covered containers lined with plastic bags. |
| R9-10-820.A.1.b. Environmental Standards: Failed to ensure premises free from conditions causing physical injury. |
| R9-10-803.J. Documentation: Failed to provide required documentation to Department within two hours of request. |
Report Facts
Inspections on page: 20
Total deficiencies: 63
Complaint inspections: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karina Villacorta | Assisted Living Manager | Named as person responsible in multiple deficiency findings related to emergency notifications and documentation |
| E1 | Named in multiple interviews and findings related to documentation and compliance issues | |
| E2 | Named in multiple interviews and findings related to documentation and compliance issues | |
| E3 | Named in interviews related to training and documentation deficiencies | |
| E5 | Named in findings related to fall prevention training and medication administration | |
| E6 | Named in findings related to CPR training, medication administration, and service plan deficiencies | |
| E7 | Named in findings related to medication administration and training | |
| E8 | Named in findings related to tuberculosis documentation | |
| E10 | Named in findings related to tuberculosis documentation and medication orders | |
| E11 | Named in interviews and findings related to medication administration and documentation | |
| E12 | Named in findings related to tuberculosis documentation and training |
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