Inspection Reports for The Gardens at Immanuel
11295 N 99th Ave, Peoria, AZ 85345, AZ, 85345
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Inspection Report
Annual Inspection
Capacity: 10
Deficiencies: 16
Dec 2, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from 2022-12 to 2024-12 with deficiency history including complaint and annual compliance inspections.
Findings
Across all inspections, multiple deficiencies were identified including failures in documentation, staff training, medication administration, safety protocols, and service plan accuracy. Deficiencies ranged from missing emergency documentation to improper storage of toxic materials and incomplete staff orientation and verification.
Complaint Details
An on-site investigation of complaint AZ00205636 was conducted on January 29, 2024, resulting in four deficiencies related to staff verification, tuberculosis screening, orientation, and documentation.
Deficiencies (16)
| Description |
|---|
| 36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to maintain a copy of the documentation provided to an emergency responder for a resident. |
| L. If a resident is receiving services from a home health agency or hospice service agency, a manager shall ensure that care instructions are documented in the resident's service plan: Failed to document home health care instructions in the resident's service plan. |
| C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan includes specified requirements (R9-10-815(C)(1-7)): Failed to include required elements in service plans for two residents. |
| B. If an assisted living facility provides medication administration, a manager shall ensure medication administered is documented in the resident's medical record: Failed to document administration of oxygen as ordered. |
| A. A manager shall ensure that a resident is provided a diet that meets the resident's nutritional needs as specified in the resident's service plan: Failed to specify diet in service plans for two residents. |
| A. A manager shall ensure that a caregiver's or assistant caregiver's skills and knowledge are verified and documented before providing services: Failed to verify and document skills and knowledge for two personnel. |
| A. A manager shall ensure that employees provide evidence of freedom from infectious tuberculosis as specified in R9-10-113: Failed to provide evidence of freedom from infectious TB for two employees. |
| A. A manager shall ensure that personnel receive orientation specific to duties before providing services: Failed to document orientation for two personnel. |
| C. A manager shall ensure that a caregiver or assistant caregiver documents services provided in the resident's medical record: Failed to document services for one resident. |
| C. A manager shall ensure policies and procedures cover cardiopulmonary resuscitation training including demonstration of ability: Failed to ensure CPR training met policy requirements for one employee. |
| A. A manager shall ensure an assistant caregiver interacts with residents under supervision of a manager or caregiver: Failed to provide supervision for an assistant caregiver. |
| A. A manager shall ensure poisonous or toxic materials are stored in locked containers inaccessible to residents: Failed to secure poisonous or toxic materials in locked areas (repeat deficiency). |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs: Failed to administer fall prevention and recovery training to all staff. |
| A. Except as required in subsection (B), a manager shall ensure a resident has a written service plan including level of service expected: Failed to include accurate level of service in a resident's service plan. |
| B. If an assisted living facility provides medication administration, a manager shall ensure medication is administered in compliance with orders: Failed to administer medication as ordered for one resident. |
| A. A manager shall ensure hot water temperatures are maintained between 95º F and 120º F in resident areas: Failed to maintain hot water temperature within required range (repeat deficiency). |
Report Facts
Inspections on page: 4
Total deficiencies: 17
Complaint inspections: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Acknowledged multiple deficiencies during interviews across inspections | |
| E2 | Assistant Caregiver | Named in deficiencies related to skill verification, tuberculosis screening, orientation, CPR training, and supervision |
| E3 | Caregiver | Named in deficiencies related to skill verification, tuberculosis screening, and orientation |
| E4 | Observed supervising staff during assistant caregiver supervision deficiency |
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