Inspection Reports for The Retreat at Alameda

AZ, 85085

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Inspection Report Enforcement Capacity: 104 Deficiencies: 13 Aug 22, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022-12 to 2025-08 with deficiency history and enforcement actions.
Findings
Across multiple inspections, deficiencies were found related to emergency responder documentation, resident death notification, residency agreements, medical record safeguards, disaster plan reviews, fire inspections, and staff training. Several deficiencies were repeated and posed risks to resident safety and compliance.
Complaint Details
This revised Statement of Deficiencies (SOD) replaces the SOD sent on September 30, 2025. Deficiencies were found during on-site investigations of complaints 00141814, 00141832, and 00121538 on August 22, 2025, and prior complaints including AZ00122464, AZ00222788, AZ00220213, AZ00219207, AZ00215248, AZ00213065, AZ00212953, AZ00212301, AZ00210337, AZ00208646, AZ00202431, AZ00204354, AZ00205830, and #AZ00183610 from 2023-2025.
Deficiencies (13)
Description
A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to provide emergency responders with a written document including all required resident information.
A.R.S. § 36-420.04.D. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to maintain a copy of the document provided to emergency responders for two years.
R9-10-803.K.1. Administration: Failed to provide written notification to the Department of a resident’s death within one working day as required.
R9-10-807.D.1-10. Residency and Residency Agreements: Failed to ensure a documented residency agreement was available for a resident.
R9-10-807.F.1.a-c. Residency and Residency Agreements: Failed to provide a resident or representative a copy of the policy and procedure on health care directives at acceptance.
R9-10-811.B.1-2. Medical Records: Failed to ensure safeguards exist to prevent unauthorized access to electronic medical records.
36-420. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition: Failed to provide appropriate first aid according to certification training before EMS arrival.
36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document: Failed to provide emergency responders with required written documentation.
A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented before providing services and according to policies and procedures: Failed to document and verify caregiver skills and knowledge.
A. A manager shall ensure that: 1.b. The premises and equipment are free from conditions that may cause physical injury: Failed to ensure premises were free from hazards blocking an exit.
A. A manager shall ensure that: 2. The disaster plan required is reviewed at least once every 12 months: Failed to review the disaster plan annually.
E. A manager shall ensure that: 3. A fire inspection is conducted by local fire department or State Fire Marshal according to required timeframe: Failed to conduct required fire inspection.
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition: Failed to develop and administer a fall prevention and recovery training program for all staff.
Report Facts
Inspections on page: 7 Total deficiencies: 14 Complaint Inspections: 6
Employees Mentioned
NameTitleContext
David DeRushiaCertified ManagerNamed as person responsible in medical records deficiency INSP-0101756
Carol BlackmanDirector of Care, LPNNamed in temporary solution education for medical records deficiency INSP-0101756
Rianna DeYoungResident Care CoordinatorNamed in temporary solution education for medical records deficiency INSP-0101756
Chanricka SargentResident Care CoordinatorNamed in temporary solution education for medical records deficiency INSP-0101756

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