Inspection Report
Complaint Investigation
Capacity: 99
Deficiencies: 17
Sep 16, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2023-10 to 2025-09 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies were found related to physical plant modifications without approval, incomplete tuberculosis screening documentation for employees and residents, incomplete resident service plans, medication storage issues, disaster and evacuation drill deficiencies, and staff training and verification gaps.
Complaint Details
Multiple complaint investigations are included, with complaint numbers such as 00144114, 00131800, 00133630, 00129235, 00109074, 00104949, 00104910, 00104816, 00105789, AZ00205315, AZ00205241, AZ00202947, AZ00204561, AZ00199226, AZ00199234, AZ00191054, and AZ00191692 referenced in the inspections.
Deficiencies (17)
| Description |
|---|
| R9-10-110.A.1-5. Modification of a Health Care Institution: Failed to submit a request for approval of a modification of a health care institution when planning physical plant changes including walls not extending to ceiling in residential units. |
| R9-10-806.A.8.a-b. Personnel: Failed to ensure employees provided documentation of freedom from infectious tuberculosis on or before the date services began for three of nine employees sampled. |
| R9-10-807.A.1-2. Residency and Residency Agreements: Failed to ensure residents provided evidence of freedom from infectious tuberculosis within seven calendar days after occupancy for three of ten residents sampled. |
| R9-10-808.A.3.c. Service Plans: Failed to ensure residents had written service plans including amount, type, and frequency of assisted living services for four of ten residents sampled. |
| R9-10-810.B.1. Resident Rights: Failed to ensure a resident was treated with dignity, respect, and consideration related to physical plant modifications causing privacy and comfort issues. |
| R9-10-816.F.1. Medication Services: Failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. |
| R9-10-818.A.4. Emergency and Safety Standards: Failed to ensure disaster drills for employees were conducted on each shift at least once every three months and documented. |
| R9-10-818.A.5.a. Emergency and Safety Standards: Failed to ensure evacuation drills for employees and residents were conducted at least once every six months. |
| R9-10-820.D.4.d. Physical Plant Standards: Failed to ensure resident sleeping areas had floor-to-ceiling walls with at least one door; walls had gaps at ceiling level. |
| A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented before providing physical health services and according to policies and procedures; failed for four of six caregivers reviewed. |
| F. A manager of an assisted living facility authorized to provide directed care services shall ensure means of exiting the facility for residents without keys or special knowledge provide access to outside area and alert employees; failed to ensure alarm alerted employees of egress. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that includes how medication stored and controlled in resident's bedroom; failed for three of eight residents sampled. |
| B. If an assisted living facility provides medication administration, a manager shall ensure medication is administered in compliance with a medication order; failed for one of eight residents sampled. |
| B. If the assisted living facility offers therapeutic diets, a manager shall ensure therapeutic diet is provided according to written order; failed for two residents. |
| A. A manager shall ensure that disaster drills for employees are conducted on each shift at least once every three months and documented; failed to provide documentation for previous twelve months. |
| A. A governing authority shall ensure compliance with A.R.S. § 36-411; failed for one of ten personnel members sampled due to employment history gap and fingerprint clearance issues. |
| A. A manager shall ensure caregiver provides current documentation of first aid training and CPR certification specific to adults prior to providing assisted living services; failed for one of ten personnel members sampled. |
Report Facts
Inspections on page: 6
Total deficiencies: 18
Complaint inspections: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Named in multiple findings related to physical plant modifications, tuberculosis documentation, service plans, medication storage, disaster drills, and resident dignity |
| E2 | Unspecified staff | Named in findings related to caregiver skills verification, medication administration, and exit door alarm |
| E3 | Unspecified staff | Named in caregiver skills verification deficiency |
| E4 | Unspecified staff | Named in tuberculosis documentation and caregiver skills verification deficiencies |
| E5 | Unspecified staff | Named in tuberculosis documentation deficiency |
| E6 | Medication Aide | Named in first aid training deficiency and exit door alarm incident |
| E7 | Unspecified staff | Named in tuberculosis documentation and caregiver skills verification deficiencies |
| E10 | Caregiver | Named in employment history and fingerprint clearance deficiency |
| Executive Director | Executive Director | Responsible person for multiple deficiencies including physical plant, service plans, and emergency drills |
| Maintenance Director | Maintenance Director | Responsible person for physical plant and emergency drill deficiencies |
| Business Office Manager | Business Office Manager | Responsible person for tuberculosis documentation compliance |
| Wellness Director | Wellness Director | Responsible person for resident service plans and medication storage deficiencies |
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