Inspection Reports for The Gardens at Immanuel
11295 N 99th Ave, Peoria, AZ 85345, AZ, 85345
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 2, 2024, identified five deficiencies related to emergency responder documentation, home health care instructions, service plans, medication documentation, and resident diet. Earlier inspections showed a pattern of similar issues, including caregiver skills verification, staff training, medication compliance, and safety procedures, with multiple enforcement actions resulting in fines totaling at least $1,250. Complaint investigations included one substantiated case involving caregiver skills verification and documentation. Enforcement actions were noted but no license suspensions or immediate jeopardy findings were listed in the available reports. The facility’s deficiencies have been consistent over time without a clear trend of improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Capacity: 10
Deficiencies: 5
Date: Dec 2, 2024
Visit Reason
Five deficiencies found related to emergency responder documentation, home health care instructions, service plans, medication documentation, and resident diet.
Findings
Five deficiencies found related to emergency responder documentation, home health care instructions, service plans, medication documentation, and resident diet.
Deficiencies (5)
36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document D. Documentation not maintained for emergency responder
L. Manager failed to ensure care instructions from home health or hospice services were documented in service plans
C. Manager failed to ensure service plans for directed care services included required elements
B. Medication administered to resident was not documented in medical record
A. Resident diet did not meet nutritional needs as specified in service plan
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Feb 13, 2024
Summary
The enforcement action resulted in a $250 fine which has been paid in full.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Fine issued as part of enforcement action | Paid |
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Jan 29, 2024
Summary
The deficient practice posed a health and safety risk to residents because caregivers or assistant caregivers did not have documented skills and knowledge to provide care and services.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Failure to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented, posing a health and safety risk to residents. | — |
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 4
Date: Jan 29, 2024
Visit Reason
Four deficiencies cited related to caregiver skills verification, tuberculosis evidence, orientation, and documentation of services.
Complaint Details
Complaint AZ00205636 investigated on January 29, 2024
Findings
Four deficiencies cited related to caregiver skills verification, tuberculosis evidence, orientation, and documentation of services.
Deficiencies (4)
A. Manager failed to verify and document caregiver or assistant caregiver skills and knowledge before employment
A. Manager failed to ensure caregiver and assistant caregiver provided evidence of freedom from infectious tuberculosis
A. Manager failed to ensure caregiver or assistant caregiver received orientation before providing assisted living services
C. Manager failed to ensure caregiver documented services provided in resident's medical record
Enforcement Action
Enforcement
Fines: 2
Total: $1,000.00
Date: Jan 2, 2024
Summary
The facility was found to have deficiencies in health and safety practices, including inadequate CPR training for employees and unsafe storage of toxic materials, resulting in civil fines.
Fines & Penalties (2)
| Amount | Reason | Status |
|---|---|---|
| $500.00 | Failure to implement CPR training policies and procedures to protect resident health and safety. | — |
| $500.00 | Failure to ensure poisonous or toxic materials were stored in a locked and inaccessible area, posing risk to residents. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $1,000.00
Date: Dec 12, 2023
Summary
The facility was fined $1,000.00 and the fine has been paid in full as of 2024-01-29.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,000.00 | Enforcement action fine | Paid |
Inspection Report
Annual Inspection
Capacity: 10
Deficiencies: 3
Date: Nov 14, 2023
Visit Reason
Three deficiencies found related to policies and procedures for resident safety, supervision of assistant caregivers, and storage of poisonous or toxic materials.
Findings
Three deficiencies found related to policies and procedures for resident safety, supervision of assistant caregivers, and storage of poisonous or toxic materials.
Deficiencies (3)
C. Manager failed to implement policies and procedures to protect resident health and safety covering cardiopulmonary resuscitation
A. Assistant caregiver did not interact with residents under supervision of manager or caregiver
A. Poisonous or toxic materials were not stored in locked area inaccessible to residents
Inspection Report
Annual Inspection
Capacity: 10
Deficiencies: 5
Date: Dec 15, 2022
Visit Reason
Five deficiencies found related to staff training on fall prevention, resident service plans, medication compliance, hot water temperature, and storage of poisonous or toxic materials.
Findings
Five deficiencies found related to staff training on fall prevention, resident service plans, medication compliance, hot water temperature, and storage of poisonous or toxic materials.
Deficiencies (5)
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Training program for staff regarding fall prevention and recovery not administered
A. Resident's written service plan did not include expected level of service
B. Medication administered to resident was not in compliance with medication order
A. Hot water temperatures not maintained between 95º F and 120º F in resident areas
A. Poisonous or toxic materials were not stored in locked area inaccessible to residents
Enforcement Action
Enforcement
Total: $0.00
Date: Nodate Enforcement
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