BROOKDALE CAMINO DEL SOL

INSP-0162589

Complete

Date: 10/30/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-10-31

Summary:

No deficiencies were found during the on-site investigation of complaint 00149306 conducted on October 30, 2025.

✓ No deficiencies cited during this inspection.

INSP-0160258

Complete

Date: 9/26/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-10-08

Summary:

The following deficiency was found during the on-site investigation of complaints 00145405 and 00145457 conducted on September 26, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander; 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of R2's medical record revealed a document titled "Resident Incident Report" dated September 18, 2025. This document stated "R1 was seen walking on the sidewalk on Aleppo and N 138th Ave at 8 am this morning, about .5 miles from the building by an off-duty caregiver, E4. It was found that the resident was able to get out through an unlocked door and gate at our community that were left unlocked by a staff member yesterday after her lunch break...." 3. In an interview, E1 reported R1 eloped from the facility through the door connecting the living room to the courtyard. At the time of the elopement, the door that was exited and the courtyard gate were unlocked; therefore, the alarm did not activate. 4. A review of an internal investigation document revealed R1 was last seen around 0755. E4 was off duty and recognized R1. E4 called the facility and stayed with R1. R1 was returned to the facility around 0810. R1 was fully assessed, and all parties were notified. The doors and gates were checked and locked. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Temporary Solution:

The exterior door was immediately secured and all perimeter doors were checked to verify they were locked and functioning.
Re-education provided to associates on duty at time of elopement on elopement prevention and door-security expectations Susan McDonald, Health and Wellness Director.
Additional staff received re-education on elopement prevention and door security expectations on September 24, 2025 by Susan McDonald, Health and Wellness Director.

Permanent Solution:

Associates will complete daily checks on door alarm function and to check that doors are secure. Maintenance Director will complete routine audits of system function in TELS.

Person Responsible:

McKenna Botts, Executive Director

INSP-0159055

Complete

Date: 9/3/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-09-04

Summary:

The following deficiency was found during the on-site investigation of complaints 00142732 and 00142733 conducted on September 3, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-803.J.1-6. Administration J. If a manager has a reasonable basis, according to A.R.S. § 46- 454, to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility’s manager, caregiver, or assistant caregiver, the manager shall: 1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454; 3. Document: a. The suspected abuse, neglect, or exploitation; b. Any action taken according to subsection (J)(1); and c. The report in subsection (J)(2); 4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2); 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident’s physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and 6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Evidence/Findings:

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional... or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. A review of facility documentation revealed an incident report. The report detailed an incident which occurred between R1 and R2 at 8:30 PM on August 27, 2025. The report stated the incident was “Reported to APS.” The review further revealed a printout of an email confirmation sent to E2. The email stated, “Thank you for contacting Adult Protective Services on 8/28/25.” 4. In an interview, E1 reported E2 reported the suspected abuse at approximately 11:00 AM on August 28, 2025, the morning after the incident. When the Compliance Officer asked why the suspected abuse was not reported immediately, E2 reported facility personnel were supervising R2 for several hours to help control R2’s behavior. E2 reported R2 finally went to bed at approximately 11:00 PM. E2 reported E2 worked on the incident report and report to A.P.S. for several hours the next morning.

Temporary Solution:

On 9/24/25 all staff were re-trained on the Abuse, Neglect and Exploitation policy, including reporting requirements by the Executive Director.

Permanent Solution:

An audit of incidents from the past 90 days was completed on 9/5/25 by McKenna Botts Executive Director to verify no other delays in reporting occurred with no additional instances of delayed reporting identified.

Community leadership will continue to log confirmation of report submission for reasonable suspicion of Abuse.

Person Responsible:

McKenna Botts- Executive Director

INSP-0147296

Complete

Date: 8/6/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-08-13

Summary:

The following deficiency was found during the on-site compliance inspection and investigation of complaint 00137662 conducted on August 6, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-120.F.4.a-c. Opioid Prescribing and Treatment F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall: 4. Except as provided in subsection (H), ensure that an individual authorized by policies and procedures to administer an opioid in treating a patient or to provide assistance in the self-administration of medication for a prescribed opioid: a. Before administering an opioid or providing assistance in the self-administration of medication for a prescribed opioid in compliance with an order as part of the treatment for a patient, identifies the patient's need for the opioid; b. Monitors the patient's response to the opioid; and c. Documents in the patient's medical record: i. An identification of the patient ' s need for the opioid before the opioid was administered or assistance in the self-administration of medication for a prescribed opioid was provided, and ii. The effect of the opioid administered or for which assistance in the self-administration of medication for a prescribed opioid was provided.

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer opioids identified the resident's need for an opioid before administering the opioid and monitored the resident's response to the opioid for residents who did not have an active malignancy or an end-of-life condition. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled, “Medication & Treatment,” which stated, “11. Administration of opioid medications requires assessment of resident pain with the use of the 0-10 verbal pain scale or faces scale as applicable. a. The assessment of pain is conducted prior to administration. b. Within an hour after administration the resident should be assessed for response and effectiveness of the opioid administration. c. documentation of the resident’s pain before administration of the opioid and the effect of the opioid administration should be documented on the MAR or eMAR.” 2. Review of R4’s medical record revealed a current service plan indicating R4 was at the directed level of care and received medication administration. The service did not indicate R4 was on hospice, was receiving treatment for an active malignancy, or had an end-of-life condition. 3. Review of R4’s medical record revealed a medication administration record (MAR), which revealed R4 received Tramadol HCI oral tablet 50 MG three times a day for the entire month of July 2025. 4. Review of R4’s medical record revealed a medication order for Tramadol HCI 50 MG, the start date was listed as November 2024. 5. Review of R4’s medical record did not reveal documentation of R4’s pain level or the effectiveness of the Tramadol HCI 50 MG. 6. In an interview, E5 reported E5 did not know scheduled opioid documentation was to also include the resident’s pain scale and the effectiveness of the opioid medication. 7. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Permanent Solution:

On 8/13 Health and Wellness Director conducted mandatory re-training for all nursing staff and medication technician’s on the Medication and Treatment Administration/Assistance policy, including:

Correct timing and documentation of pain scales for scheduled opioids for residents not on hospice or receiving end of life care, before and after administration.

Health and Wellness Director or designee will review all MAR’s weekly for 4 weeks, then monthly thereafter, for appropriate documentation of pain scale for before and after administration on scheduled opioid dose for residents not on hospice or receiving end of life care.

Person Responsible:

McKenna Botts

INSP-0136241

Complete

Date: 7/16/2025 - 7/17/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-07-24

Summary:

No deficiencies were found during the on-site investigation of complaints 00136479 and 00136520 conducted on July 16, 2025.

✓ No deficiencies cited during this inspection.

INSP-0134352

Complete

Date: 6/18/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-06-27

Summary:

The following deficiencies were found during the on-site investigation of complaint 00133808 conducted on June 18th 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-803.C.1.g. Administration C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: g. Cover how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure that policies and procedures were implemented in response to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings Include: 1. During the complaint inspection, E1 showed a video to the Compliance Officer regarding the incident that included E2, E3, and R1. The video showed no signs of the staff attempting to de-escalate the situation with R1. 2. A review of policies and procedures revealed a document title: "Response to Aggressive Behavior". It provided steps on how to manage a resident who showed aggressive behaviors: "attempt to move the resident away from the immediate situation, while attempting to calm the resident", "remain with the resident in the area in a non threatening manner". 3. In an interview, E1 acknowledged that policies and procedures were not implemented by E2 and E3 in response to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

Temporary Solution:

Upon identification of the incident involving R1, E2 and E3, both staff members were immediately removed from schedule pending investigation and retraining. E2 and E3, received individual coaching by the Health and Wellness Director and Business Office Manager on response to aggressive behaviors and safe transfers, they also completed Relies training courses on managing aggressive behaviors before returning back to job duties on June 27, 2025. R1 was assessed by the clinical team for any immediate or lingering effects of the incident. Care plan was reviewed and updated with behavioral triggers and intervention strategies.

Permanent Solution:

Staff received re-education on the Behavioral Expressions Policy on 6/25/25 by Executive Director.

Person Responsible:

McKenna Botts, Executive Director

INSP-0131598

Complete

Date: 5/15/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-05-21

Summary:

The following deficiency was found during the on-site investigation of complaint 00129287, 00130599, 00130744, 00130748, and 00130598 conducted on May 15, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-816.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of five residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R5’s medical record revealed an incident report dated April 29, 2025, that stated, “On 04/25/25 [E2] notified [E3] of [E2’s] med error. [E2] gave LANTIS in the PM for at least 10 days prior to 4/25/25 since it was d/c.” 2. Review of R5’s current service plan dated March 8, 2025, revealed R5 received medication administration. 3. Review of R5’s medical record revealed a signed medical order dated March 28, 2025, which stated, “Discontinue: effective 3/28/25 insulin glargine 100 units/mL Subcutaneous solutions; inject 5 units subcutaneous once a day (in the evening) for diabetes…” 4. In an interview, R5 was unable to provide an interview statement. 5. In an interview, E1 acknowledged E2 administered medication that was not in compliance with a medication order.

Permanent Solution:

Plan of Correction for R9-10-816.B.3.b

1. Corrective action taken for the Affected Resident (R5):
Upon discovery on 4/25/25, the med error was reported and documented.
Resident monitoring: R5 was assessed by the nurse and monitored for any adverse effects. No significant change in condition was noted post error. Vitals and blood glucose levels were monitored closely post discovery of med error.
2. Identification of Other Residents Potentially Affected:
An audit of all current medication orders versus active MARs was completed to ensure all medications being administered were in compliance with current orders. No additional discrepancies were identified. Ongoing audits will occur monthly as per Brookdale policy.
3. The employee who made the med error was terminated from employment and reported to the nursing board.
4. Communication protocols:
Our floor nurses now send an end of shift report detailing any med change orders.

Person Responsible:

McKenna Botts Executive Director

INSP-0130989

Complete

Date: 5/7/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-05-08

Summary:

No deficiencies were found during the on-site investigation of complaint 00129287 conducted on May 7, 2025.

✓ No deficiencies cited during this inspection.

INSP-0065091

Complete

Date: 12/4/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-12-18

Summary:

An on-site investigation of complaint AZ00219620 was conducted on December 4, 2024 and no deficiencies were cited.

✓ No deficiencies cited during this inspection.

INSP-0064891

Complete

Date: 8/28/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-09-03

Summary:

No deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00215095 conducted on August 28, 2024.

✓ No deficiencies cited during this inspection.

INSP-0064890

Complete

Date: 4/30/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-06-10

Summary:

An on-site investigation of complaints AZ00205423 and AZ00206250 was conducted on April 30, 2024, and the following deficiency was cited :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

C. A manager shall ensure that policies and procedures are:
1. Established, documented, and implemented to protect the health and safety of a resident that:
m. Cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide;

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. The deficient practice prevented the facility's staff from ensuring the health and safety of the resident, as R1 wandered away from the facility and the personnel members were unaware R1 had left the facility.

Findings include:

1. In documentation review, a review of Department documentation revealed AL2003 was authorized to provide directed care services. E1 reported the entire facility is directed care/memory care.

2. A review of R1's medical record contained a service plan dated February 5, 2024 for directed care services.

3. In documentation review, the facility submitted documentation, dated December 23, 2023, which documented, nurse was called over the radio to help look for [R1] ...a search of the building was conducted...[R1] was found by sheriff at the golf course down the street...[R1] was returned to the community.." Further documentation indicated the time of the event was 5:00 PM. Additionally, a form titled "Survey of Discomfort" dated December 26, 2024 documented ""once earlier in the day, resident attempted to follow another visitor out the door...several times resident attempted to follow staff or visitor out the door." E1 reported this document to be the follow-up from the elopement that occurred on December 23, 2024.

4. A review of the facility policies and procedures dated August 2023 contained a General Whereabouts of a Resident and a Missing Resident Policy that identified procedural steps until a resident is found. However, a system was not in place to ensure the general or specific whereabouts which lead to a missing resident.

5. During an interview, E1 and E2 reported to believe that R1 followed a visitor out the door. E1 acknowledged R1's general or specific whereabouts were unknown on December 23, 2023, from approximately 5:00 PM to about 5:30 PM.

INSP-0064889

Complete

Date: 2/6/2024

Type: Complaint

Worksheet: Assisted Living Center

Summary:

✓ No deficiencies cited during this inspection.

INSP-0064887

Complete

Date: 8/23/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-08-28

Summary:

The following deficiency was found during the on-site compliance inspection and investigation of complaint AZ00193234 conducted on August 23, 2023:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.

Evidence/Findings:

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(A), for one of seven personnel members sampled. The deficient practice posed a risk if E5 was a danger to a vulnerable population.

Findings include:

A.R.S. \'a7 36-411(A) Except as provided in subsections F, G, H and I of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work. (This A.R.S. was amended and went into effect on September 24, 2022.)

1. A review of facility documentation revealed a staffing schedule for August 2023. The staffing schedule revealed E5 was scheduled to work the day shift on the following dates:
-August 1-5, 2023;
-August 8-12, 2023;
August 15, 2023;
-August 22-26, 2023; and
-August 29-31, 2023.

2. A review of E5's (hired in 2023) personnel record revealed E5 was hired as an assistant caregiver and was an employee for over two (2) months.

3. A review of E5's personnel record revealed a receipt for a transaction with the Arizona Department of Public Safety (AZDPS) (dated June 20, 2023). The receipt revealed payment for the following:
-"ACCT - Regular Application;"
-"Board of Fingerprinting;"
-"FBI Fingerprinting Regular;" and
-"Service Fees."
However, documentation of a current fingerprint clearance card was not available for review.

4. A review of the AZDPS fingerprint clearance card website (https://psp.azdps.gov/services/cardStatusRequest), conducted on August 23, 2023, revealed E5's fingerprint clearance application was received on June 20, 2023, however, the status stated "Waiting On Applicant Fingerprints."

5. A review of E5's personnel record revealed a receipt from Arizona LiveScan Fingerprinting Network (dated August 21, 2023) with a different application number than the AZDPS receipt.

6. A review of the AZDPS fingerprint clearance card website (https://psp.azdps.gov/services/cardStatusRequest), conducted on August 23, 2023, returned no results.

7. In an interview, E1 reported there were issues with E5's fingerprints. E1 reported AZDPS provided no information or a letter regarding the status of E5's fingerprint clearance card. E1 reported AL2003 reached out to AZDPS and was notified the application was still pending.

8. In an interview, E1 stated E5 was a "no call, no show" on August 23, 2023 and was terminated from employment.

9. In a joint interview, the findings were reviewed with E1, E8, and E9 and no additional comments or statements were provided regarding the findings.

Facility Information

Inspection History

INSP-0162589

Summary:

INSP-0160258

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0159055

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0147296

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0136241

Summary:

INSP-0134352

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0131598

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0130989

Summary:

INSP-0065091

Summary:

INSP-0064891

Summary:

INSP-0064890

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

INSP-0064889

Summary:

INSP-0064887

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings: