A Golden Retreat Care Home

Last inspection

April 21, 2025

Inspections

1, 8 deficiencies cited

Complaint inspections

0, 0 with deficiencies cited

Enforcement cases

1, $1,000 in civil penalties

• License active since 2018

Enforcement cases

• May 16, 2025: Civil Penalty $1,000 (complete) case closed (complete)

April 21, 2025: compliance (annual) inspection, 8 deficiencies

• Personnel R9-10-806.A.4.a-b
  Based on observation, record review, and interview, for two of two caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services. The deficient practice posed a health and safety risk to a resident if a caregiver did not have the documented skills and knowledge to provide wound care services for a resident.
  Plan of correction accepted; correction date given by the community: May 27, 2025
• Service Plans R9-10-808.A.4.a
  Based on observation, record review, and interview, for one of two residents reviewed, the manager failed to ensure a resident's service plan was reviewed and updated after a significant change in the resident's condition. The deficient practice posed a risk to a resident if the resident's service plan was not updated when the resident developed a stage 4 pressure ulcer, and the service plan did not include the services provided.
  Plan of correction accepted; correction date given by the community: May 27, 2025
• Service Plans R9-10-808.C.1.g
  Based on observation, record review, and interview, for one of two residents reviewed, the manager failed to ensure a caregiver documented the services provided in the resident's medical record. The deficient practice posed a risk if services were not provided per the physician's order, and/or the services provided could not be verified.
  Plan of correction accepted; correction date given by the community: May 27, 2025
• Medical Records R9-10-811.C.13.b
  Based on record review and interview, for one of two residents reviewed, who received medication administration, the manager failed to ensure a resident's medical record included the dosage of medication administered to the resident. The deficient practice posed a risk if documentation of a medication administered to a resident did not include the dosage administered to the resident, ensuring the resident was administered the correct dosage per the resident's medication order.
  Plan of correction accepted; correction date given by the community: May 27, 2025
• Directed Care Services R9-10-815.B.2
  Based on observation, record review, and interview, the manager failed to ensure the facility did not retain a resident who had a stage 4 pressure sore, without obtaining a signed and dated determination from a registered nurse (RN) or medical practitioner (MP), according to R9-10-814(B)(2). The deficient practice posed a risk if the facility was unable to meet a resident's needs.
  Plan of correction accepted; correction date given by the community: May 27, 2025

Read the full record on AZ Care Check →

ADHS writes a Statement of Deficiencies after each inspection that finds a rule was not met. The community then files a plan of correction, which ADHS accepts or rejects. ADHS investigates complaints on site. A complaint inspection that ends with “No deficiencies were found” did not find a rule violation; deficiencies cited on a complaint inspection are listed with that inspection. AZ Care Check does not list complaints that did not lead to an on-site inspection. Enforcement cases are actions ADHS takes after an inspection, such as a civil money penalty, a provisional license or a license revocation, with their status. This community is licensed for 8 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Arizona Department of Health Services, Licensing Services, AZ Care Check, data as of October 15, 2026, showing all records on AZ Care Check (back to September 5, 2023). Always visit in person and ask the community about anything listed here.