16 deficiencies cited
The agency cited 16 deficiencies concerning Modification of a Health Care Institution, Tuberculosis clearance, Administration, Personnel, Residency and Residency Agreements, Resident Rights and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- A.R.S. § 36-420.04.C
Cited requirement:A.R.S. § 36-420.04.C. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document C. Each assisted living center and assisted living home must maintain a standardized form for each resident that includes the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. Each assisted living center and assisted living home shall periodically update this form for each resident as necessary.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 12, 2025. A provider’s plan does not establish agency-confirmed correction.
- Modification of a Health Care InstitutionR9-10-110.E
Cited requirement:R9-10-110.E. Modification of a Health Care Institution E. A licensee shall not implement a modification described in subsection (C) until an approval or amended license is issued by the Department.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Mar 31, 2026. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-113.A.2.a-f
Cited requirement:R9-10-113.A.2.a-f. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom fr…
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 12, 2025. A provider’s plan does not establish agency-confirmed correction.
- AdministrationR9-10-803.A.5
Cited requirement:R9-10-803.A.5. Administration A. A governing authority shall: 5. Review and evaluate the effectiveness of the quality management program at least once every 12 months;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- AdministrationR9-10-803.C.3
Cited requirement:R9-10-803.C.3. Administration C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 12, 2025. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-806.A.8.a-b
Cited requirement:R9-10-806.A.8.a-b. Personnel A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 12, 2025. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.9
Cited requirement:R9-10-806.A.9. Personnel A. A manager shall ensure that: 9. Before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the caregiver or assistant caregiver; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-807.A.1-2
Cited requirement:R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident’s date of occupancy, and 2. As specified in R9-10-113
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 12, 2025. A provider’s plan does not establish agency-confirmed correction.
- Residency and Residency AgreementsR9-10-807.D.1-10
Cited requirement:R9-10-807.D.1-10. Residency and Residency Agreements D. Before or at the time of an individual’s acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 1. The individual’s name; 2. Terms of occupancy, including: a. Date of occupancy or expected date of occupancy, b. Resident responsibilities, and c. Responsibilities of the assisted living facility; 3. A list of the services to be provided by the assisted living facility to the resident; 4. A list of the services available from the assisted living facility at an additional fee or charge; 5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours; 6. The policy for refunding fees, charges, or deposits; 7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident’s service plan; 8. The policy and procedure for an assisted living facility to terminate residency; 9. The complaint process; and 10. The manager’s signature and date signed.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Resident RightsR9-10-810.B.3.b
Cited requirement:R9-10-810.B.3.b. Resident Rights B. A manager shall ensure that: 3. A resident or the resident’s representative: b. Consents to photographs of the resident before the resident is photographed, except that a resident may be photographed when accepted as a resident by an assisted living facility for identification and administrative purposes;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 31, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.F.1
Cited requirement:R9-10-817.F.1. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.A.2
Cited requirement:R9-10-819.A.2. Emergency and Safety Standards A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.A.4
Cited requirement:R9-10-819.A.4. Emergency and Safety Standards A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.A.5.a
Cited requirement:R9-10-819.A.5.a. Emergency and Safety Standards A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.B.1-2
Cited requirement:R9-10-819.B.1-2. Emergency and Safety Standards B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident’s acceptance by the assisted living facility, and 2. The resident’s orientation is documented.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 31, 2026. A provider’s plan does not establish agency-confirmed correction.
- Hazardous-material storageR9-10-820.A.11
Cited requirement:R9-10-820.A.11. Environmental Standards A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.