Compliance (Annual)
12 deficiencies cited
The agency cited 12 deficiencies concerning Administration, Personnel, Residency and Residency Agreements, Service Plans, Medication Services, Emergency and Safety Standards 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.
Correction information is not available in the records reviewed.
- AdministrationR9-10-803.A.9
Cited requirement:R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411 and
Correction information is not available in the records reviewed.
- PersonnelR9-10-806.B.4.a-b
Cited requirement:R9-10-806.B.4.a-b. Personnel B. A manager of an assisted living home shall ensure that: 4. At least the manager or a caregiver is present at an assisted living home when a resident is present in the assisted living home and: a. Except for nighttime hours, the manager or caregiver is awake; and b. If the manager or caregiver is not awake during nighttime hours: i. The manager or caregiver can hear and respond to a resident needing assistance; and ii. If the assisted living home is authorized to provide directed care services, policies and procedures are developed, documented, and implemented to establish a process for checking on a resident receiving directed care services during nighttime hours to ensure the resident’s health and safety.
Correction information is not available in the records reviewed.
- Residency and Residency AgreementsR9-10-807.D.10
Cited requirement:R9-10-807.D.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: 10. The manager’s signature and date signed.
Correction information is not available in the records reviewed.
- Service PlansR9-10-808.A.3.f
Cited requirement:R9-10-808.A.3.f. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 3. Includes the following: f. For a resident who will be storing medication in the resident’s bedroom or residential unit, how the medication will be stored and controlled;
Correction information is not available in the records reviewed.
- Medication ServicesR9-10-817.B.1
Cited requirement:R9-10-817.B.1. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 1. Medication is stored by the assisted living facility;
Correction information is not available in the records reviewed.
- Medication ServicesR9-10-817.B.3.b
Cited requirement:R9-10-817.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
Correction information is not available in the records reviewed.
- 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;
Correction information is not available in the records reviewed.
- Medication ServicesR9-10-817.F.3.a
Cited requirement:R9-10-817.F.3.a. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented for: a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication;
Correction information is not available in the records reviewed.
- Emergency and Safety StandardsR9-10-819.F.4.a-b
Cited requirement:R9-10-819.F.4.a-b. Emergency and Safety Standards F. A manager of an assisted living home shall ensure that: 4. Except as provided in subsection (G): a. A smoke detector is: i. Installed in each bedroom, hallway that adjoins a bedroom, storage room, laundry room, attached garage, and room or hallway adjacent to the kitchen, and other places recommended by the manufacturer; ii. Either battery operated or, if hard-wired into the electrical system of the assisted living home, has a back-up battery; iii. In working order; and iv. Tested at least once a month; and b. Documentation of the test required in subsection (F)(4)(a)(iv) is maintained for at least 12 months after the date of the test;
Correction information is not available in the records reviewed.
- Environmental StandardsR9-10-820.A.1.b
Cited requirement:R9-10-820.A.1.b. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;
Correction information is not available in the records reviewed.
- 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;
Correction information is not available in the records reviewed.