Compliance (Annual)
19 deficiencies cited
The agency cited 19 deficiencies concerning Medication services, Personnel, Residency and Residency Agreements, Medical Records, Directed Care Services, Memory Care Services and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- Medication servicesA.R.S. § 36-420.04.A.1-9
Cited requirement:A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or expe…
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 2, 2025. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.2.a-b
Cited requirement:R9-10-806.A.2.a-b. Personnel A. A manager shall ensure that: 2. An assistant caregiver: a. Is 16 years of age or older, and b. Interacts with residents under the supervision of a manager or caregiver;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 24, 2025. A provider’s plan does not establish agency-confirmed correction.
- Residency and Residency AgreementsR9-10-807.B.1.a-b
Cited requirement:R9-10-807.B.1.a-b. Residency and Residency Agreements B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 2, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medical RecordsR9-10-811.A.5
Cited requirement:R9-10-811.A.5. Medical Records A. A manager shall ensure that: 5. A resident’s medical record is protected from loss, damage, or unauthorized use.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 16, 2025. A provider’s plan does not establish agency-confirmed correction.
- Directed Care ServicesR9-10-815.F.2.a-c
Cited requirement: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
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 16, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.b
Cited requirement:R9-10-816.A.1.b. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: b. Interventions used for behavior management;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.c
Cited requirement:R9-10-816.A.1.c. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: c. Systems to accommodate visitors, staff, and residents who do not need controlled egress;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 25, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.d
Cited requirement:R9-10-816.A.1.d. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: d. The requirements in R9-10-815(C)(8) regarding the prevention of unsafe wandering or exit seeking, which may include the use of tracking systems;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.e
Cited requirement:R9-10-816.A.1.e. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: e. Promotion of nutrition and hydration care;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.f
Cited requirement:R9-10-816.A.1.f. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: f. Evacuation and emergency procedures specific to residents receiving memory care services, that include the requirements in R9-10-819(A)(5);
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 25, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.g
Cited requirement:R9-10-816.A.1.g. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: g. Prevention techniques of elopement and responding to elopement incidents promptly and effectively;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.h
Cited requirement:R9-10-816.A.1.h. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: h. Monitoring residents receiving memory care services in outdoor areas on the premises;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.i.i
Cited requirement:R9-10-816.A.1.i.i. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: i. Specialized environmental features to support memory care that include: i. Secure areas to prevent wandering and spaces designed for cognitive stimulation and engagement; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.i.ii
Cited requirement:R9-10-816.A.1.i.ii. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: i. Specialized environmental features to support memory care that include: ii. Strategies for providing person-centered care that aligns with the principles of dementia-friendly environments, including familiar surroundings, optimized sensory stimulation, and meaningful activities; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 25, 2025. A provider’s plan does not establish agency-confirmed correction.
- Memory Care ServicesR9-10-816.A.1.j
Cited requirement:R9-10-816.A.1.j. Memory Care Services A. If an assisted living facility is authorized to provide directed care services, a manager shall ensure that: 1. Policies and procedures for memory care services are established, documented, and implemented to cover the following: j. Specialized accommodations and progressive support for activities of daily living tailored to persons living with dementia following evidence-based best practices;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.B.3.a-c
Cited requirement:R9-10-817.B.3.a-c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under the direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident’s medical record.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 16, 2025. A provider’s plan does not establish agency-confirmed correction.
- Food ServicesR9-10-818.C.1
Cited requirement:R9-10-818.C.1. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 1. Food is free from spoilage, filth, or other contamination and is safe for human consumption;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 25, 2025. 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: Oct 25, 2025. A provider’s plan does not establish agency-confirmed correction.
- Physical Plant StandardsR9-10-821.C.3.a-g
Cited requirement:R9-10-821.C.3.a-g. Physical Plant Standards C. A manager shall ensure that: 3. A resident bathroom provides privacy when in use and contains: a. A mirror; b. Toilet tissue for each toilet; c. Soap accessible from each sink; d. Paper towels in a dispenser or a mechanical air hand dryer for a bathroom that is not in a residential unit and used by more than one resident; e. A window that opens or another means of ventilation; f. Grab bars for the toilet and, if applicable, the bathtub or shower and other assistive devices, if required to provide for resident safety; and g. Nonporous surfaces for shower enclosures and slipresistant surfaces in tubs and showers.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 16, 2025. A provider’s plan does not establish agency-confirmed correction.