Compliance (Annual)
31 deficiencies cited
The agency cited 31 deficiencies concerning Fall-prevention training, Tuberculosis clearance, Administration, Personnel, Residency and Residency Agreements, Service Plans and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- Fall-prevention trainingA.R.S. § 36-420.01.A
Cited requirement:A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 20, 2025. 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: Sep 20, 2025. A provider’s plan does not establish agency-confirmed correction.
- 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.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 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: Sep 20, 2025. A provider’s plan does not establish agency-confirmed correction.
- AdministrationR9-10-803.F.1
Cited requirement:R9-10-803.F.1. Administration F. If a requirement in this Article states that a manager shall ensure an action or condition or sign a document: 1. A governing authority or licensee may ensure the action or condition or sign the document and retain the responsibility to ensure compliance with the requirement in this Article;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 21, 2025. A provider’s plan does not establish agency-confirmed correction.
- R9-10-804.1.a-e
Cited requirement:R9-10-804.1.a-e. Quality Management A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to residents; c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 21, 2025. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.10
Cited requirement:R9-10-806.A.10. Personnel A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 21, 2025. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.4.a-b
Cited requirement:R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and b. According to policies and procedures;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 21, 2025. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.7
Cited requirement:R9-10-806.A.7. Personnel A. A manager shall ensure that: 7. Documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 21, 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: Sep 21, 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: Sep 21, 2025. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-806.C.1.a-c
Cited requirement:R9-10-806.C.1.a-c. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual's name, date of birth, and contact telephone number; b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties; ii. The individual's education and experience applicable to the individual's job duties; iii. The individual's completed orientation and in-service education required by policies and procedures; iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or polici…
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 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: Sep 21, 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: Sep 21, 2025. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.C.1.g
Cited requirement:R9-10-808.C.1.g. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.E.1-4
Cited requirement:R9-10-808.E.1-4. Service Plans E. A manager shall ensure that: 1. Daily social, recreational, or rehabilitative activities are planned according to residents' preferences, needs, and abilities; 2. A calendar of planned activities is: a. Prepared at least one week in advance of the date the activity is provided, b. Posted in a location that is easily seen by residents, c. Updated as necessary to reflect substitutions in the activities provided, and d. Maintained for at least 12 months after the last scheduled activity; 3. Equipment and supplies are available and accessible to accommodate a resident who chooses to participate in a planned activity; and 4. Multiple media sources, such as daily newspapers, current magazines, internet sources, and a variety of reading materials, are available and accessible to a resident to maintain the resident's continued awareness of current news, social events, and other noteworthy information.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Resident RightsR9-10-810.B.2.i
Cited requirement:R9-10-810.B.2.i. Resident Rights B. A manager shall ensure that: 2. A resident is not subjected to: i. Restraint;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Directed Care ServicesR9-10-815.E.1-2
Cited requirement:R9-10-815.E.1-2. Directed Care Services E. A manager shall ensure that: 1. A bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies is available in a bedroom being used by a resident receiving directed care services; or 2. An assisted living facility has implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 22, 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: 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, and ii. Controls 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, and ii. Controls 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: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-816.B.3.c
Cited requirement:R9-10-816.B.3.c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident's medical record.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-816.F.1
Cited requirement:R9-10-816.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: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Food ServicesR9-10-817.A.1.a-e
Cited requirement:R9-10-817.A.1.a-e. Food Services A. A manager shall ensure that: 1. A food menu: a. Is prepared at least one week in advance, b. Includes the foods to be served each day, c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served, d. Includes any food substitution no later than the morning of the day of meal service with a food substitution, and e. Is maintained for at least 60 calendar days after the last day included in the food menu;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Food refrigerationR9-10-817.C.4.a
Cited requirement:R9-10-817.C.4.a. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-818.A.2
Cited requirement:R9-10-818.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: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-818.A.4
Cited requirement:R9-10-818.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: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-818.A.5.a
Cited requirement:R9-10-818.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: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-818.F.4.a-b
Cited requirement:R9-10-818.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;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-819.A.1.b
Cited requirement:R9-10-819.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;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Hazardous-material storageR9-10-819.A.11
Cited requirement:R9-10-819.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: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-819.A.12
Cited requirement:R9-10-819.A.12. Environmental Standards A. A manager shall ensure that: 12. Combustible or flammable liquids and hazardous materials stored by the assisted living facility are stored in the original labeled containers or safety containers in a locked area inaccessible to residents;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-819.A.14.a-c
Cited requirement:R9-10-819.A.14.a-c. Environmental Standards A. A manager shall ensure that: 14. If pets or animals are allowed in the assisted living facility, pets or animals are: a. Controlled to prevent endangering the residents and to maintain sanitation; b. Licensed consistent with local ordinances; and c. For a dog or cat, vaccinated against rabies;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 22, 2025. A provider’s plan does not establish agency-confirmed correction.