Compliance (Annual)
12 deficiencies cited
The agency cited 12 deficiencies concerning Administration, Personnel, Residency and Residency Agreements, Service Plans, Resident Rights, Directed Care Services and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- 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
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Mar 17, 2026. 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: Feb 2, 2026. 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: 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: Feb 5, 2026. A provider’s plan does not establish agency-confirmed correction.
- Residency and Residency AgreementsR9-10-807.E.1-4
Cited requirement:R9-10-807.E.1-4. Residency and Residency Agreements E. Before or within five working days after a resident’s acceptance by an assisted living facility, a manager shall obtain on the documented agreement, required in subsection (D), the signature of one of the following individuals: 1. The resident, 2. The resident’s representative, 3. The resident’s legal guardian, or 4. Another individual who has been designated by the individual under A.R.S. § 36-3221 to make health care decisions on the individual’s behalf.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Feb 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.3.c
Cited requirement:R9-10-808.A.3.c. 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: c The amount, type, and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Feb 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.3.e.i.1-4
Cited requirement:R9-10-808.A.3.e.i.1-4. 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: e. For a resident who requires behavioral care: i. Any of the following that is necessary to provide assistance with the resident’s psychosocial interactions to manage the resident’s behavior: (1) The psychosocial interactions or behaviors for which the resident requires assistance, (2) Psychotropic medications ordered for the resident, (3) Planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and (4) Goals for changes in the resident’s psychosocial interactions or behaviors; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Feb 1, 2026. 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: Feb 2, 2026. 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: Jan 30, 2026. 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: Feb 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.B.3.c
Cited requirement:R9-10-817.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: Feb 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.A.1.a-d
Cited requirement:R9-10-819.A.1.a-d. Emergency and Safety Standards A. A manager shall ensure that: 1. A disaster plan is developed, documented, maintained in a location accessible to caregivers and assistant caregivers, and, if necessary, implemented that includes: a. When, how, and where residents will be relocated; b. How a resident’s medical record will be available to individuals providing services to the resident during a disaster; c. A plan to ensure each resident’s medication will be available to administer to the resident during a disaster; and d. A plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility’s relocation site during a disaster;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Feb 1, 2026. 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: Feb 1, 2026. A provider’s plan does not establish agency-confirmed correction.