15 deficiencies cited
The agency cited 15 deficiencies concerning Fall-prevention training, Tuberculosis clearance, Administration, Personnel, Service Plans, Medical Records 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: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.
- 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: Jan 30, 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 30, 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: Jan 2, 2026. 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: Dec 30, 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: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medical RecordsR9-10-811.C.12
Cited requirement:R9-10-811.C.12. Medical Records C. A manager shall ensure that a resident’s medical record contains: 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medical RecordsR9-10-811.C.17
Cited requirement:R9-10-811.C.17. Medical Records C. A manager shall ensure that a resident’s medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- 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
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 29, 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: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.
- Food ServicesR9-10-818.A.1.a-e
Cited requirement:R9-10-818.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: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.
- Food refrigerationR9-10-818.C.4.a
Cited requirement:R9-10-818.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: Dec 30, 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 30, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.D.2.a-f
Cited requirement:R9-10-819.D.2.a-f. Emergency and Safety Standards D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 2. Documents the following: a. The date and time of the accident, emergency, or injury; b. A description of the accident, emergency, or injury; c. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver; e. The individuals notified by the caregiver or assistant caregiver; and f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 30, 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: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.