18 deficiencies cited
The agency cited 18 deficiencies concerning Tuberculosis clearance, Administration, Service Plans, Resident Rights, Medical Records, Personal Care Services and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- A.R.S. § 36-420.04.D
Cited requirement:A.R.S. § 36-420.04.D. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document D. An assisted living center or assisted living home shall maintain a copy of the document provided to the emergency responder and documentation of the actions required by subsection B of this section for a period of two years after the date of the emergency.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Aug 28, 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: Aug 12, 2026. A provider’s plan does not establish agency-confirmed correction.
- AdministrationR9-10-803.C.1.m
Cited requirement:R9-10-803.C.1.m. Administration C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: m. Cover methods by which the assisted living facility is aware of the general or specific hereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jun 17, 2026. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-806.B.1.a-b
Cited requirement:R9-10-806.B.1.a-b. Personnel B. A manager of an assisted living home shall ensure that: 1. An individual residing in an assisted living home, who is not a resident, a manager, a caregiver, or an assistant caregiver: a. Either: i. Complies with the fingerprinting requirements in A.R.S. § 36-411, or ii. Interacts with residents only under the supervision of an individual who has a valid fingerprint clearance card; and b. If the individual is 12 years of age or older, provides evidence of freedom from infectious tuberculosis as specified in R9-10-113;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jun 17, 2026. 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: Jun 17, 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: Aug 6, 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: Jun 16, 2026. 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: Aug 6, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medical RecordsR9-10-811.C.13.a-d
Cited requirement:R9-10-811.C.13.a-d. Medical Records C. A manager shall ensure that a resident’s medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: a. The date and time of administration or assistance; b. The name, strength, dosage, and route of administration; c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and d. An unexpected reaction the resident has to the medication;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jun 17, 2026. A provider’s plan does not establish agency-confirmed correction.
- Personal Care ServicesR9-10-814.E
Cited requirement:R9-10-814.E. Personal Care Services E. A manager shall ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available and accessible in a bedroom or residential unit being used by a resident receiving personal care services.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jun 17, 2026. A provider’s plan does not establish agency-confirmed correction.
- Personal Care ServicesR9-10-814.F.1
Cited requirement:R9-10-814.F.1. Personal Care Services F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 1. Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Aug 6, 2026. A provider’s plan does not establish agency-confirmed correction.
- Personal Care ServicesR9-10-814.F.2
Cited requirement:R9-10-814.F.2. Personal Care Services F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 2. Offering sufficient fluids to maintain hydration;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jun 17, 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: Jun 17, 2026. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.D.1
Cited requirement:R9-10-819.D.1. 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: 1. Immediately notifies the resident’s emergency contact and primary care provider; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 29, 2026. 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: Aug 6, 2026. 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: Jul 29, 2026. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-820.A.2
Cited requirement:R9-10-820.A.2. Environmental Standards A. A manager shall ensure that: 2. A pest control program that complies with A.A.C. R3-8201(C)(4) is implemented and documented;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 11, 2026. A provider’s plan does not establish agency-confirmed correction.
- Physical Plant StandardsR9-10-821.D.4.b.i-ii
Cited requirement:R9-10-821.D.4.b.i-ii. Physical Plant Standards D. A manager shall ensure that: 4. A resident’s sleeping area: b. Is not used as a passageway to a common area, another sleeping area, or common bathroom unless the resident’s sleeping area: i. Was used as a passageway to a common area, another sleeping area, or common bathroom before October 1, 2013; and ii. Written consent is obtained from the resident or the resident’s representative;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 19, 2026. A provider’s plan does not establish agency-confirmed correction.