15 deficiencies cited
The agency cited 15 deficiencies concerning Tuberculosis clearance, Personnel, Residency and Residency Agreements, Service Plans, Medical Records, Personal Care Services and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- 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: Jun 19, 2026. 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: Jun 30, 2026. 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: Jun 30, 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: Jul 2, 2026. 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: Jul 10, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.3.b
Cited requirement:R9-10-808.A.3.b. 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: b. The level of service the resident is expected to receive;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 30, 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 8, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.4.a
Cited requirement:R9-10-808.A.4.a. 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: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): a. No later than 14 calendar days after a significant change in the resident’s physical, cognitive, or functional condition; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jun 30, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.C.1.a
Cited requirement:R9-10-808.C.1.a. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident’s service plan;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jun 19, 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: Jun 19, 2026. A provider’s plan does not establish agency-confirmed correction.
- Personal Care ServicesR9-10-814.F.1-4
Cited requirement:R9-10-814.F.1-4. 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; 2. Offering sufficient fluids to maintain hydration; 3. Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; and 4. If applicable, the determination in subsection (B)(2)(b)(iii).
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jun 30, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.F.1
Cited requirement:R9-10-817.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: Jun 30, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.F.3.a
Cited requirement:R9-10-817.F.3.a. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented for: a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Aug 30, 2026. 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: May 24, 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: Jun 30, 2026. A provider’s plan does not establish agency-confirmed correction.