Compliance (Annual)
11 deficiencies cited
The agency cited 11 deficiencies concerning Fall-prevention training, Tuberculosis clearance, Administration, Service Plans, Personal Care Services, Medication Services 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: Nov 15, 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: Oct 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: Oct 20, 2025. A provider’s plan does not establish agency-confirmed correction.
- AdministrationR9-10-803.C.1.a
Cited requirement:R9-10-803.C.1.a. 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: a. Cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 5, 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: Oct 31, 2025. 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: Nov 1, 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: Nov 10, 2025. A provider’s plan does not establish agency-confirmed correction.
- Personal Care ServicesR9-10-814.B.1-2
Cited requirement:R9-10-814.B.1-2. Personal Care Services B. A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: 1. The condition is a result of a short-term illness or injury; or 2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: a. The resident or resident’s representative requests that the resident be accepted by or remain in the assisted living facility; b. The resident’s primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident’s condition; ii. Reviews the assisted living facility’s scope of services; and iii. Signs and dates a determination stating that the resident’s needs can be met by the assisted living facility within the assisted living facility’s scope of services and, for retention of a resident, are being met by the assisted living facility; and c. The resident’s service plan…
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 1, 2025. 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: Oct 25, 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: Oct 31, 2025. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-820.A.6
Cited requirement:R9-10-820.A.6. Environmental Standards A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 31, 2025. A provider’s plan does not establish agency-confirmed correction.