Complaint · Compliance (Annual)
8 deficiencies cited
The agency cited 8 deficiencies concerning Fall-prevention training, Tuberculosis clearance, Personnel, Service Plans, Medication Services, Emergency and Safety Standards. 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: Apr 17, 2026. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-113.A.1-2
Cited requirement:R9-10-113.A.1-2. 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: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 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, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exp…
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 16, 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: Apr 17, 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: Apr 20, 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: Apr 20, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.5.a-d
Cited requirement:R9-10-808.A.5.a-d. 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: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident’s representative; b. The manager; c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 30, 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: Apr 20, 2026. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.F.3.a-b
Cited requirement:R9-10-819.F.3.a-b. Emergency and Safety Standards F. A manager of an assisted living home shall ensure that: 3. A rechargeable fire extinguisher: a. Is serviced at least once every 12 months, and b. Has a tag attached to the fire extinguisher that specifies the date of the last servicing and the identification of the person who serviced the fire extinguisher;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 13, 2026. A provider’s plan does not establish agency-confirmed correction.