20 deficiencies cited
The agency cited 20 deficiencies concerning Tuberculosis clearance, Administration, Residency and Residency Agreements, Service Plans, Medical Records, Medication 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.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: Mar 27, 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: Apr 20, 2026. A provider’s plan does not establish agency-confirmed correction.
- AdministrationR9-10-803.A.9
Cited requirement:R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411 and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Mar 27, 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: Apr 6, 2026. A provider’s plan does not establish agency-confirmed correction.
- Residency and Residency AgreementsR9-10-807.D.1-10
Cited requirement:R9-10-807.D.1-10. Residency and Residency Agreements D. Before or at the time of an individual’s acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 1. The individual’s name; 2. Terms of occupancy, including: a. Date of occupancy or expected date of occupancy, b. Resident responsibilities, and c. Responsibilities of the assisted living facility; 3. A list of the services to be provided by the assisted living facility to the resident; 4. A list of the services available from the assisted living facility at an additional fee or charge; 5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours; 6. The policy for refunding fees, charges, or deposits; 7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident’s service plan; 8. The policy and procedure for an assisted living facility to terminate residency; 9. The complaint process; and 10. The manager’s signature and date signed.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 6, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.3.a
Cited requirement:R9-10-808.A.3.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: 3. Includes the following: a. A description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 7, 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: Apr 8, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.4.b.i
Cited requirement:R9-10-808.A.4.b.i. 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): b. As follows: i. At least once every 12 months for a resident receiving supervisory care services,
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 11, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.4.b.ii
Cited requirement:R9-10-808.A.4.b.ii. 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): b. As follows: ii. At least once every six months for a resident receiving personal care services, and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Apr 11, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.5.b
Cited requirement:R9-10-808.A.5.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: 5. When initially developed and when updated, is signed and dated by: b. The manager;
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.
- Service PlansR9-10-808.A.5.c
Cited requirement:R9-10-808.A.5.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: 5. When initially developed and when updated, is signed and dated by: c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
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.
- 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: Apr 13, 2026. 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: Apr 13, 2026. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-811.C.7
Cited requirement:R9-10-811.C.7. Medical Records C. A manager shall ensure that a resident’s medical record contains: 7. Except as allowed in R9-10-808(B)(2), documentation of freedom from infectious tuberculosis as required in R9-10-807(A);
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Mar 20, 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: Mar 18, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.C.1
Cited requirement:R9-10-817.C.1. Medication Services C. If an assisted living facility provides assistance in the self-administration of medication, a manager shall ensure that: 1. A resident’s medication is stored by the assisted living facility;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Mar 18, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.C.4.a-b
Cited requirement:R9-10-817.C.4.a-b. Medication Services C. If an assisted living facility provides assistance in the self-administration of medication, a manager shall ensure that: 4. Assistance in the self-administration of medication provided to a resident: a. Is in compliance with an order, and b. Is documented in the resident’s medical record.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Mar 18, 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 27, 2026. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-820.A.1.b
Cited requirement:R9-10-820.A.1.b. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Mar 18, 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: Mar 18, 2026. A provider’s plan does not establish agency-confirmed correction.