Complaint · Compliance (Annual)
23 deficiencies cited
The agency cited 23 deficiencies concerning Medication services, Tuberculosis clearance, Administration, Personnel, Residency and Residency Agreements, Service Plans and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- Medication servicesA.R.S. § 36-420.04.A.1-9
Cited requirement:A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or expe…
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 14, 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: Jan 15, 2026. A provider’s plan does not establish agency-confirmed correction.
- AdministrationR9-10-803.C.3
Cited requirement:R9-10-803.C.3. Administration C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 13, 2026. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.7
Cited requirement:R9-10-806.A.7. Personnel A. A manager shall ensure that: 7. Documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 14, 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: Jan 13, 2026. A provider’s plan does not establish agency-confirmed correction.
- R9-10-804.1.a-e
Cited requirement:R9-10-804.1.a-e. Quality Management A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to residents; c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 17, 2026. A provider’s plan does not establish agency-confirmed correction.
- R9-10-804.3
Cited requirement:R9-10-804.3. Quality Management A manager shall ensure that: 3. The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 17, 2026. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.2.a-b
Cited requirement:R9-10-806.A.2.a-b. Personnel A. A manager shall ensure that: 2. An assistant caregiver: a. Is 16 years of age or older, and b. Interacts with residents under the supervision of a manager or caregiver;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 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: Jul 17, 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: Jan 14, 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: Jan 13, 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: Jan 13, 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: Jan 13, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.5.a
Cited requirement:R9-10-808.A.5.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: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident’s representative;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 13, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medical RecordsR9-10-811.A.5
Cited requirement:R9-10-811.A.5. Medical Records A. A manager shall ensure that: 5. A resident’s medical record is protected from loss, damage, or unauthorized use.
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.
- Medical RecordsR9-10-811.C.11
Cited requirement:R9-10-811.C.11. Medical Records C. A manager shall ensure that a resident’s medical record contains: 11. Documentation of assisted living services provided to the resident;
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.
- 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: Jul 19, 2026. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.B.2.a
Cited requirement:R9-10-817.B.2.a. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 2. Policies and procedures for medication administration: a. Are reviewed and approved by a medical practitioner, registered nurse, or pharmacist;
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.
- 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: Jul 19, 2026. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.A.2
Cited requirement:R9-10-819.A.2. Emergency and Safety Standards A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 14, 2026. A provider’s plan does not establish agency-confirmed correction.
- Physical Plant StandardsR9-10-821.C.3.a-g
Cited requirement:R9-10-821.C.3.a-g. Physical Plant Standards C. A manager shall ensure that: 3. A resident bathroom provides privacy when in use and contains: a. A mirror; b. Toilet tissue for each toilet; c. Soap accessible from each sink; d. Paper towels in a dispenser or a mechanical air hand dryer for a bathroom that is not in a residential unit and used by more than one resident; e. A window that opens or another means of ventilation; f. Grab bars for the toilet and, if applicable, the bathtub or shower and other assistive devices, if required to provide for resident safety; and g. Nonporous surfaces for shower enclosures and slipresistant surfaces in tubs and showers.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 13, 2026. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-820.A.1.a
Cited requirement:R9-10-820.A.1.a. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and
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.
- 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.