Compliance (Annual)
20 deficiencies cited
The agency cited 20 deficiencies concerning Tuberculosis clearance, Administration, Personnel, Residency and Residency Agreements, Medical Records, Personal Care 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: Aug 31, 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: Aug 31, 2025. A provider’s plan does not establish agency-confirmed correction.
- AdministrationR9-10-803.L.1.a-c
Cited requirement:R9-10-803.L.1.a-c. Administration L. If a resident is receiving services from a home health agency or hospice service agency, a manager shall ensure that: 1. The resident’s medical record contains: a. The name, address, and contact individual, including contact information, of the home health agency or hospice service agency; b. Any information provided by the home health agency or hospice service agency; and c. A copy of resident follow-up instructions provided to the resident by the home health agency or hospice service agency; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Aug 31, 2025. A provider’s plan does not establish agency-confirmed correction.
- R9-10-804.2.a-b
Cited requirement:R9-10-804.2.a-b. Quality Management A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes: a. An identification of each concern about the delivery of services related to resident care, and b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Aug 31, 2025. 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, 2025. 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: Aug 1, 2025. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.B.4.a-b
Cited requirement:R9-10-806.B.4.a-b. Personnel B. A manager of an assisted living home shall ensure that: 4. At least the manager or a caregiver is present at an assisted living home when a resident is present in the assisted living home and: a. Except for nighttime hours, the manager or caregiver is awake; and b. If the manager or caregiver is not awake during nighttime hours: i. The manager or caregiver can hear and respond to a resident needing assistance; and ii. If the assisted living home is authorized to provide directed care services, policies and procedures are developed, documented, and implemented to establish a process for checking on a resident receiving directed care services during nighttime hours to ensure the resident’s health and safety.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 20, 2025. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-806.C.1.a-c
Cited requirement:R9-10-806.C.1.a-c. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual’s name, date of birth, and contact telephone number; b. The individual’s starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual’s qualifications, including skills and knowledge applicable to the individual’s job duties; ii. The individual’s education and experience applicable to the individual’s job duties; iii. The individual’s completed orientation and in-service education required by policies and procedures; iv. The individual’s license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or polici…
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 17, 2025. 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: Aug 31, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medical RecordsR9-10-811.C.17
Cited requirement:R9-10-811.C.17. Medical Records C. A manager shall ensure that a resident’s medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Aug 8, 2025. A provider’s plan does not establish agency-confirmed correction.
- Personal Care ServicesR9-10-814.E
Cited requirement:R9-10-814.E. Personal Care Services E. A manager shall ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available and accessible in a bedroom or residential unit being used by a resident receiving personal care services.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 18, 2025. A provider’s plan does not establish agency-confirmed correction.
- Directed Care ServicesR9-10-815.F.2.a-c
Cited requirement:R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander; 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 18, 2025. 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 18, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.D.1
Cited requirement:R9-10-817.D.1. Medication Services D. A manager shall ensure that: 1. A current drug reference guide is available for use by personnel members, and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 18, 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: Jul 25, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.F.3.d
Cited requirement:R9-10-817.F.3.d. 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: d. Storing, inventorying, and dispensing controlled substances.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 25, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.A.8
Cited requirement:R9-10-819.A.8. Emergency and Safety Standards A. A manager shall ensure that: 8. An evacuation path is conspicuously posted in each hallway of each floor of the assisted living facility.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 24, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.C
Cited requirement:R9-10-819.C. Emergency and Safety Standards C. A manager shall ensure that a first-aid kit is maintained in the assisted living facility in a location accessible to caregivers and assistant caregivers.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 18, 2025. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-820.A.2
Cited requirement:R9-10-820.A.2. Environmental Standards A. A manager shall ensure that: 2. A pest control program that complies with A.A.C. R3-8201(C)(4) is implemented and documented;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Aug 1, 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: Jul 22, 2025. A provider’s plan does not establish agency-confirmed correction.