Complaint · Compliance (Annual)
20 deficiencies cited
The agency cited 20 deficiencies concerning Fall-prevention training, Medication services, Tuberculosis clearance, Administration, Personnel, Residency and Residency Agreements 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 14, 2025. A provider’s plan does not establish agency-confirmed correction.
- 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: Nov 14, 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: Jul 1, 2025. A provider’s plan does not establish agency-confirmed correction.
- A.R.S. § 36-420.04.D
Cited requirement:A.R.S. § 36-420.04.D. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document D. An assisted living center or assisted living home shall maintain a copy of the document provided to the emergency responder and documentation of the actions required by subsection B of this section for a period of two years after the date of the emergency.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 14, 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: Nov 14, 2025. 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.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 1, 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: Jul 1, 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: Nov 14, 2025. A provider’s plan does not establish agency-confirmed correction.
- Residency and Residency AgreementsR9-10-807.D.7
Cited requirement:R9-10-807.D.7. 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: 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;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 2, 2025. A provider’s plan does not establish agency-confirmed correction.
- Residency and Residency AgreementsR9-10-807.H.1-5
Cited requirement:R9-10-807.H.1-5. Residency and Residency Agreements H. A manager shall ensure that the written notice of termination of residency in subsection (G) includes: 1. The date of notice; 2. The reason for termination; 3. The policy for refunding fees, charges, or deposits; 4. The deposition of a resident's fees, charges, and deposits; and 5. Contact information for the State Long-Term Care Ombudsman.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 14, 2025. 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: Nov 14, 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: Oct 6, 2025. 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: Nov 14, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medical RecordsR9-10-811.C.13.a
Cited requirement:R9-10-811.C.13.a. Medical Records C. A manager shall ensure that a resident's medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: a. The date and time of administration or assistance;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 14, 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: 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, and ii. Controls 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, and ii. Controls 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: Jul 2, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-816.B.3.b
Cited requirement:R9-10-816.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: Nov 14, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-818.D.2.a-f
Cited requirement:R9-10-818.D.2.a-f. Emergency and Safety Standards D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 2. Documents the following: a. The date and time of the accident, emergency, or injury; b. A description of the accident, emergency, or injury; c. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver; e. The individuals notified by the caregiver or assistant caregiver; and f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 14, 2025. A provider’s plan does not establish agency-confirmed correction.
- Hazardous-material storageR9-10-819.A.11
Cited requirement:R9-10-819.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: Nov 14, 2025. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-819.A.12
Cited requirement:R9-10-819.A.12. Environmental Standards A. A manager shall ensure that: 12. Combustible or flammable liquids and hazardous materials stored by the assisted living facility are stored in the original labeled containers or safety containers in a locked area inaccessible to residents;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 6, 2025. A provider’s plan does not establish agency-confirmed correction.
- Physical Plant StandardsR9-10-820.F.1.a-f
Cited requirement:R9-10-820.F.1.a-f. Physical Plant Standards F. If there is a swimming pool on the premises of the assisted living facility, a manager shall ensure that: 1. Unless the assisted living facility has documentation of having received an exception from the Department before October 1, 2013, the swimming pool is enclosed by a wall or fence that: a. Is at least five feet in height as measured on the exte- rior of the wall or fence; b. Has no vertical openings greater that four inches across; c. Has no horizontal openings, except as described in subsection (F)(1)(e); d. Is not chain-link; e. Does not have a space between the ground and the bottom fence rail that exceeds four inches in height; and f. Has a self-closing, self-latching gate that: i. Opens away from the swimming pool, ii. Has a latch located at least 54 inches from the ground, and iii. Is locked when the swimming pool is not in use;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 18, 2025. A provider’s plan does not establish agency-confirmed correction.