Complaint · Compliance (Annual)
13 deficiencies cited
The agency cited 13 deficiencies concerning Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition, Administration, Personnel, Residency and Residency Agreements, Directed Care Services, Food 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.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: Jan 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definitionA.R.S. § 36-420.B.1
Cited requirement:A.R.S. § 36-420.B.1. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition B. Each health care institution: 1. Shall initiate cardiopulmonary resuscitation in accordance with its certification training for cardiopulmonary resuscitation before the arrival of emergency medical services, to a resident who is nonresponsive or has a cessation of normal respiration. The cardiopulmonary resuscitation shall be in accordance with that resident's advance directives, if known. Staff who are certified in cardiopulmonary resuscitation shall be available at all times.
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.
- AdministrationR9-10-803.K.1
Cited requirement:R9-10-803.K.1. Administration K. A manager shall provide written notification to the Department of a resident’s: 1. Death, if the resident’s death is required to be reported according to A.R.S. § 11-593, within one working day after the resident’s death;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 31, 2026. 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: Jan 5, 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 2, 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: Jan 2, 2026. 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: Jan 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Food ServicesR9-10-818.A.1.a-e
Cited requirement:R9-10-818.A.1.a-e. Food Services A. A manager shall ensure that: 1. A food menu: a. Is prepared at least one week in advance, b. Includes the foods to be served each day, c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served, d. Includes any food substitution no later than the morning of the day of meal service with a food substitution, and e. Is maintained for at least 60 calendar days after the last day included in the food menu;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Food ServicesR9-10-818.A.2
Cited requirement:R9-10-818.A.2. Food Services A. A manager shall ensure that: 2. Meals and snacks provided by the assisted living facility are served according to posted menus;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.B.1-2
Cited requirement:R9-10-819.B.1-2. Emergency and Safety Standards B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident’s acceptance by the assisted living facility, and 2. The resident’s orientation is documented.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 2, 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: Mar 2, 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: Jan 2, 2026. A provider’s plan does not establish agency-confirmed correction.
- Physical Plant StandardsR9-10-821.D.4.f
Cited requirement:R9-10-821.D.4.f. Physical Plant Standards D. A manager shall ensure that: 4. A resident’s sleeping area: f. Has a window or door that can be used for direct egress to outside the building;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jan 2, 2026. A provider’s plan does not establish agency-confirmed correction.