Compliance (Annual)
12 deficiencies cited
The agency cited 12 deficiencies concerning Medication services, Administration, Personnel, Tuberculosis clearance, Service Plans, Resident Rights 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: Aug 1, 2025. A provider’s plan does not establish agency-confirmed correction.
- AdministrationR9-10-803.A.8
Cited requirement:R9-10-803.A.8. Administration A. A governing authority shall: 8. Ensure that a manager or caregiver who is able to read, write, understand, and communicate in English is on an assisted living facility’s premises;
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.
- AdministrationR9-10-803.B.3.a-b
Cited requirement:R9-10-803.B.3.a-b. Administration B. A manager: 3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is: a. At least 21 years of age, and b. Present on the assisted living facility’s premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises.
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.A.10
Cited requirement:R9-10-806.A.10. Personnel A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.
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.
- 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: Aug 1, 2025. 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: Aug 1, 2025. 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: Aug 1, 2025. A provider’s plan does not establish agency-confirmed correction.
- Resident RightsR9-10-810.B.1
Cited requirement:R9-10-810.B.1. Resident Rights B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 15, 2025. 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: Aug 1, 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: Jul 30, 2025. A provider’s plan does not establish agency-confirmed correction.
- Food refrigerationR9-10-818.C.4.a
Cited requirement:R9-10-818.C.4.a. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Jul 10, 2025. 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: Jul 15, 2025. A provider’s plan does not establish agency-confirmed correction.