Compliance (Annual)
13 deficiencies cited
The agency cited 13 deficiencies concerning Fall-prevention training, Tuberculosis clearance, Service Plans, Medical Records, Directed Care Services, Medication Services 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 7, 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: Nov 5, 2025. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.3.e.i.1-4
Cited requirement:R9-10-808.A.3.e.i.1-4. 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: e. For a resident who requires behavioral care: i. Any of the following that is necessary to provide assistance with the resident’s psychosocial interactions to manage the resident’s behavior: (1) The psychosocial interactions or behaviors for which the resident requires assistance, (2) Psychotropic medications ordered for the resident, (3) Planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and (4) Goals for changes in the resident’s psychosocial interactions or behaviors; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 7, 2025. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.3.e.ii
Cited requirement:R9-10-808.A.3.e.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: 3. Includes the following: e. For a resident who requires behavioral care: ii. Review by a medical practitioner or behavioral health professional; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 10, 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 5, 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: Nov 5, 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: Nov 4, 2025. A provider’s plan does not establish agency-confirmed correction.
- Food ServicesR9-10-818.C.7
Cited requirement:R9-10-818.C.7. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 7. Tableware, utensils, equipment, and food-contact surfaces are clean and in good repair.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 4, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.D.2.a-f
Cited requirement:R9-10-819.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 5, 2025. 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: Nov 4, 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: Nov 4, 2025. A provider’s plan does not establish agency-confirmed correction.
- Hazardous-material storageR9-10-820.A.11
Cited requirement:R9-10-820.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 4, 2025. A provider’s plan does not establish agency-confirmed correction.
- Physical Plant StandardsR9-10-821.B.4.a-c
Cited requirement:R9-10-821.B.4.a-c. Physical Plant Standards B. A manager shall ensure that: 4. At least one bathroom is accessible from a common area and: a. May be used by residents and visitors; b. Provides privacy when in use; and c. Contains the following: i. At least one working sink with running water, ii. At least one working toilet that flushes and has a seat, iii. Toilet tissue for each toilet, iv. Soap in a dispenser accessible from each sink, v. Paper towels in a dispenser or a mechanical air hand dryer, vi. Lighting, and vii. A window that opens or another means of ventilation;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 4, 2025. A provider’s plan does not establish agency-confirmed correction.