12 deficiencies cited
The agency cited 12 deficiencies concerning Fall-prevention training, Personnel, Residency and Residency Agreements, 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: Oct 22, 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: Oct 24, 2025. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.4.a-b
Cited requirement:R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: A caregiver’s or assistant caregiver’s skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and b. According to policies and procedures;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 20, 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: Oct 20, 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: Oct 1, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medical RecordsR9-10-811.C.12
Cited requirement:R9-10-811.C.12. Medical Records C. A manager shall ensure that a resident’s medical record contains: 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 22, 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: Oct 3, 2025. A provider’s plan does not establish agency-confirmed correction.
- Medication ServicesR9-10-817.B.3.c
Cited requirement:R9-10-817.B.3.c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident’s medical record.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 16, 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: Sep 30, 2025. A provider’s plan does not establish agency-confirmed correction.
- Food refrigerationR9-10-818.C.5
Cited requirement:R9-10-818.C.5. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 5. A refrigerator used by an assisted living facility to store food or medication contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Sep 29, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.A.1.a-d
Cited requirement:R9-10-819.A.1.a-d. Emergency and Safety Standards A. A manager shall ensure that: 1. A disaster plan is developed, documented, maintained in a location accessible to caregivers and assistant caregivers, and, if necessary, implemented that includes: a. When, how, and where residents will be relocated; b. How a resident’s medical record will be available to individuals providing services to the resident during a disaster; c. A plan to ensure each resident’s medication will be available to administer to the resident during a disaster; and d. A plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility’s relocation site during a disaster;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 28, 2025. A provider’s plan does not establish agency-confirmed correction.
- Emergency and Safety StandardsR9-10-819.F.4.a-b
Cited requirement:R9-10-819.F.4.a-b. Emergency and Safety Standards F. A manager of an assisted living home shall ensure that: 4. Except as provided in subsection (G): a. A smoke detector is: i. Installed in each bedroom, hallway that adjoins a bedroom, storage room, laundry room, attached garage, and room or hallway adjacent to the kitchen, and other places recommended by the manufacturer; ii. Either battery operated or, if hard-wired into the electrical system of the assisted living home, has a back-up battery; iii. In working order; and iv. Tested at least once a month; and b. Documentation of the test required in subsection (F)(4)(a)(iv) is maintained for at least 12 months after the date of the test;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Oct 15, 2025. A provider’s plan does not establish agency-confirmed correction.