Complaint · Compliance (Annual)
17 deficiencies cited
The agency cited 17 deficiencies concerning Fall-prevention training, Tuberculosis clearance, Personnel, Service Plans, Medical Records, Personal Care 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: Mar 31, 2026. 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: Mar 1, 2026. 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: Mar 13, 2026. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.2.a-b
Cited requirement:R9-10-806.A.2.a-b. Personnel A. A manager shall ensure that: 2. An assistant caregiver: a. Is 16 years of age or older, and b. Interacts with residents under the supervision of a manager or caregiver;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Mar 1, 2026. 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: Feb 27, 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: Mar 1, 2026. 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: Mar 1, 2026. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.A.9
Cited requirement:R9-10-806.A.9. Personnel A. A manager shall ensure that: 9. Before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the caregiver or assistant caregiver; and
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 31, 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: Feb 27, 2026. A provider’s plan does not establish agency-confirmed correction.
- Service PlansR9-10-808.A.3.c
Cited requirement:R9-10-808.A.3.c. 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: c The amount, type, and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Feb 27, 2026. 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: Oct 1, 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: Sep 30, 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: Oct 10, 2025. A provider’s plan does not establish agency-confirmed correction.
- Personal Care ServicesR9-10-814.F.1-4
Cited requirement:R9-10-814.F.1-4. Personal Care Services F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 1. Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; 2. Offering sufficient fluids to maintain hydration; 3. Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; and 4. If applicable, the determination in subsection (B)(2)(b)(iii).
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Feb 27, 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: Oct 1, 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: Oct 1, 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: Oct 1, 2025. A provider’s plan does not establish agency-confirmed correction.