Complaint · Compliance (Annual)
11 deficiencies cited
The agency cited 11 deficiencies concerning Prohibited acts; required acts, Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition, Personnel, Tuberculosis clearance, Directed Care Services, Medication Services and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- Prohibited acts; required actsA.R.S. § 36-407.A
Cited requirement:A.R.S. § 36-407.A. Prohibited acts; required acts A. A person shall not establish, conduct or maintain in this state a health care institution or any class or subclass of health care institution unless that person holds a current and valid license issued by the department specifying the class or subclass of health care institution the person is establishing, conducting or maintaining. The license is valid only for the establishment, operation and maintenance of the class or subclass of health care institution, the type of services and, except for emergency admissions as prescribed by the director by rule, the licensed capacity specified by the license.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 1, 2025. 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: Dec 1, 2025. 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: Dec 1, 2025. 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: Dec 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: Dec 1, 2025. A provider’s plan does not establish agency-confirmed correction.
- PersonnelR9-10-806.B.4.a-b
Cited requirement:R9-10-806.B.4.a-b. Personnel B. A manager of an assisted living home shall ensure that: 4. At least the manager or a caregiver is present at an assisted living home when a resident is present in the assisted living home and: a. Except for nighttime hours, the manager or caregiver is awake; and b. If the manager or caregiver is not awake during nighttime hours: i. The manager or caregiver can hear and respond to a resident needing assistance; and ii. If the assisted living home is authorized to provide directed care services, policies and procedures are developed, documented, and implemented to establish a process for checking on a resident receiving directed care services during nighttime hours to ensure the resident’s health and safety.
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Nov 1, 2025. A provider’s plan does not establish agency-confirmed correction.
- Tuberculosis clearanceR9-10-806.C.1.a-c
Cited requirement:R9-10-806.C.1.a-c. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual’s name, date of birth, and contact telephone number; b. The individual’s starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual’s qualifications, including skills and knowledge applicable to the individual’s job duties; ii. The individual’s education and experience applicable to the individual’s job duties; iii. The individual’s completed orientation and in-service education required by policies and procedures; iv. The individual’s license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or polici…
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 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: Nov 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: Dec 1, 2025. A provider’s plan does not establish agency-confirmed correction.
- Environmental StandardsR9-10-820.A.10
Cited requirement:R9-10-820.A.10. Environmental Standards A. A manager shall ensure that: 10. Oxygen containers are secured in an upright position;
View provider’s plan of correction (opens a new tab)Provider-listed correction date: Dec 1, 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: Dec 1, 2025. A provider’s plan does not establish agency-confirmed correction.