Inspection Report
Enforcement
Capacity: 10
Deficiencies: 12
Jul 2, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-02 to 2025-07 with deficiency history and enforcement actions.
Findings
Across four inspections, multiple deficiencies were identified including failures in policy implementation, personnel documentation, resident safety measures, and emergency preparedness. One complaint investigation found no deficiencies.
Complaint Details
An on-site investigation of complaint AZ00213637 was conducted on August 7, 2024, and no deficiencies were cited.
Deficiencies (12)
| Description |
|---|
| R9-10-803.C.1.a. Administration C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: a. Cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers; |
| 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; |
| 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: 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; |
| 36-420.01. 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. |
| 36-420.04. 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. |
| R9-10-113. 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: c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; |
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411. |
| C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and |
| C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d); |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2): 1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or |
| A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented; |
| A. A manager shall ensure that: 14. If pets or animals are allowed in the assisted living facility, pets or animals are: b. Licensed consistent with local ordinances; |
Report Facts
Inspections on page: 4
Total deficiencies: 12
Complaint inspections: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Named in multiple findings and interviews related to policy and documentation deficiencies | |
| E2 | Referenced in personnel and training documentation deficiencies | |
| E3 | Referenced in personnel documentation deficiencies | |
| O1 | Volunteer | Referenced in personnel record deficiency |
| O2 | Referenced as a pet in licensing deficiency |
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