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Source: AZ State Licensing Agency
The following deficiencies were found during the on-site compliance inspection conducted on October 20, 2025:
Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for three of three caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1 . A review of facility documentation revealed an employee schedule for October 2025. E1, E2, and E3 all worked at least one day in October. 2 . A review of E1's, E2's, and E3's personnel records revealed documentation of skills and knowledge verification was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided.
Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed and updated at least once every three years. Findings include: 1 . A review of facility documentation revealed a policy and procedure binder. The binder was last dated as reviewed in November 2020. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.
Based on record review and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis as specified in R9-10-113, for two of three personnel sampled. Findings include: 1 . A review of E2's and E3's personnel records revealed documentation of negative TB skin tests. However, documentation of a signs and symptoms screening and risk assessment was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.
Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented and implemented that covered required skills and knowledge. Findings include: 1 . A review of facility documentation revealed a policy which covered required skills and knowledge verification was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.
Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention, which included initial training and continued competency training. Findings include: 1 . A review of facility documentation revealed a program documenting when initial training and continued competency training was required to be completed for personnel was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.
Based on documentation review and interview, the assisted living home failed to maintain a standardized form for each resident that included 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, for two of two residents sampled. Findings include: 1 . A review of facility documentation revealed a standardized from for emergency responders was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.
No deficiencies were found during the on-site compliance inspection conducted on August 24, 2023. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.
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