Eternal Spring Of Gilbert

Cited requirement:R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.

Provider-listed correction date: Jul 31, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.1-5. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 calendar days after the resident's date of acceptance; 2. Is developed with assistance and review from: a. The resident or resident's representative, b. The manager, and c. Any individual requested by the resident or the resident's representative; 3. Includes the following: a. A description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; b. The level of service the resident is expected to receive; c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication; d. For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner; e. For a resident who requires behavioral care: i. Any of the following that is necessary to provide assistance with the resident's psychosocial interactions to manage the resident's behavior: (1) The psychosocial inte…

Provider-listed correction date: Jul 31, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.4.a. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): a. No later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition; and

Provider-listed correction date: Jul 31, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.4.b.ii. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: ii. At least once every six months for a resident receiving personal care services, and

Provider-listed correction date: Jul 31, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.4.b.iii. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: iii. At least once every three months for a resident receiving directed care services; and

Provider-listed correction date: Jul 31, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:36-420.04. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing freque…

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 4. 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

Correction information is not available in the records reviewed.

Cited requirement: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.

Correction information is not available in the records reviewed.

Cited requirement: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 policies and procedures; and ix. Do…

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1;

Correction information is not available in the records reviewed.

Cited requirement:J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall: 1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454; 3. Document: a. The suspected abuse, neglect, or exploitation; b. Any action taken according to subsection (J)(1); and c. The report in subsection (J)(2); 4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2); 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotio…

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 4. 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

Correction information is not available in the records reviewed.

Cited requirement: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

Correction information is not available in the records reviewed.

Cited requirement: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 policies and procedures; and ix. Do…

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 12. Combustible or flammable liquids and hazardous materials stored by the assisted living facility are stored in the original labeled containers or safety containers in a locked area inaccessible to residents;

Correction information is not available in the records reviewed.