Desert Hills Assisted Living LLC

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.

Correction information is not available in the records reviewed.

Cited requirement:R9-10-803.K.3. Administration K. A manager shall provide written notification to the Department of a resident’s: Elopement, within 24 hours of the elopement being discovered.

Correction information is not available in the records reviewed.

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

Correction information is not available in the records reviewed.

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

Correction information is not available in the records reviewed.

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

Correction information is not available in the records reviewed.

Cited requirement:R9-10-816.B. Memory Care Services B. A manager shall ensure that staff obtain a certificate of completion, as specified in R9-10-126, including the minimum eight hours of initial memory care services training within the first 30 days of hire or provide a copy of a certificate of completion, as specified in R9-10-126, obtained within the preceding 12 months from the date of hire. If a staff member or contractor has not worked at an assisted living facility that is licensed to provide directed care services for a period of 12 months, the staff member or contractor must complete the minimum eight hours of initial memory care services training within 30 days after the date of hire, rehire, or returning to work.

Correction information is not available in the records reviewed.

Cited requirement:R9-10-817.B.3.a-c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under the direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident’s medical record.

Correction information is not available in the records reviewed.

Cited requirement:R9-10-820.A.1.b. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

Correction information is not available in the records reviewed.

Cited requirement:R9-10-808.A.4.b.i-iii. 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: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: i. At least once every 12 months for a resident receiving supervisory care services, ii. At least once every six months for a resident receiving personal care services, and iii. At least once every three months for a resident receiving directed care services; and

Provider-listed correction date: Mar 1, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.C.1.a-g. 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; b. Is only assigned to provide the assisted living services the caregiver or assistant caregiver has the documented skills and knowledge to perform; c. Provides assistance with activities of daily living according to the resident’s service plan; d. If applicable, suggests techniques a resident may use to maintain or improve the resident’s independence in performing activities of daily living; e. Provides assistance with, supervises, or directs a resident’s personal hygiene according to the resident’s service plan; f. Encourages a resident to participate in activities planned according to subsection (E); and g. Documents the services provided in the resident’s medical record; and

Provider-listed correction date: Mar 1, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-811.A.5. Medical Records A. A manager shall ensure that: 5. A resident’s medical record is protected from loss, damage, or unauthorized use.

Provider-listed correction date: Mar 1, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.B.3.a-c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under the direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident’s medical record.

Provider-listed correction date: Mar 1, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-110.E. Modification of a Health Care Institution E. A licensee shall not implement a modification described in subsection (C) until an approval or amended license is issued by the Department.

Provider-listed correction date: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-807.H.1-5. Residency and Residency Agreements H. A manager shall ensure that the written notice of termination of residency in subsection (G) includes: 1. The date of notice; 2. The reason for termination; 3. The policy for refunding fees, charges, or deposits; 4. The deposition of a resident’s fees, charges, and deposits; and 5. Contact information for the State Long-Term Care Ombudsman.

Provider-listed correction date: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.

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

Provider-listed correction date: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-811.C.1-24. Medical Records C. A manager shall ensure that a resident’s medical record contains: 1. Resident information that includes: a. The resident’s name, and b. The resident’s date of birth; 2. The names, addresses, and telephone numbers of: a. The resident’s primary care provider; b. Other persons, such as a home health agency or hospice service agency, involved in the care of the resident; and c. An individual to be contacted in the event of an emergency, significant change in the resident’s condition, or termination of residency; 3. If applicable, the name and contact information of the resident’s representative and: a. The document signed by the resident consenting for the resident’s representative to act on the resident’s behalf; or b. If the resident’s representative: i. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or ii. Is a legal guardian, a copy of the court order establishing guardianship; 4. The date of acceptance and, if applicable, the date of termination of residency; 5. …

Provider-listed correction date: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-815.B.1-2. Directed Care Services 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 2. Has a stage 3 or stage 4 pressure sore, as determined by a registered nurse or medical practitioner

Provider-listed correction date: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Provider-listed correction date: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.B.3.c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident’s medical record.

Provider-listed correction date: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.F.3.a. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented for: a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication;

Provider-listed correction date: Dec 30, 2025. A provider’s plan does not establish agency-confirmed correction.