Canyon Winds Retirement LLC

Cited requirement:R9-10-803.J.1-6. Administration 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, …

Provider-listed correction date: Oct 1, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.A.2. Emergency and Safety Standards A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Provider-listed correction date: Oct 1, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.D.2.a-f. Emergency and Safety Standards D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 2. Documents the following: a. The date and time of the accident, emergency, or injury; b. A description of the accident, emergency, or injury; c. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver; e. The individuals notified by the caregiver or assistant caregiver; and f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.

Provider-listed correction date: Oct 1, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;

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: c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

Correction information is not available in the records reviewed.

Cited requirement: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.

Correction information is not available in the records reviewed.

Cited requirement: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;

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and

Correction information is not available in the records reviewed.

Cited requirement:E. A manager of an assisted living center shall ensure that: 3. A fire inspection is conducted by a local fire department or the State Fire Marshal before licensing and according to the time-frame established by the local fire department or the State Fire Marshal;

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 3. Garbage and refuse are: a. Stored in covered containers lined with plastic bags, and

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 10. Oxygen containers are secured in an upright position;

Correction information is not available in the records reviewed.

Cited requirement: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;

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;

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: c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

Correction information is not available in the records reviewed.

Cited requirement: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.

Correction information is not available in the records reviewed.

Cited requirement: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;

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and

Correction information is not available in the records reviewed.

Cited requirement:E. A manager of an assisted living center shall ensure that: 3. A fire inspection is conducted by a local fire department or the State Fire Marshal before licensing and according to the time-frame established by the local fire department or the State Fire Marshal;

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 3. Garbage and refuse are: a. Stored in covered containers lined with plastic bags, and

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 10. Oxygen containers are secured in an upright position;

Correction information is not available in the records reviewed.

Cited requirement: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;

Correction information is not available in the records reviewed.

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:C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 2. Food is protected from potential contamination;

Correction information is not available in the records reviewed.

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

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.