The Citadel Senior Living Community

Cited requirement:R9-10-814.E. Personal Care Services E. A manager shall ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available and accessible in a bedroom or residential unit being used by a resident receiving personal care services.

Correction information is not available in the records reviewed.

Cited requirement:R9-10-815.E.1-2. Directed Care Services E. A manager shall ensure that: 1. A bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available in a bedroom being used by a resident receiving directed care services; or 2. An assisted living facility has implemented another means to alert a caregiver or assistant caregiver to a resident’s needs or emergencies.

Correction information is not available in the records reviewed.

Cited requirement:R9-10-811.C.14. Medical Records C. A manager shall ensure that a resident’s medical record contains: 14. Documentation of the resident’s refusal of a medication, if applicable;

Correction information is not available in the records reviewed.

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

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

Provider-listed correction date: Mar 23, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-820.A.1.a. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

Provider-listed correction date: Mar 23, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.10. Personnel 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.

Provider-listed correction date: Mar 23, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.3.c. 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: 3. Includes the following: c The amount, type, and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication;

Provider-listed correction date: Mar 23, 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 23, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-810.B.1. Resident Rights B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

Provider-listed correction date: Mar 23, 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 23, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-820.A.1.a. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

Provider-listed correction date: Mar 23, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.8.a-b. Personnel 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;

Provider-listed correction date: Feb 27, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.10. Personnel 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.

Provider-listed correction date: Feb 27, 2026. A provider’s plan does not establish agency-confirmed correction.

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

Provider-listed correction date: Feb 27, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.3.f. 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: 3. Includes the following: f. For a resident who will be storing medication in the resident’s bedroom or residential unit, how the medication will be stored and controlled;

Provider-listed correction date: Feb 27, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-810.B.1. Resident Rights B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

Provider-listed correction date: Feb 27, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-815.C.3. Directed Care Services C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 3. Cognitive stimulation and activities to maximize functioning;

Provider-listed correction date: Feb 27, 2026. 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: Feb 27, 2026. 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: Feb 27, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-821.C.3.a-g. Physical Plant Standards C. A manager shall ensure that: 3. A resident bathroom provides privacy when in use and contains: a. A mirror; b. Toilet tissue for each toilet; c. Soap accessible from each sink; d. Paper towels in a dispenser or a mechanical air hand dryer for a bathroom that is not in a residential unit and used by more than one resident; e. A window that opens or another means of ventilation; f. Grab bars for the toilet and, if applicable, the bathtub or shower and other assistive devices, if required to provide for resident safety; and g. Nonporous surfaces for shower enclosures and slipresistant surfaces in tubs and showers.

Provider-listed correction date: Feb 27, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.D.1. 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: 1. Immediately notifies the resident’s emergency contact and primary care provider; and

Provider-listed correction date: Dec 8, 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: Dec 8, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-820.A.1.a. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

Provider-listed correction date: Dec 8, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-120.F.4.a-c. Opioid Prescribing and Treatment F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall: 4. Except as provided in subsection (H), ensure that an individual authorized by policies and procedures to administer an opioid in treating a patient or to provide assistance in the self-administration of medication for a prescribed opioid: a. Before administering an opioid or providing assistance in the self-administration of medication for a prescribed opioid in compliance with an order as part of the treatment for a patient, identifies the patient's need for the opioid; b. Monitors the patient's response to the opioid; and c. Documents in the patient's medical record: i. An identification of the patient ' s need for the opioid before the opioid was administered or assistance in the self-administration of medicat…

Correction information is not available in the records reviewed.

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, …

Correction information is not available in the records reviewed.

Cited requirement:R9-10-808.A.3.c. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: 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;

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: 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, and ii. Controls 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, and ii. Controls 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:R9-10-817.A.1.a-e. Food Services A. A manager shall ensure that: 1. A food menu: a. Is prepared at least one week in advance, b. Includes the foods to be served each day, c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served, d. Includes any food substitution no later than the morning of the day of meal service with a food substitution, and e. Is maintained for at least 60 calendar days after the last day included in the food menu;

Correction information is not available in the records reviewed.

Cited requirement:R9-10-818.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.

Correction information is not available in the records reviewed.

Cited requirement:R9-10-819.A.11. Environmental Standards 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:R9-10-820.C.3.a-g. Physical Plant Standards C. A manager shall ensure that: 3. A resident bathroom provides privacy when in use and contains: a. A mirror; b. Toilet tissue for each toilet; c. Soap accessible from each sink; d. Paper towels in a dispenser or a mechanical air hand dryer for a bathroom that is not in a residential unit and used by more than one resident; e. A window that opens or another means of ventilation; f. Grab bars for the toilet and, if applicable, the bathtub or shower and other assistive devices, if required to provide for resident safety; and g. Nonporous surfaces for shower enclosures and slip-resistant surfaces in tubs and showers.

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: b. Is administered in compliance with a medication order, 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 b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and

Correction information is not available in the records reviewed.

Cited requirement: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: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

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 b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and

Correction information is not available in the records reviewed.

Cited requirement: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: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

Correction information is not available in the records reviewed.

Cited requirement:E. A manager shall ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies is available and accessible in a bedroom or residential unit being used by a resident receiving personal care services.

Correction information is not available in the records reviewed.

Cited requirement:A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: 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;

Correction information is not available in the records reviewed.

Cited requirement: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: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: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.