Cactus-Star Assisted Living LLC

Cited requirement:36-420.01. 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: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:K. A manager shall provide written notification to the Department of a resident's: 1. Death, if the resident's death is required to be reported according to A.R.S. § 11-593, within one working day after the resident's death; and

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 1. A caregiver: b. Provides documentation of: i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers;

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 5. An assisted living facility has a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to: a. Provide the assisted living services, behavioral health services, behavioral care, and ancillary services in the assisted living facility's scope of services; b. Meet the needs of a resident; and c. Ensure the health and safety of a resident;

Correction information is not available in the records reviewed.

Cited requirement:B. A manager of an assisted living home shall ensure that: 4. At least the manager or a caregiver is present at an assisted living home when a resident is present in the assisted living home and: a. Except for nighttime hours, the manager or caregiver is awake; and b. If the manager or caregiver is not awake during nighttime hours:

Correction information is not available in the records reviewed.

Cited requirement: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;

Correction information is not available in the records reviewed.

Cited requirement:C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: f. Encourages a resident to participate in activities planned according to subsection (E); 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:F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 1. Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;

Correction information is not available in the records reviewed.

Cited requirement: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;

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:D. A manager shall ensure that: 4. A resident's sleeping area: b. Is not used as a passageway to a common area, another sleeping area, or common bathroom unless the resident's sleeping area: i. Was used as a passageway to a common area, another sleeping area, or common bathroom before October 1, 2013; and ii. Written consent is obtained from the resident or the resident's representative;

Correction information is not available in the records reviewed.

Cited requirement:36-420. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition B. Each health care institution: 2. Shall provide appropriate first aid in accordance with its certification training for first aid before the arrival of emergency medical services to a resident who is in distress and to a noninjured resident who has fallen, appears to be uninjured and is unable to reasonably recover independently. The first aid shall be in accordance with the resident's advance directives, if known. Staff who are certified in first aid shall be available at all times.

Correction information is not available in the records reviewed.

Cited requirement:36-420.01. 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:C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: w. Cover a quality management program, including incident report and supporting documentation;

Correction information is not available in the records reviewed.

Cited requirement:L. If a resident is receiving services from a home health agency or hospice service agency, a manager shall ensure that: 2. Any care instructions for a resident provided to the assisted living facility by the home health agency or hospice service agency are: c. Documented in the resident's service plan.

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: 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

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: b. Includes all individuals on the premises except for: i. A resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident, and

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 6. Documentation of each evacuation drill is created, is maintained for at least 12 months after the date of the evacuation drill, and includes: c. If applicable: ii. An identification of residents who were not evacuated;

Correction information is not available in the records reviewed.

Cited requirement:D. A manager shall ensure that: 4. A resident's sleeping area: b. Is not used as a passageway to a common area, another sleeping area, or common bathroom unless the resident's sleeping area: i. Was used as a passageway to a common area, another sleeping area, or common bathroom before October 1, 2013; and ii. Written consent is obtained from the resident or the resident's representative;

Correction information is not available in the records reviewed.