Desert Gem Assisted Living Facility

Cited requirement:R9-10-113.A.2.a-f. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom fr…

Correction information is not available in the records reviewed.

Cited requirement:R9-10-803.A.7. Administration A. A governing authority shall: 7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager;

Correction information is not available in the records reviewed.

Cited requirement:R9-10-803.B.3.a-b. Administration B. A manager: 3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is: a. At least 21 years of age, and b. Present on the assisted living facility’s premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises.

Correction information is not available in the records reviewed.

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 service plan that is established, documented, and implemented 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 and ancillary 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 interactio…

Correction information is not available in the records reviewed.

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 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): 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:R9-10-810.B.2.i. Resident Rights B. A manager shall ensure that: 2. A resident is not subjected to: i. Restraint;

Correction information is not available in the records reviewed.

Cited requirement:R9-10-815.C.1-8. 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: 1. The requirements in R9-10-814(F)(1) through (3); 2. If applicable, the determination in R9-10-814(B)(2)(b)(iii); 3. Cognitive stimulation and activities to maximize functioning; 4. Strategies to ensure a resident’s personal safety; 5. Encouragement to eat meals and snacks; 6. Documentation: a. Of the resident’s weight, or b. From a medical practitioner stating that weighing the resident is contraindicated; and 7. Coordination of communications with the resident’s representative, family members, and, if applicable, other individuals identified in the resident’s service plan.; and 8. If the resident is receiving memory care services: a. Identification of specialized environmental features to support memory care services, such as secure areas to prevent wandering and spaces designed for cognitive stimulation and engagement; b. Strategies for providing person-centered care that aligns with the principles of dementia-friendly environments, including familiar surroundings, optimized sensor…

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:R9-10-818.A.2. Food Services A. A manager shall ensure that: 2. Meals and snacks provided by the assisted living facility are served according to posted menus;

Correction information is not available in the records reviewed.

Cited requirement:A.R.S. § 36-420.04.A.1-9. 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 expe…

Provider-listed correction date: Sep 18, 2026. A provider’s plan does not establish agency-confirmed correction.

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: Sep 25, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.7. Personnel A. A manager shall ensure that: 7. Documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each;

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

Cited requirement:R9-10-806.C.2.a-b. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: Is maintained: a. Throughout the individual’s period of providing services in or for the assisted living facility, and b. For at least 24 months after the last date the individual provided services in or for the assisted living facility; and

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

Cited requirement:R9-10-808.C.1.a. 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;

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

Cited requirement:R9-10-811.A.1. Medical Records 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;

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

Cited requirement:R9-10-811.C.11. Medical Records C. A manager shall ensure that a resident’s medical record contains: 11. Documentation of assisted living services provided to the resident;

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

Cited requirement:R9-10-811.C.12. Medical Records C. A manager shall ensure that a resident’s medical record contains: 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;

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

Cited requirement:R9-10-113.B.1-2. Tuberculosis Screening B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC), ii. Was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution, and iii. Includes the date and the type of tuberculosis screening test; b. If the individual had a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, compliance with subsection (A)(2)(b); or c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infectio…

Provider-listed correction date: Jul 31, 2026. A provider’s plan does not establish agency-confirmed correction.

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

Provider-listed correction date: Jul 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: 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 b. According to policies and procedures;

Provider-listed correction date: Jul 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.9. Personnel A. A manager shall ensure that: 9. Before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the caregiver or assistant caregiver; and

Provider-listed correction date: Jul 31, 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: Jul 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-807.D.1-10. Residency and Residency Agreements D. Before or at the time of an individual’s acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 1. The individual’s name; 2. Terms of occupancy, including: a. Date of occupancy or expected date of occupancy, b. Resident responsibilities, and c. Responsibilities of the assisted living facility; 3. A list of the services to be provided by the assisted living facility to the resident; 4. A list of the services available from the assisted living facility at an additional fee or charge; 5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours; 6. The policy for refunding fees, charges, or deposits; 7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident’s service plan; 8. The policy and procedure for an assisted living facility to terminate residency; 9. The complaint process; and 10. The manager’s signature and date signed.

Provider-listed correction date: Jul 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.1. 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: 1. Is completed no later than 14 calendar days after the resident’s date of acceptance;

Provider-listed correction date: Jul 31, 2026. A provider’s plan does not establish agency-confirmed correction.

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.

Provider-listed correction date: Jul 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.B.1-2. Emergency and Safety Standards B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident’s acceptance by the assisted living facility, and 2. The resident’s orientation is documented.

Provider-listed correction date: Jul 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-821.F.2. Physical Plant Standards F. If there is a swimming pool on the premises of the assisted living facility, a manager shall ensure that: 2. A life preserver or shepherd’s crook is available and accessible in the swimming pool area; and

Provider-listed correction date: Jul 31, 2026. A provider’s plan does not establish agency-confirmed correction.