Everlasting Services At Estrella Center

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: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.

Correction information is not available in the records reviewed.

Cited requirement:A.R.S. § 36-420.04.D. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document D. An assisted living center or assisted living home shall maintain a copy of the document provided to the emergency responder and documentation of the actions required by subsection B of this section for a period of two years after the date of the emergency.

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

Cited requirement:R9-10-803.A.10. Administration A. A governing authority shall: 10. Ensure the health, safety, or welfare of a resident is not placed at risk of harm.

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

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.

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

Cited requirement:R9-10-806. Personnel 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; ii. For supervisory care services, employment as a manager or caregiver of a supervisory care home before November 1, 1998; iii. For supervisory care services or personal care services, employment as a manager or caregiver of a supportive residential living center before November 1, 1998; or iv. For supervisory care services, personal care services, or directed services, one of the following: (1) A nursing care institution administrator’s license issued by the Board of Examiners; (2) A nurse’s license issued to the individual under A.R.S. Title 32, Chapter 15; (3) Documentation of employment as a manager or caregiver of an unclassified residential care institution before November 1, 1998; or (4) Documentation of sponsorship of or employment as a caregiver in an adult foster care home before November 1, 1998;

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

Cited requirement:R9-10-803.A.10. Administration A. A governing authority shall: 10. Ensure the health, safety, or welfare of a resident is not placed at risk of harm.

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

Cited requirement:R9-10-820.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;

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

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.

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

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.

Provider-listed correction date: Oct 6, 2025. 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: Sep 1, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:A. A manager shall ensure that: 4. 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

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 4. 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

Correction information is not available in the records reviewed.

Cited requirement: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

Correction information is not available in the records reviewed.

Cited requirement: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

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. 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: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

Correction information is not available in the records reviewed.

Cited requirement: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

Correction information is not available in the records reviewed.

Cited requirement:R9-10-808.A.3.e.ii. 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: e. For a resident who requires behavioral care: ii. Review by a medical practitioner or behavioral health professional; and

Provider-listed correction date: May 29, 2025. A provider’s plan does not establish agency-confirmed correction.

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…

Provider-listed correction date: Oct 1, 2025. 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: Oct 1, 2025. 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: 4. 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: Oct 1, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.4.b.iii. Service Plans 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): b. As follows: iii. At least once every three months for a resident receiving directed care services; and

Provider-listed correction date: Oct 1, 2025. 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;

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

Cited requirement:R9-10-816.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 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: Sep 1, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:A. A manager shall ensure that: 2. An assistant caregiver: b. Interacts with residents under the supervision of a manager or caregiver;

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: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: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.

Correction information is not available in the records reviewed.

Cited requirement: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

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 4. 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

Correction information is not available in the records reviewed.

Cited requirement: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

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: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

Correction information is not available in the records reviewed.