Paseo Highlands Assisted Living

Cited requirement:A.R.S. § 36-420.04.C. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document C. Each assisted living center and assisted living home must maintain a standardized form for each resident that includes the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. Each assisted living center and assisted living home shall periodically update this form for each resident as necessary.

Provider-listed correction date: May 22, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.B.2.a. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 2. Policies and procedures for medication administration: a. Are reviewed and approved by a medical practitioner, registered nurse, or pharmacist;

Provider-listed correction date: May 24, 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: May 22, 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: May 12, 2026. A provider’s plan does not establish agency-confirmed correction.

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

Provider-listed correction date: Jul 30, 2025. A provider’s plan does not establish agency-confirmed correction.

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;

Provider-listed correction date: Jul 30, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.A.12. Environmental Standards A. A manager shall ensure that: 12. Combustible or flammable liquids and hazardous materials stored by the assisted living facility are stored in the original labeled containers or safety containers in a locked area inaccessible to residents;

Provider-listed correction date: Jul 30, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.A.14.a-c. Environmental Standards A. A manager shall ensure that: 14. If pets or animals are allowed in the assisted living facility, pets or animals are: a. Controlled to prevent endangering the residents and to maintain sanitation; b. Licensed consistent with local ordinances; and c. For a dog or cat, vaccinated against rabies;

Provider-listed correction date: Jul 30, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement: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:A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes: a. An identification of each concern about the delivery of services related to resident care, and b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care;

Correction information is not available in the records reviewed.

Cited requirement: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;

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: b. The level of service the resident is expected to receive;

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): b. As follows: ii. At least once every six months for a resident receiving personal care services, and

Correction information is not available in the records reviewed.

Cited requirement:C. A manager shall ensure that a resident's medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: a. The date and time of administration or assistance; b. The name, strength, dosage, and route of administration; c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and d. An unexpected reaction the resident has to the medication;

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:F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented for: a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication;

Correction information is not available in the records reviewed.

Cited requirement:F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented for: d. Storing, inventorying, and dispensing controlled substances.

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:R9-10-120. 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: 1. Establish, document, and implement policies and procedures for administering an opioid as part of treatment or providing assistance in the self-administration of medication for a prescribed opioid, to protect the health and safety of a patient, that: a. Cover which personnel members may administer an opioid in treating a patient and the required knowledge and qualifications of these personnel members; b. Cover which personnel members may provide assistance in the self administration of medication for a prescribed opioid and the required knowledge and qualifications of these personnel members; c. Include how, when, and by whom a patient ' s need for opioid administration is assessed; d. Include how, when, and by whom a pa…

Correction information is not available in the records reviewed.

Cited requirement:R9-10-120. 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 medication for …

Correction information is not available in the records reviewed.