Ridge at the Stratford

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 31, 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: Oct 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: Oct 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.5.a-c. Personnel 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;

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

Cited requirement:R9-10-807.B.1.a-b. Residency and Residency Agreements 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

Provider-listed correction date: Nov 30, 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: Oct 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.3.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: 3. Includes the following: a. A description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments;

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

Cited requirement:R9-10-808.A.3.b. 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: b. The level of service the resident is expected to receive;

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

Cited requirement:R9-10-808.A.5.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: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident’s representative;

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

Cited requirement:R9-10-811.C.18. Medical Records C. A manager shall ensure that a resident’s medical record contains: Documentation of the resident’s orientation to exits from the assisted living facility required in R9-10-819(B);

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

Cited requirement:R9-10-814.F.1-4. Personal Care Services 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; 2. Offering sufficient fluids to maintain hydration; 3. Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; and 4. If applicable, the determination in subsection (B)(2)(b)(iii).

Provider-listed correction date: Oct 31, 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: Aug 1, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.A.4. Emergency and Safety Standards 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;

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

Cited requirement:R9-10-819.A.5.a. Emergency and Safety Standards A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and

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

Cited requirement:R9-10-819.F.4.a-b. Emergency and Safety Standards F. A manager of an assisted living home shall ensure that: 4. Except as provided in subsection (G): a. A smoke detector is: i. Installed in each bedroom, hallway that adjoins a bedroom, storage room, laundry room, attached garage, and room or hallway adjacent to the kitchen, and other places recommended by the manufacturer; ii. Either battery operated or, if hard-wired into the electrical system of the assisted living home, has a back-up battery; iii. In working order; and iv. Tested at least once a month; and b. Documentation of the test required in subsection (F)(4)(a)(iv) is maintained for at least 12 months after the date of the test;

Provider-listed correction date: Oct 31, 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: Dec 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: Dec 2, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.3.b. 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: b. The level of service the resident is expected to receive;

Provider-listed correction date: Dec 2, 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: Apr 2, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.4.b.i-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: i. At least once every 12 months for a resident receiving supervisory care services, ii. At least once every six months for a resident receiving personal care services, and iii. At least once every three months for a resident receiving directed care services; and

Provider-listed correction date: Dec 3, 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: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-815.C.7. 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: 7. Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan.

Provider-listed correction date: Dec 3, 2025. A provider’s plan does not establish agency-confirmed correction.

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 written service plan 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 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 interactions to manage the resident's behavior: (1) The psychosocial inte…

Provider-listed correction date: Nov 3, 2025. A provider’s plan does not establish agency-confirmed correction.

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: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: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

Correction information is not available in the records reviewed.

Cited requirement:C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: c. Provides assistance with activities of daily living according to 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: 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:C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: c. Provides assistance with activities of daily living according to the resident's service plan;

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: 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): d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and

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: 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;

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; 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;

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. 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: 3. Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; 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: 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.

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: 5. When initially developed and when updated, is signed and dated by: c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; 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:D. A manager shall ensure that the following are conspicuously posted: 4. The location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed.

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:A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes: 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; 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 2. If an individual is requesting or is expected to receive behavioral health services, other than behavioral care, in addition to supervisory care services, personal care services, or directed care services from an assisted living facility: a. Includes whether the individual requires continuous behavioral health services, and b. Is signed and dated by a behavioral health professional.

Correction information is not available in the records reviewed.

Cited requirement:C. A manager shall not accept or retain an individual if: 1. The individual requires continuous: a. Medical services;

Correction information is not available in the records reviewed.

Cited requirement:C. A manager shall not accept or retain an individual if: 1. The individual requires continuous: b. Nursing services, unless the assisted living facility complies with A.R.S. § 36-401(C); or

Correction information is not available in the records reviewed.

Cited requirement:E. Before or within five working days after a resident's acceptance by an assisted living facility, a manager shall obtain on the documented agreement, required in subsection (D), the signature of one of the following individuals: 4. Another individual who has been designated by the individual under A.R.S. § 36-3221 to make health care decisions on the individual's behalf.

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:A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative; b. The manager; c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the 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: g. Documents the services provided in the resident's medical record; and

Correction information is not available in the records reviewed.

Cited requirement:B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

Correction information is not available in the records reviewed.

Cited requirement: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:B. A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: 2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: b. The resident's primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition;

Correction information is not available in the records reviewed.

Cited requirement:B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2): 1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or

Correction information is not available in the records reviewed.

Cited requirement: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,

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: 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.