St Joseph Assisted Living LLC

Cited requirement:R9-10-806.B.4.a-b. Personnel 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: i. The manager or caregiver can hear and respond to a resident needing assistance; and ii. If the assisted living home is authorized to provide directed care services, policies and procedures are developed, documented, and implemented to establish a process for checking on a resident receiving directed care services during nighttime hours to ensure the resident’s health and safety.

Provider-listed correction date: Jul 30, 2025. 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: 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander; 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 that is secure, and ii. Monitors 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 that is secure, and ii. Monitors 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: Mar 15, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-820.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: Mar 15, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.2.a-b. Personnel A. A manager shall ensure that: 2. An assistant caregiver: a. Is 16 years of age or older, and b. Interacts with residents under the supervision of a manager or caregiver;

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

Cited requirement:R9-10-806.B.4.a-b. Personnel 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: i. The manager or caregiver can hear and respond to a resident needing assistance; and ii. If the assisted living home is authorized to provide directed care services, policies and procedures are developed, documented, and implemented to establish a process for checking on a resident receiving directed care services during nighttime hours to ensure the resident’s health and safety.

Provider-listed correction date: Jan 5, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.4.b.ii. 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): b. As follows: ii. At least once every six months for a resident receiving personal care services, and

Provider-listed correction date: Sep 30, 2025. 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: 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander; 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 that is secure, and ii. Monitors 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 that is secure, and ii. Monitors 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: Oct 1, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.C.5. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 5. A refrigerator used by an assisted living facility to store food or medication contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator;

Provider-listed correction date: Jul 7, 2025. A provider’s plan does not establish agency-confirmed correction.

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 a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties; ii. The individual's education and experience applicable to the individual's job duties; iii. The individual's completed orientation and in-service education required by policies and procedures; iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or policies and procedures; and ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);

Correction information is not available in the records reviewed.

Cited requirement: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.

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: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.

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: 1. Is completed no later than 14 calendar days after the resident's date of acceptance;

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: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;

Correction information is not available in the records reviewed.

Cited requirement:C. A manager shall ensure that a resident's medical record contains: 1. Resident information that includes: a. The resident's name, and b. The resident's date of birth; 2. The names, addresses, and telephone numbers of: a. The resident's primary care provider; b. Other persons, such as a home health agency or hospice service agency, involved in the care of the resident; and c. An individual to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency; 3. If applicable, the name and contact information of the resident's representative and: a. The document signed by the resident consenting for the resident ' s representative to act on the resident's behalf; or b. If the resident's representative: i. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or ii. Is a legal guardian, a copy of the court order establishing guardianship; 4. The date of acceptance and, if applicable, date of termination of residency; 5. Documentation of the resident's needs r…

Correction information is not available in the records reviewed.

Cited requirement:A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.

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: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: 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;

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 a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties; ii. The individual's education and experience applicable to the individual's job duties; iii. The individual's completed orientation and in-service education required by policies and procedures; iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or policies and procedures; and ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);

Correction information is not available in the records reviewed.

Cited requirement: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.

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: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.

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: 1. Is completed no later than 14 calendar days after the resident's date of acceptance;

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: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;

Correction information is not available in the records reviewed.

Cited requirement:C. A manager shall ensure that a resident's medical record contains: 1. Resident information that includes: a. The resident's name, and b. The resident's date of birth; 2. The names, addresses, and telephone numbers of: a. The resident's primary care provider; b. Other persons, such as a home health agency or hospice service agency, involved in the care of the resident; and c. An individual to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency; 3. If applicable, the name and contact information of the resident's representative and: a. The document signed by the resident consenting for the resident ' s representative to act on the resident's behalf; or b. If the resident's representative: i. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or ii. Is a legal guardian, a copy of the court order establishing guardianship; 4. The date of acceptance and, if applicable, date of termination of residency; 5. Documentation of the resident's needs r…

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:C. A manager shall ensure that a resident's medical record contains: 18. Documentation of the resident's orientation to exits from the assisted living facility required in R9-10-818(B);

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: 1. A food menu: d. Includes any food substitution no later than the morning of the day of meal service with a food substitution, and

Correction information is not available in the records reviewed.

Cited requirement: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;

Correction information is not available in the records reviewed.