Emerald Groves Central

Based on record review and interview, the assisted living center failed to maintain a standardized form for each resident that includes the information prescribed in A.R.S. § 36-420.04.A.1-9 for three out of three residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R1's medical record revealed there was a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: The point-of-contact information for the assisted living center or assisted living home, as well as the telephone number, if available, cell phone number and email address; Whether the resident received medication services; and Basic information about the resident's physical and mental conditions and basic medical history. 2. A review of R2's medical record revealed there was a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: The name, address and telephone number of the resident's current pharmacy. The point-of-contact information for the assisted living center or assisted living home, as well as the telephone number, if available, cell phone number and email address; A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home; Whether the resident received medication services; and Basic information about the resident's physical and mental conditions and basic medical history. 3. A review of R3's medical record revealed there was a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: The point-of-contact information for the assisted living center or assisted living home, as well as the telephone number, if available, cell phone number and email address; and Whether the resident received medication services. 4. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R1's medical record revealed a document titled "Incident Report" dated February 6, 2026, at 9:50 pm. This report stated, "...While transporting [R1] to bed on the Hoyer lift, the lift tripped in the carpet and fell on the floor causing [R1] hit [R1's] head on the bed...[R1] was transported to Banner Baywood...". 2. In an interview, E1 reported the caregiver attempted to move R1 but was unable to safely transport them using the Hoyer lift. This resulted in R1 falling down and needing hospitalization. R1 was sent home afterwards with stitches. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a disaster plan included when and where residents would be relocated during a disaster. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. A review of the facility’s documentation/policies and procedures revealed a disaster plan for the facility, however, the disaster plan did not include where and how residents would be relocated. 2. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's documentation records revealed a disaster drill conducted on October 9, 2025. A disaster drill after October 9, 2025, was not available for review. 2. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that if pets or animals were allowed in the assisted living facility, pets or animals were licensed consistent with local ordinances. Findings include: 1. In an interview, E4 acknowledged a dog was currently living at the facility. 2. A review of the dog's record revealed no documentation of a current license with Maricopa County. 3. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of 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, for one individual hired as a caregiver. The deficient practice posed a risk if E2 was not qualified to provide the required services. Findings include: 1. The Compliance Officer observed E1 and E2 working at the facility upon arrival at 8:20 AM. 2. A review of E2's (hired in 2021) personnel record revealed E2 was hired as a caregiver. The record revealed a caregiver certificate (dated May 15, 2012) from "Platinum Training Services LLC...ALTP0185." 3. A review of https://nciaboard.az.gov/news/caregiver-certificate-verification website revealed the caregiver training program "ALTP #185" was valid from July 16, 2012 through August 2, 2013. 4. A review of https://nciaboard.az.gov/news/fraudulent-caregiver-certificates revealed E2 had not completed a caregiver training program. 5. In an interview, E2 reported E2 completed caregiver training at an assisted living facility E2 worked at previously. 6. In a joint interview, E3 and E4 acknowledged E2 did not provide documentation of 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.

Based on observation, record review, documentation review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk as a qualified personnel member was not present to meet a resident's needs and ensure the health and safety of a resident. Findings include: 1. The Compliance Officer observed E1 and E2 working at the facility upon arrival at 8:20 AM. 2. A review of E2's (hired in 2021) personnel record revealed E2 was hired as a caregiver. The record revealed a caregiver certificate (dated May 15, 2012) from "Platinum Training Services LLC...ALTP0185." 3. A review of https://nciaboard.az.gov/news/caregiver-certificate-verification website revealed the caregiver training program "ALTP #185" was valid from July 16, 2012 through August 2, 2013. 4. A review of https://nciaboard.az.gov/news/fraudulent-caregiver-certificates revealed E2 had not completed a caregiver training program. 5. In an interview, E2 reported E2 completed caregiver training at an assisted living facility E2 worked at previously. 6. In a joint interview, E3 and E4 acknowledged the assisted living facility did not have a caregiver with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety.