Emerald Assisted Living Home

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

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:R9-10-113.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: May 22, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-804.1.a-e. Quality Management A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to residents; c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority;

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

Cited requirement:R9-10-806.C.1.a-c. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual’s name, date of birth, and contact telephone number; b. The individual’s starting date of employment or volunteer service and, if applicable, the ending date; and 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 polici…

Provider-listed correction date: May 22, 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: 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: May 19, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.B.3.b. Medication Services 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

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

Cited requirement:R9-10-817.D.1. Medication Services D. A manager shall ensure that: 1. A current drug reference guide is available for use by personnel members, and

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

Cited requirement:R9-10-817.D.2. Medication Services D. A manager shall ensure that: 2. A current toxicology reference guide is available for use by personnel members.

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

Cited requirement:R9-10-818.C.1. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 1. Food is free from spoilage, filth, or other contamination and is safe for human consumption;

Provider-listed correction date: May 19, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.A.2. Emergency and Safety Standards A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Provider-listed correction date: May 22, 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: May 22, 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: May 19, 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 19, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-821.F.2. Physical Plant Standards F. If there is a swimming pool on the premises of the assisted living facility, a manager shall ensure that: 2. A life preserver or shepherd’s crook is available and accessible in the swimming pool area; and

Provider-listed correction date: May 19, 2026. A provider’s plan does not establish agency-confirmed correction.

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

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: 2. Is developed with assistance and review from: a. The resident or resident's representative,

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. 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:F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

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: 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.