A Place of Joy Assisted Living

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411. The deficient practice posed a risk if E1 and E2 were a danger to a vulnerable population. Findings include: 1 . A review of E1's and E2's employee records revealed no evidence of a search of the Adult Protective Services (APS) registry. 2 . A search of the APS website was conducted by the Compliance Officer and revealed no record with APS for E1 or E2. 3 . In an interview, E1 acknowledged that there were no APS registry search results available for E1 or E2, for review during the inspection.

Based on document review and interview, the manager failed to ensure that there was a plan established, documented, and implemented for an ongoing quality management program. Findings include: 1 . A review of facility documents revealed no Quality Management program that was used to identify, document and evaluate incidents at the facility. 2 . In an interview, E1 acknowledged that the manager failed to ensure there was a Quality management program used to identify, document and evaluate incidents at the facility.

Based on record review and interview the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. Findings include: 1 . A review of E2's personnel record revealed that E2's position was manager. 2. A review of E2's employee records revealed a CPR (Cardiopulmonary Resuscitation) card, however, it did not include first aid. 3 . In an interview, E1 acknowledged that the manager failed to ensure that an employee record contained certifications for CPR and First Aid trainings.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented , and implemented for one of two residents sampled. The deficient practice posed a risk if the resident's representative and other individuals identified were unable to participate in decisions concerning the assisted living services the resident was to receive. Findings include: 1 . A review of R1's record reveal no current service plan for review. 2 . In an interview, E1 acknowledged a documented service plan for R1 was not provided for review.

Based on observation and interview, the manager failed to ensure that an exit that provided access to an outside area was monitored or alerted staff of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1 . During a tour of the facility, the Compliance Officer observed the alert on the front door to be in the off position, not alerting employees of the egress of a resident from the facility. 2 . In an interview, E1 acknowledged that the means of alerting employees to the egress of a resident was turned off.

Based on document review and interview, the manager failed to ensure that documentation for each evacuation drill included the amount of time taken for employees and resident to evacuate the assisted living facility, an identification of residents needing assistance for evacuation, or identification of residents who were not evacuated. Findings include: 1 . During a review of facility documents, the Compliance Officer observed Evacuation drill forms, however the forms were missing the following information: Amount of time it took to evacuate residents and staff Names of residents evacuated Any residents that were not evacuated and the reason 2 . In an interview, E1 acknowledged that documentation for each evacuation drill did not include the amount of time take for employees and resident to evacuate the assisted living facility, an identification of residents needing assistance for evacuation, or identification of residents who were not evacuated.