Emmanuel Care Home III

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for one of three personnel records reviewed. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(A) and (C) states: “A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.” and; “C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to… 2. Verify the current status of a person's fingerprint clearance card…” 2. A review of E1's personnel record revealed E1 was in a position that required a fingerprint clearance card. Further review revealed E1’s fingerprint clearance card expired on November 4, 2025, and was initialed as checked on November 13, 2021. 3. In an interview, E2 acknowledged the fingerprint clearance card for E1 was expired; however, provided no additional information.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 10, 2025, for personal care services and a primary diagnosis of “neurocognitive disorder”. The symptoms are noted to be “forgetful at times”. The “Actions” to be taken by the caregiver are “1) Always use a calm tone when talking to R1. 2) Care staff communicate clearly using simple, direct statements. 3) Care staff redirect as indicated due to behavior. 4) Care staff monitor resident every two hours to assure safety.” 2. A review of R1's medical record revealed documentation R1 had accused R1's roommate of stealing R1's belongings and admitted to hearing loud voices, in July 2025. In August 2025, R1 reported R2 was having sex with a man, though no one was present; R1 reported there was someone lying on R1’s bed, though there was not; and R1 reported R2 had a lighter under R2’s bed and made the caregiver check several times. The notes continue to detail R1’s confusion, hallucinations, and insomnia through September 2025 and October 2025. E2 reported several urinalyses were conducted to check for a “UTI” and all were negative. 3. During the inspection, R1 was observed to be confused and refused to eat lunch. 4. In an interview, E2 acknowledged R1's service plan had not been updated within 14 calendar days after R1 had a significant change in cognition and behavior. E2 agreed R1’s level of services should be updated to reflect directed care, including memory care services.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10) for two of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a documented residency agreement. However, the residency agreement was signed the day after admission and did not include the following: - The name of the facility contracted in the residency agreement; and - The terms of occupancy: Date of occupancy, monthly fee amount, date due, and any prorated fees. 2. A review of R2's medical record revealed a documented residency agreement. However, the residency agreement did not include the following: - The terms of occupancy: Date of occupancy, monthly fee amount, date due, and any prorated fees. 3. In an interview, E1 acknowledged R1's and R2's residency agreements did not include all requirements in R9-10-807(D)(1-10) and R1's residency agreement was not signed on or before acceptance.

Based on record review, and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for two of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a service plan update, dated December 8, 2022, for personal care services. However, the next service plan update was signed August 8, 2023, more than six months later. 2. A review of R2's medical record revealed a service plan update, for personal care services, was due on or before March 9, 2023. The service plan update was signed on April 24, 2023. 3. In an interview, E1 acknowledged R1's and R2's service plans were not reviewed and updated at least once every six months.