Hacienda Granada

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for one of three employees sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(A) 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of E2's personnel record revealed a fingerprint clearance card. However, the fingerprint clearance card expired April 2011. 3. A review of department documentation revealed technical assistance was provided for E2 on December 7, 2022 for renewing E2's fingerprint clearance card. 4. In an interview, E2 acknowledged E2 had no documentation of a current fingerprint clearance card.

Based on documentation review, observation, and interview, the manager failed to ensure the 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, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officers observed the following doorways exiting the facility: -Two glass sliding doors leading from separate resident rooms to the backyard of the facility. Both had alerts, however the alerts were turned off; - One door leading from a resident room to the backyard of the facility. The door had neither a control or alert; - One glass sliding door leading from the main walkway to the backyard. The door had an alert, however the alert was turned off; - One door leading from a resident room to the front yard of the facility. The door had neither a control or alert; and - One door leading to an outdoor garage area. The door had a control and an alert, however the control was not engaged and the alert was turned off. 3. In an interview, E2 acknowledged the doors mentioned previously had either no control or alerts, or the alerts were turned off and could pose a risk to the residents.