Joyful Haven Assisted Living Home, LLC

Based on documentation review and interview, the manager failed to ensure a training program was developed to include initial training and continued competency training in fall prevention and fall recovery. Findings include: 1 . A review of facility documentation revealed documentation of a training program for fall prevention and fall recovery was not available for review at the time of the inspection. 2 . In an interview, E2 acknowledged documentation of a training program for fall prevention and fall recovery was not available for review.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented which covered required skills and knowledge. Findings include: 1 . A review of facility documentation revealed a policy titled "Employees and volunteer qualification." The policy stated, "The hiring person or manager will ensure, check, and document that each caregiver or assistant caregiver providing physical health services or behavioral health services have the required skills and knowledge before providing any services." However, a policy describing how the hiring person would check and document skills and knowledge for a caregiver was not available for review at the time of inspection. 2 . In an interview, E2 acknowledged a policy covering how skills and knowledge are verified and documented was not available for review at the time of inspection.

Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services, for two of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of E2's and E3's personnel records revealed that documentation of skills and knowledge verified was not available for review at the time of inspection. 2. In an interview, E2 acknowledged E2's and E3's personnel file did not include documentation of verified skills and knowledge.

Based on record review and interview, the manager failed to ensure a caregiver received orientation to duties specific to the duties performed by the caregiver, for two of three personnel sampled. Findings include: 1 . A review of E2's personnel record revealed an "Employee Orientation Checklist." However, the documentation was not initialed or completed by the employee or the individual who provided the orientation. 2 . A review of E3's personnel record revealed documentation of orientation conducted was not available for review at the time of inspection. 3 . In an interview, E2 acknowledged that E2's and E3's personnel files did not include completed documentation of orientation.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record was maintained for one of three sampled employees or volunteers. Findings include: 1. The Compliance Officer observed E3 arrive at the facility at approximately 11:50 AM. E3 greeted E1 and went to the facility's caregiver quarters. 2. A review of facility documentation revealed E3 was listed as an employee who participated in facility evacuation drills on April 2, and October 3, 2022, and on April 2, 2023. Facility documentation also revealed documentation of an "Employee Disaster Drill" conducted on July 2, 2023. E3 was listed as an "employee participating in the drill." 3. In an interview, E1 reported E3 lived at the facility. E1 reported E3 acted as a volunteer and helped out with household chores, but did not provide direct services to the residents. E1 reported E3 would be helping out at the facility more moving forward, but was not aware E3 required a personnel record outside of a documented negative tuberculosis screening. E1 acknowledged the manager failed to maintain a personnel record for E3.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccinations for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for one of four residents sampled. Findings include: 1. A.R.S. \'a7 36-406(1) states: "The department shall...(d) Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized." 2. A review of R2's medical record revealed documentation indicating R2 was notified of the availability of vaccination for flu and pneumonia on September 2, 2021. However, no documentation to indicate R2 was notified of the availability of influenza and pneumonia vaccinations after October 20, 2021 was available for review. 3. In an interview, E1 reported E1 believed R2's representative was notified of the availability of the vaccinations for influenza and pneumonia in 2022 or 2023. However, E2 acknowledged documentation of this notification was not available in R2's medical record.