Rejoice Assisted Living Home #2

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for two of five sampled employees. The deficient practice posed a risk if the individuals were 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 E3's personnel record revealed a fingerprint clearance card issued December 26, 2017 and expired December 26, 2023. There was no other documentation in E3's record to reflect E3 possessed a current, valid fingerprint clearance card. 3. A review of E5's personnel record revealed a fingerprint clearance card issued December 12, 2017 and expired December 6, 2023. There was no other documentation in E5's record to reflect E5 possessed a current, valid fingerprint clearance card. 4. A review of the Arizona Department of Public Safety website reflected E3's and E5's fingerprint clearance cards were no longer valid. 5. A review of the facility's December 2023 work schedule reflected E3 and E5 both worked from 7:00 AM to 7:00 PM on December 3, 7, 10, 14, 17, 21, 24, 28, and 31, 2023. 6. In an interview, E1 reported being unaware E3's and E5's fingerprint clearance cards were no longer valid.

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 one of three residents sampled. Findings include: 1. A review of R3's medical record revealed no documented residency agreement available for review. 2. In an interview, E1 confirmed no additional documentation was available for review to reflect R3's medical record contained a residency agreement.

Based on record review and interview, the manager failed to ensure a resident or resident's representative received a complete written copy of the requirements in subsection (B) and the resident rights in subsection (C) at the time of admission, for one of three sampled residents. Findings include: 1. A review of R3's medical record revealed no documentation to indicate R3 or R3's representative received a complete written copy of the requirements in subsection (B) and the resident rights in subsection (C). 2. In an interview, E1 acknowledged R3's medical record contained no documentation to indicate R3 or R3's representative received a copy of the requirements in subsection (B) and the resident rights in subsection (C) at the time of admission.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider and emergency contact. Findings include: 1. In an interview, E1 reported R3 went to the hospital the night of January 4, 2024. 2. A review of R3's medical record revealed no documentation to indicate R3's primary care provider and emergency contact were notified of the incident in January 2024. 3. In an interview, E1 reported R3's hospice provider was notified, however there was no documentation available for review to reflect R3's primary care provider and emergency contact were notified.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. The deficient practice posed a potential risk of re-injury. Findings include: 1. In an interview, E1 reported R3 went to the hospital the night of January 4, 2024. 2. A review of R3's medical record revealed no documentation to indicate the names of individuals who observed the incident on January 4, 2024, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. 3. In an interview, E1 reported R3 went to the hospital, but no incident report was created to document the date and time of the incident, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future.