Rejoice Assisted Living Incorporated

Violation cited

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for two of three caregivers reviewed. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents. Findings included: 1. A review of E2's personnel record revealed a hire date of December 2024. The personnel record revealed no documentation indicating verification of skills and knowledge. 2. A review of E3's personnel record revealed a hire date of December 2024. The personnel record revealed no documentation indicating verification of skills and knowledge. 3. A review of facility documentation revealed a "work schedule" for the month of January 2025. The schedule revealed E2 worked January 1-16, 2025 and E3 worked January 1-19, 2025. 4. A documentation review of the facility's policies and procedures revealed a document tilted "Verifying Caregiver's Skills and Knowledge", that stated, "All staff need to be trained and their skills and knowledge verified prior to staff providing assistance with new equipment or procedures. The manager will interview and assess the staff and test on caregiver skills". 5. In an interview, E1 acknowledged E2's and E3's personnel records did not include documentation of skills and knowledge verification prior to the caregivers providing physical services to the residents.

Based on documentation review, record review, and interview, the manger failed to ensure personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), for two of three personnel records reviewed. The deficient practice posed a health and safety risk. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E2's personnel record revealed a hire date of December 2024. The personnel record revealed a negative TB skin test on or before the date of hire. However, there was no documentation of the second TB skin test. A further review of E2's record revealed no documentation of assessing risk of prior exposure to infectious TB, and no documentation of a determination of signs and symptoms of TB. 4. A review of E3's personnel record revealed a hire date of December 2024. The personnel record revealed a negative TB skin test after the date of hire. However, there was no documentation of the second TB skin test. A further review of E3's record revealed no documentation of assessing risk of prior exposure to infectious TB, and no documentation of a determination of signs and symptoms of TB. 5. In an interview, E1 acknowledged, E2's and E3's employee records did not include documentation of freedom from infectious TB as specified in R9-10-113.

Violation cited

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a 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 and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled or alerted employees 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. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officers observed ambulatory residents in the facility. 3. The Compliance Officers observed a front door that was unlocked. The door had an alarm installed, however, the alarm was not turned on, therefore, could not alert employees of the egress of the residents. 4. The Compliance Officers observed a door exiting to the backyard from the dining area, the door was unlocked and had an alarm installed, however, the alarm was not turned on, therefore, could not alert employees of the egress of the residents. 5. In an interview, E1 stated E1 was aware that the alarms were turned off because the residents did not like the noise. E1 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's service plan revealed R2 received medication administration. 2. A review of R2's medical record revealed a Medication Administration Record (MAR) for January 2025 documenting R2 was administered Glipizide 5mg one tab by mouth every day. 3. A review of R2's medical record revealed no medication order for Glipizide 5mg one tab by mouth every day. 4. The Compliance Officers observed a medication bottle of Glipizide 5mg. 5. In an interview E1 reported R2 was administered the medication. E1 acknowledged R2's medications was not administered in compliance with an available medication order.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed the following: In the hallway, in the top drawer of a black unlocked file cabinet: -One container of "Extra Strength Bengay"; -One container of "Ondansetrom 8mg tablets"; and -One container of "Mediline Povidone Iodine 10% solution". On the kitchen table: -One bottle of "Extra Strength Tylenol 500mg"; and -Plastic medication organizer with multiple unlabeled medications. 2. In an interview, E1 acknowledged the medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Violation cited

Based on observation, documentation, and interview, the manager failed to ensure a pest control program was implemented and documented. Findings include: 1. During the inspection, the Compliance Officers observed areas with spider webs. 2. A documentation review revealed no documentation of routine pest control. 3. During an interview, E1 reported an exterminator had not been out to the facility for treatment. E1 acknowledged there was no documentation of routine pest control for the facility.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During the environmental inspection, the Compliance Officers observed a small green upright but unsecured oxygen container located in a hallway closet. 2. In an interview, E1 acknowledged an oxygen container was not secured in an upright position.

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental inspection, the Compliance Officers observed ambulatory residents. 3. During the environmental inspection, the Compliance Officers observed the following poisonous or toxic material in unlocked areas: -In the laundry room on the floor, there was a large bottle of "Fabuloso"; -In the front hallway closet, on the floor, a spray bottle of Great Value glass cleaner and an unlabeled plastic bottle with purplish/brownish colored substance; and -In the front atrium, in an unlocked file cabinet, there was a bottle of Swan hydrogen peroxide, Equate 3% hydrogen peroxide, and Medline Ready Prep PVP povidone-iodine 10% solution. 4. In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area, labeled and inaccessible to residents.

Based on documentation review, observation, and interview, the manager failed to ensure combustible or flammable liquids stored by the assisted living facility were stored in the original labeled containers in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection, the Compliance Officers observed ambulatory residents. 3. During an environmental inspection, the Compliance Officers observed the following: -A gallon of "Glidden semi-gloss paint" in an unlocked storage room in the back outdoor area -A container "Equate 91% Isopropyl alcohol" in a canvas bag on the kitchen floor 4. In an interview, E1 acknowledged combustible or flammable liquids materials stored by the assisted living facility were not maintained in a locked area, labeled and inaccessible to residents.