Rejoice Assisted Living Home #2.

“Based on record review and interview, the manager failed to ensure a resident had a written service plan that was signed and dated by the resident or the resident's representative and the manager. This posed a health and safety risk if the resident or the resident's representative and the manager did not acknowledge the services that were to be provided.   Findings include:   1. A review of R2's medical record did not include documentation that the resident's service plan was signed and dated by the resident or the resident's representative, and the manager for the service plan dated June 2025. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency Findings include: 1. A review of E2's personnel record revealed documentation of CPR that was obtained from "NationalCPRFoundation" with an issue date of March 3, 2025.   2. A search on the National CPR Foundation website FAQ's page revealed a section regarding hands-on training. That stated, "No, we do not offer hands-on training. If your employer has requested you to receive hands-on training or a skills check, please visit CPRNearMe.com." 3. In an interview, E1 acknowledged E2 did not have CPR training that included a demonstration of the individual's ability to perform CPR.”

“Based on documentation review, record review, and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113. The deficient practice posed a potential risk of TB exposure to residents.   Findings include: 1. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC).”   2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test healthcare personnel upon hire (pre-placement), two-step testing should be used."   3. A review of E2's personnel record revealed documentation of a single negative TB skin test. However, there was no documentation of a second TB skin test.   4. In an interview, E1 acknowledged E2 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility.”

“Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy, with a screening and risk assessment. Findings Include: 1. A record review of R1 revealed no sign/symptom screening and risk assessment. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged R1 did not have evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy, with a screening and risk assessment. This is a repeat deficiency from the compliance inspection conducted on January 10, 2025.”

“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.”