Agape Senior Living.

“Based on documentation review and interview, the manager failed to ensure that a Quality Management plan was implemented at the frequency determined by the facility's policies and procedures. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided.  Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management Program Including Incident Reports." The policy stated, "1. Facility personnel will document and evaluate incidents at the facility to ensure quality services are provided...3. Facility may use a survey tool (Quality of Service Monthly Recording Form) to help in identifying and collecting information." 2. A review of facility documentation revealed a form titled "Quality Management - Monthly Recordings" for 2024, and another for 2025. The data had not been completed for September, October, November, or December of 2024, and January and February of 2025. 3. Further review of facility documentation revealed a binder with all incident reports. 4. In an interview, E1 explained the facility had kept track of all incidents but also acknowledged the facility had not properly documented the breakdown of incidents on the monthly quality management form as required by the facility's policy.”

“Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Disaster Plan, Relocation, Records, Medication, Food and Water. The policy stated, "8. The disaster plan is reviewed and the review is documented at least once every 12 months and includes the date and time of the disaster plan review, the name of each employee or volunteer participating in the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. 9. Please see the next page for the disaster plan review." The following page which contained the disaster plan review had not been completed for 2024. 2. In an interview, E1 acknowledged the disaster plan review had not been documented for 2024.”

“Based on documentation review and interview, the manager failed to ensure an employee had a valid fingerprint clearance card as required by A.R.S. § 36-411, for one of four employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A review of E4's personnel record revealed E4's fingerprint clearance card had expired on January 3, 2025. 2. An on-line check of the State of Arizona Department of Public Safety website revealed E4's fingerprint clearance card had expired on January 3, 2025, and there was not another valid fingerprint card on record. 3. In an interview, E1 reported E4 was responsible for the administrative portion of the facility and was not on the schedule to provide care to the residents during the time the fingerprint card was expired; however, E4 did reside in the residence. E1 acknowledged E4's fingerprint clearance card had recently expired and E4 had not yet applied for another card. [Note: E4 was issued a valid fingerprint clearance card on March 31, 2025.]”