Park Senior Villas at Goodyear

Based on documentation review, record review, and interview, the manager failed to ensure when a resident has an accident, emergency, or injury that results in the resident needing medical services, the caregiver or assistant caregiver documents the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. Findings include: 1 . A review of facility documentation revealed a policy titled "Incident reporting." The policy stated, "An accident or incident shall be considered any unusual or unordinary event that causes injury or undue stress to a resident and may include the following:...Any event that causes a need for emergency medical services... Park Senior Villas staff will immediately complete an accident/injury report..." 2 . A review of R1's medical record revealed a progress note dated April 19, 2025. The progress note reported R1 went to the hospital due to low oxygen level. However, documentation of an "Accident/injury report" was not available for review at the time of inspection. 3 . In an interview, E1 acknowledged R1 had no accident/injury report for the incident which occurred on April 19, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. The deficient practice posed a risk as the established and documented policies and procedures were not followed. Findings include: 1. A review of facility documentation revealed a policy title "Response to Out of Control Behavior Policy & Procedure" The policy states "..1. Redirection by means of one or all of the below methods. ..b.) Remove other residents/visitors from danger if needed." 2. A review of facility documentation revealed an incident report date October 22, 2024. The incident report stated "[R2] came out of [R2's] room forcing their way out the back and front door. [R2] was redirected and went back to [R2's] room. [R2] came out of [R2's] room again and approached staff talking aggressively. [E3] tried redirecting [R2] but [R2] started threaten staff with living room pillows. [E3] moved away from [R2] and [R2] starting chasing [E3]. [E3] stepped outside the back door till [R2] calmed down. [R2] grabbed [R2's] metal hydro flask and threaten to throw it at [E3]. [R2] grabbed water and threw it at the door from the inside. [R1] came out of [R1's] room due to the alarm going off from the door. [R1] was asking for help. [R1] started gesturing for [E3] to come inside but [R2] was still by the door waiting for [E3]. [R2] took the walker away from [R1] and sat [R]1 on the chair. [R1] resisted and [R2] started hitting and pushing [R1] from the chair to throw [R1] outside. [E3] kept pushing the door from opening from the outside. [E3] felt [a] blood pressure spike and decided to take [E3's] medication from [E3's] car. [R1] and [R2] were both calm before. On [E3's] return, [E3] saw [R1] on the floor with blood from [R1's] hand. [R2] was roaming in the living, calm. [E3] called the paramedics and [R1] was sent to the hospital." 3. In an interview, E1 and E2 reported staff were trained on working with dementia related behaviors to include out-of-control behaviors. However, E1 and E2 acknowledged E3 had left R1 and other residents alone with R2 during R2's sudden, intense, or out-of-control behavior.

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB), as specified in Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i), for one of three sampled personnel members. The deficient practice posed a potential TB infection risk to residents. Findings include: 1. A.A.C. 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 specific 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 CDC 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 health care personnel upon hire (preplacement), two-step testing should be used." The web page indicated two-step testing involves an initial TST, and if negative, a second TST is administered one to three weeks after the initial TST. 3. A review of E3's personnel records revealed no documentation for an initial TST, and if negative, a second TST administered one to three weeks after the initial TST is available for review. 5. In an interview, E1 and E2 acknowledged documentation of evidence of freedom from infectious TB, as specified in A.A.C. R9-10-113(B)(1)(a)(i), for E3 was not available for review.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months, for one of two sampled residents who received directed care services. The deficient practice posed a risk if the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan for directed care services dated September 9, 2023. No more recent service plan for R1 was available for review at the time of the inspection. 2. In an interview, E1 acknowledged there was no updated service plan for R1 available for review at the time of the inspection.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a health and safety risk to residents with access to the medications. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an unattended medication cart in the common area in Villa Seven. The medication cart was unlocked and was fully stocked with medication. 2. In an interview, E1 acknowledged the medication cart was unlocked.