Park Senior Villas at Goodyear

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 four 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 E2's personnel record revealed no documentation for an initial TST, and if negative, a second TST administered one to three weeks after the initial TST was available for review. Based on E2's date of hire, this documentation was required. 5. In an interview, E1 and E4 acknowledged documentation of evidence of freedom from infectious TB, as specified in A.A.C. R9-10-113(B)(1)(a)(i), for E2 was not available for review.

Based on documentation review, record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of the facility's policies and procedures revealed an undated policy titled "Fall Prevention and Fall Recovery Program." The policy stated "...shall include initial training in Fall Prevention and Fall Recovery upon start of employment...continued competency training...conducted annually." 2. A review of E1's personnel record revealed E1 received a fall prevention and fall recovery training from a caregiver training school, however, documentation to demonstrate E1 was trained to the facility's Fall Prevention and Fall Recovery training program, upon hire, was not available for review. 3. In an interview, E1 acknowledged E1 was not trained to the facility's specific training program. E1 reported E1 had completed partial orientation upon hire but had not been trained to the facility's Fall Prevention and Fall Recovery training program.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training, for one manager. The deficient practice posed a risk if E1 was unable to perform CPR. Findings include: 1. A review of E1's personnel record revealed a CPR training card issued on October 10, 2023 from NationalCPRFoundation. 2. A review of nationalcprfoundation.com revealed the following, "National CPR Foundation... We're a Premium Online Certification Provider for Healthcare Providers, Workplace Individuals and the Community. We offer a 100% risk-free, money-back guarantee on all Courses! Made Quick, Easy & Simple!" 3. In an interview, E1 acknowledged E1's CPR training card was from online program and documentation of current CPR training, with demonstration, was not available for review.

Based on documentation, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of first aid training, for one of four caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an accident, injury or a fall. Findings include: 1. A review of the facility's staffing schedule revealed E8 was scheduled for the following dates and times: -October 1, 2023 through October 4, 2023: 6:00AM to 2:00PM; -October 9, 2023 through October 11, 2023: 6:00AM to 2:00PM; -October 15, 2023 through October 18, 2023: 6:00AM to 2:00PM; -October 22, 2023 through October 25, 2023: 6:00AM to 2:00PM; and -October 29, 2023 through October 31, 2023: 6:00AM to 2:00PM. 2. A review of E8's personnel record revealed documentation for a first aid card was not available for review. 3. In an interview E1 aknowledge E8 did not have a first aid training card.

Based on record review and interview, the manager failed to ensure a personnel record for each employee or volunteer was maintained for at least 24 months after the last date the individual provided services in or for the assisted living facility, for one of one former employee sampled. The deficient practice posed a risk as required information could not be verified for E2. Findings include: 1. The Compliance Officers requested E2's personnel record for review. However, E2's personnel record was not provided for review initially. Several hours after the request, a few documents were provided for review, including the following: -E2's resume -E2's tax documents -E2's photocopied license -E2's photocopied social security card -E2's manager's license renewal receipt -E2's documentation of appointment to be manager of the facility -E2's practical nursing license verification -E2's documentation of payroll deductions -E2's expired freedom from infectious tuberculosis documentation (administered January 2020) -E2's expired cardiopulmonary resuscitation documentation (expired June 2021) However, documentation required, per 806.C.1.a-c was not provided for review. 2. In an interview, E1 acknowledged E2's personnel record was not maintained for at least 24 months after the last date E1 provided services for the assisted living facility. E1 reported E2 was terminated the prior week and E2 must have taken E2's personnel record when E2 left the premises.

Based on record review and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order, for two of three residents sampled. Findings include: 1. A review of R2's medical record revealed a medication order (dated June 22, 2023) for Metoprolol Tartrate 25mg, twice daily. 2. A review of R2's medical record revealed a medication administration record (MAR) for October 2023. The MAR revealed "Metoprolol Tartrate 25mg" was not documented as administered on the following dates and times: -October 4, 2023; for 8:00AM; -October 5, 2023; for 5:00PM; -October 6, 2023; for 5:00PM; -October 9, 2023; for 8:00AM; -October 10, 2023; for 5:00PM; -October 11, 2023; for 8:00AM; -October 14, 2023 for 5:00PM; -October 15, 2023; for 8:00AM; -October 16, 2023; for 8:00AM; -October 16, 2023; for 5:00PM; -October 17, 2023; for 8:00AM; -October 18, 2023; for 8:00AM; and -October 18, 2023; for 5:00PM. 3. A review of R2's medical record revealed a medication order (dated June 22, 2023) for Seroquel 50mg, at bed time every night. 4. A review of R2's medical record revealed a MAR for October 2023. The MAR revealed "Seroquel 50mg" was not documented as administered on the following dates: -October 5, 2023; -October 9, 2023; -October 10, 2023; -October 12, 2023; -October 13, 2023; and -October 14, 2023. 5. A review of R3's medical record revealed a medication order (dated June 8, 2023) for Bupropion HCL 75mg once daily. 6. A review of R3's medical record revealed a MAR for September 2023. The MAR revealed "Bupropion HCL 75mg" was not documented as administered on the following dates and times: -October 13, 2023; for 8:00AM; -October 26, 2023; for 8:00AM; and -October 28, 2023; for 8:00AM. 7. A review of R3's medical record revealed a medication order (dated June 8, 2023). The medication order did not include Lorazepam 0.5mg once daily until September 19, 2023 and was discontinue on September 25, 2023. 8. A review of R3's medical record revealed a MAR for September 2023. The MAR revealed "Lorazepam 0.5mg" was documented as administered without a prescription on the following dates: -September 1, 2023 to September 18, 2023; -September 26, 2023 to October 5, 2023; and -October 28, 2023; for 8:00AM. 9. In an interview, E1 acknowledged the MARs for R2 and R3 were inconsistent.