Park Senior Villas at Goodyear

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 sampled. 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 three 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 E6 was scheduled for the following dates and times: -October 3, 2023 and October 4, 2023: 6:00AM to 2:00PM; -October 5, 2023 through October 7, 2023: 6:00AM to 2:00PM; -October 10, 2023 through October 14, 2023: 6:00AM to 2:00PM; -October 17, 2023 through October 21, 2023: 6:00AM to 2:00PM; -October 24, 2023 through October 28, 2023: 6:00AM to 2:00PM; and -October 31, 2023: 6:00AM to 2:00PM; 2. A review of E6's personnel record revealed documentation for a first aid card was not available for review. 3. In an interview E1 aknowledge E6 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, all documentation required per R9-10-806.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 observation and interview, the manager failed to ensure a resident bathroom contained a window that opened or another means of ventilation. Findings include: 1. The Compliance Officer observed R2's bathroom did not contain a window or another means of ventilation. The Compliance Officer observed a square cut out into the ceiling and appeared to be where a vent was previously. 2. In an interview, E3 acknowledged the bathroom did not have a window or other means of ventilation. E3 reported R2's bathroom recently had a ceiling leak due to the air conditioning and the maintenance crew had recently removed the vent and exhaust fan to remedy the leak. 3. In an interview, E1 and E2 acknowledged R2's bathroom did not not have a window or other means of ventilation due to a recent leak. E1 reported the facility had a work order in to replace the vent.