Park Senior Villas at Goodyear

Violation cited

Violation cited

Violation cited

Violation cited

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, for one of three residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed an updated service plan, dated in May 2024, for personal level of care. However, the service plan was not signed or dated by R1 or R1's representative. 2. In an interview, E1 acknowledged the service plan was not signed and dated by R1's or R2's representative. 3. This is an uncorrected deficiency from the compliance inspection conducted May 9, 2024.

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of five employees sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A... 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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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..." 2. A review of E1's (hired in 2023) personnel record revealed a fingerprint clearance card with the expiration date of March 2, 2024. No other documentation to reflect E1's compliance with A.R.S. \'a7 36-411(A) was provided at the time of the inspection. 3. A review of the Arizona Department of Public Safety (DPS) website revealed E1's fingerprint clearance card expired on March 2, 2024. The website also revealed E1 submitted an application for renewal on March 19, 2024. However, the website indicated the status was "Waiting on applicant fingerprints." 4. In an interview, E1 acknowledged E1's fingerprint clearance card was expired. E1 acknowledged E1 had not yet submitted fingerprints to DPS.

Based on record review, documentation review and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services on or on behalf of the assisted living facility, for one of five personnel members sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E2's (unknown date of hire) personnel record revealed evidence of freedom from infectious TB was not available for review. 2. A review of facility documentation revealed a daily staffing schedule. The schedule revealed E2 worked the following shifts during the week of May 5: -May 5, 2024 - 7:00 AM - 7:00 PM -May 6, 2024 - 7:00 AM - 7:00 PM -May 7, 2024 - 7:00 AM - 7:00 PM -May 8, 2024 - 7:00 AM - 3:00 PM 3. In an interview, E1 acknowledged E2's did not provide evidence of freedom from infectious TB prior to E2's hire date and before E2 provided services.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included the individual's starting date of employment, for two of five personnel members sampled. Findings include: 1. A review of E2's and E3's personnel records revealed the records did not include starting dates of employment. 2. In an interview, E1 acknowledged E2's and E3's personnel records did not include starting dates of employment.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for two of three residents sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan, dated in December of 2023 for directed care services. However, a reviewed and updated service plan was not available for review. 2. A review of R2's medical record revealed a service plan, dated in December of 2023 for directed care services. However, a reviewed and updated service plan was not available for review. 3. In an interview, E1 acknowledged R1 and R2 received directed care services. E1 acknowledged R1's and R2's service plans had not been updated at least once every three months.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, for two of two residents sampled. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed an updated service plan, dated in December 2023, for directed level of care. However, the service plan was not signed or dated by R1's representative. 2. A review of R2's (admitted in 2021) medical record revealed an updated service plan, dated in December 2023, for directed level of care. However, the service plan was not signed or dated by R2's representative. 3. In an interview, E1 acknowledged the service plans were not signed and dated by R1's or R2's representatives.

Based on record review and interview, the manager failed to ensure a written service plan was signed and dated by the manager, for two of two residents sampled. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed an updated service plan, dated in December 2023, for directed level of care. However, the service plan was not signed or dated by the manager. 2. A review of R2's (admitted in 2021) medical record revealed an updated service plan, dated in December 2023, for directed level of care. However, the service plan was not signed or dated by the manager. 3. In an interview, E1 acknowledged R1's and R2's service plans were not signed and dated by the manager.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to two of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director. 2. A review of R1's (admitted in 2022) medical record revealed documentation of notification of the resident of the availability of vaccination for flu and pneumonia vaccination was offered on September 22, 2022. However, notification of the resident of the availability of vaccination for flu and pneumonia vaccinations on a yearly basis was not available for review. 3. A review of R2's (admitted in 2021) medical record revealed documentation of notification of the resident of the availability of vaccination for flu and pneumonia vaccination was not available for review. 4. In an interview, E1 acknowledged R1 and R2 had not been notified of the availability of the vaccination for flu and pneumonia in 2023.

Based on observation and interview, the manager failed to ensure a current drug reference guide was available for use by personnel members. Findings include: 1. The Compliance Officers requested to review the facility's current drug reference guide. A drug reference guide was provided for review, however, the guide was from 2012. 2. In an interview, E5 acknowledged the drug reference guide was published in 2012. E5 was asked if E5 could access an electronic version of the drug reference guide, however, E5 reported to be unable to access any electronic version of a drug reference guide. 3. In an interview, E1 acknowledged the drug reference guide was not available for review and E5 did not know how to access an electronic version of a current drug reference guide.

Based on observation and interview, the manager failed to ensure a current toxicology reference guide was available for use by personnel members. Findings include: 1. The Compliance Officers asked to see a toxicology reference guide available on premises. A toxicology reference guide was not available in the villa. 2. In an interview, E5 was asked if E5 knew how to access the facility's toxicology guide. E5 reported to be unaware of how to access any toxicology guide book or online toxicology reference. 3. In an interview, E1 acknowledged the toxicology reference guide was not available for review and E5 did not know how to access an electronic version of a current toxicology reference guide.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility documentation revealed the following evacuation drills were conducted: -March 23, 2023 -September 22, 2023 2. In an interview, E1 acknowledged the evacuation drills weren't conducted at least once every six months.

Based on documentation 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 and for one of two of caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency, accident or injury. 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. A review of E5's personnel record revealed E5 worked in the facility as a caregiver. E5's record revealed a "Statement of Participation" from "The American Healthcare Academy's Postgraduate Institute for Medicine." The document stated "[E5] has participated in the educational activity titled Adult, Child, Infant CPR & AED Training (BLS) an Internet based activity on 04/11/2022." However, E5's record did not include documentation of CPR to include a demonstration of E5's ability to perform cardiopulmonary resuscitation. 4. A review of the American Healthcare Academy's website (https://cpraedcourse.com/) revealed the company offered a "Nationally Accepted Online CPR Certification" with a "simple and easy-to-understand online CPR certification course." The company's website did not list any courses which included an in-person demonstration component. 5. In an interview, E1 acknowledged E5's and E1's CPR training cards were from online programs, and documentation of current CPR trainings with demonstrations were not available for review. This is a repeat deficiency from the compliance and complaint inspection conducted on April 10, 2023.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(A), for two of seven personnel members sampled. Findings include: A.R.S. \'a7 36-411(A) states, "... 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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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." 1. A review of E6's personnel record revealed a job description for the position of "Maintenance Director" which stated, "Duties and Responsibilities: The Director of Maintenance ...Performs various duties to maintain a clean and safe environment for residents ...Sufficient interpersonal skills to interact with facility staff and residents to answer questions and resolve grievances ...Sufficient mobility and strength to ensure resident safety at all times. Assist, transfer, or otherwise move residents of facility out of danger...Must be able to function independently and have flexibility, personal integrity and the ability to work effectively with residents ..." However, documentationof a valid fingerprint clearnce card was not available for review. 2. A review of E6's personnel record revealed a "Notice of Denial" from the Arizona Department of Public Safety dated July 27, 2023. The notice stated, "After completing a state and federal level criminal history records check the Department of Public Safety (DPS) is required to deny your application ...based on the following criminal history information: Theft,...Records indicate you were arrested and/or fingerprinted for Receive Stolen Property ..." E6's record also contained a document titled, "Arizona Board of Fingerprinting Good Cause Exception Application Form." However, the form was blank and there was no documentation demonstrating a good cause exception application had been submitted to DPS. 3. In an interview, R1 reported R1 often spoke with E6, as E6 was often doing maintenance work inside the building of AL9477. R1 reported E6 had come into R1's room recently to replace a light bulb. R1 appeared lucid and articulate. 4. In an interview, E7 reported E6 worked at the facility as a "Maintenance Technician." E7 stated E6 was "taken

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.