Park Senior Villas at Goodyear

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available. 2. In an interview, E1 reported the document was completed with a previous employee and E1 was not able to identify where it was located. E1 acknowledged documentation of an assessment of the health care institution's risk of exposure to infectious TB conducted annually was not available for review.

Based on record review and interview, the manager failed to ensure a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for two of two residents sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A review of R1's and R2's medical records revealed documentation of a standardized emergency responder patient information form completed as required by Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9). However, the following were not included in the documentation: - A copy of R1's and R2's health insurance portability and accountability act (HIPAA) release authoring a receiving hospital to communicate with the adult foster care home; and - A standardized space to be filled in with the reason or reasons the emergency responder was requested on behalf of the resident. 2. In an interview, E1 reported E1 would send over the information to have the document updated. E1 acknowledged the information required in A.R.S. \'a7 36-420.04 was not prepared in a standardized emergency responder patient information form as required.

Based on observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. The Compliance Officer observed multiple bedrooms used for residents receiving directed care services. In the bedrooms, the Compliance Officer observed devices used to alert employees to a resident's needs or emergencies. In multiple bedrooms, the Compliance Officer pulled the cords and pushed the buttons of the devices to test the system. However, the Compliance Officer heard no alert and no employees came to check. 2. In an interview, E1 stated, "They light up but they aren't going through." E2 reported the devices were not alerting the caregivers' pagers, stating the alerts were "not going to the pager[s]." E2 stated the pagers were "malfunctioning" and not alerting caregivers.

Based on documentation review and interview, the manager failed to ensure as part of the policies and procedures required in Arizona Administrative Code (A.A.C.) R9-10-803(C)(1)(h), a plan was documented to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs as the facility had not established or documented a policy and procedure to clarify the health care institution's practice. Findings include: 1. A review of the facility's policies and procedures revealed the policy and procedure required in A.A.C. R9-10-803(C)(1)(h). However, the policy and procedure did not include a plan to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. 2. In an interview, E1 stated, "We don't have a policy on that."

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 November 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 November 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 observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the health and safety to residents. Findings include: 1. The Compliance Officers observed a cabinet beneath the facility's kitchen sink. The cabinet was not locked. The cabinet contained the following poisonous or toxic material: -Clorox wipes The bottle contained a warning label. 2. The Compliance Officers observed an unlocked hallway bathroom. The bathroom contained the following poisonous or toxic material: -Glade air freshener The can contained a warning label. 3. The Compliance Officers observed numerous ambulatory residents in the facility. 4. In an interview, E1 acknowledged the poisonous or toxic materials were left unlocked and accessible to residents.

Based on record review, documentation 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 as E1 did not meet the requirement in A.R.S. \'a7 36-411 and was required to have a valid fingerprint clearance card. Findings include: 1. 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 E2's compliance with A.R.S. \'a7 36-411(A) was provided at the time of the inspection. 2. 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." 3. In an interview, E1 acknowledged E1's fingerprint clearance card was expired. E1 reported E1 submitted a new application but also acknowledged E1 never submitted new fingerprints to DPS.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. Findings include: 1. The Compliance Officers observed two lined but uncovered containers storing garbage and refuse in the facility's main kitchen. Each lined but uncovered trash can contained food products. 2. The Compliance Officers observed a lined but uncovered container storing garbage and refuse in R1's bedroom. 3. The Compliance Officers observed a covered container storing garbage and refuse in the facility's hall bathroom. However, the garbage container did not contain a liner. 4. In an interview, E1 acknowledged there were garbage containers throughout the facility that did not contain liners and/or lids.