Park Senior Villas at Goodyear

Based on observation and interview, the manager failed to ensure that a resident was treated with dignity, respect and consideration. The deficient practice posed a risk as resident rights were violated. Findings include: 1. A review of video footage with E1, revealed an incident where E2 threw water at R1. 2. In an interview, E1 acknowledged E2 did not treated R1 with dignity, respect, and consideration.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for one of two sampled employees. 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(A) states, "A. Except as providedin subsection F of this section, 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 or contracted work." 2. A review of E1's personnel record revealed a fingerprint clearance card with an 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 documentation review, record review, and interview, the manager failed to ensure, before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults, for one of two sampled personnel members. The deficient practice posed a risk if the caregivers were unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a staff schedule for April 2024. The schedule revealed E2 worked at the facility on April 14, 15, and 17, 2024 from 2:00 PM to 10:00 PM. 2. A review of E2's personnel record revealed documentation of first aid training and CPR training. However, the training expired on March 12, 2024. 3. In an interview, E1 acknowledged E2 worked at the facility on April 14, 15, and 17, 2024 as reflected on the schedule. E2 acknowledged E2's CPR and first aid training was expired.

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 two of two residents sampled 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 dated October 11, 2023. No more recent service plan for R1 was available for review at the time of the inspection. 2. A review of R2's medical record revealed a service plan dated November 30, 2023. No more recent service plan for R2 was available for review at the time of the inspection. 3. In an interview, E1 acknowledged there was no updated service plan for R1 or R2 available for review at the time of the inspection.

Based on record review and interview, the manager failed to ensure a personnel record included documentation of current cardiopulmonary resuscitation (CPR) and first aid training, for one of two sampled caregivers. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2's personnel record revealed expired first aid and CPR training certifications. E2's certification expired February 10, 2024. 2. In an interview, E1 acknowledged E2's first aid and CPR training certifications were expired, and there was no additional documentation available for review.

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, documentation review, and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver, for one of three assistant caregivers sampled. The deficient practice posed a risk as E4 was not qualified to provide the required services alone. Findings include: Arizona Revised Statutes (A.R.S.) \'a7 36-401(A)(42) states "Supervision" means: "direct overseeing and inspection of the act of accomplishing a function or activity." 1. A review of E4's record revealed E4 was hired as an assistant caregiver. 2. A review of the facility staffing schedule revealed E4 was the only staff member scheduled to work from 7:00 AM to 3:00 PM on September 16, 2023. 3. In an interview, E1 reported E1 had only recently started working at the facility and would review and adjust the schedule. E1 acknowledged E4 worked the aforementioned shift as scheduled and interacted with residents without the supervision of a manager or caregiver

Based on record review, documentation review, and interview, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. Findings include: 1. A review of E4's personnel records revealed E4 was hired as an assistant caregiver. 2. A review of the facility staffing schedule revealed E4 was the only staff member scheduled to work from 7:00 AM to 3:00 PM on September 16, 2023. 3. In an interview, E1 reported E1 had only recently started working at the facility and would review and adjust the schedule. E1 acknowledged E4 worked the aforementioned shift as scheduled and interacted with residents without the supervision of a manager or caregiver.

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 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 two 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 record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of three residents sampled. Findings include: 1. A review of R1's medical record revealed a written service plan updated in August 2023. The service plan indicated R1 received medication administration. Further review of R1's medical record revealed a medication order dated July 26, 2023 for "Divalproex DR Sprinkles, 250mg Oral, Three times daily." 2. Areview of R1's medical record revealed medication administration records (MARs) for October, 2023. R1's October MAR indicated R1 received two capsules of "Divalporex DR 125 MG CAP SP" on the following dates and times: -October 1, 10, and 14 at 8:00 AM and 8:00PM; -October 2-5, 9, 11, and 16-18 at 8:00 PM;and -October 6-8, 13, and 19 at 8:00 AM, 12:00 PM, and 8:00 PM. However, documentation R1 received the medication as ordered on October 1-5, 9-12, and 14-18 was not available for review. The missed doses of the medication on the aforementioned dates were marked on the MAR as "Exception" and the "Exception Reason" for each date was "Medication not available." 3. In an interview, E3 reported E3 was not sure how R1's Divalproex was administered at some times, then listed as "not available" at other times on the same days. E3 acknowledged R1's Divalproex was not administered as ordered in October of 2023. 4. In an interview, E1 reported E1 did not yet have a chance to review any MARs. E1 acknowledged R1's medication was not administered in compliance with a medication order.