Park Senior Villas at Goodyear

Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings include: 1. A review of facility documentation revealed a policy titled "Response to Out of Control Behavior Policy & Procedure." The policy stated: "1. Redirection by means of one or all of the below methods a. Always remain calm and use slow passive approaches b. Remove other residents/visitors from danger if needed c. Attempt to redirect agitated resident using the road map to comfort successful approaches. d. Refer to service plan for known approaches to help calm the resident e. Offer food or fluids f. Assess resident for pain or other discomfort, example; resident may need toileting attention or incontinence care." 2. A review of facility documentation revealed an Adult Protective Services (APS) submission documenting "the resident became upset and began swinging her arms at the employee. The employee restrained her arms by placing them on her lap. As a result, the resident sustained bruising." 3. A review of facility documentation revealed a witness statement dated February 25, 2025. The statement documented E5 attempted to follow the above policy while E6 was "yelling" "Don't Baby Her!" and "arguing" with R2. The statement reported E6 then took R2 to R2's room. 4. In an interview. E1 reported E6 was suspended pending termination. E1 acknowledged the facility failed to implement policies and procedures to protect the health and safety of a R2 to include how a caregiver responded to R2's sudden, intense, or out-of-control behavior to prevent harm to R2.

Based on documentation review and interview, the manager failed to ensure that a resident is not subjected to restraint for one of two residents sampled. Findings include: 1. A review of facility documentation revealed an Adult Protective Services (APS) submission documenting "the resident became upset and began swinging [R2's] arms at the employee. The employee restrained [R2's] arms by placing them on [R2's lap. As a result, the resident sustained bruising." 2. In an interview, E1 reported that E5 was placed on suspension pending termination. E1 reported that per video footage reviewed E5 had restrained R2. E1 acknowledged R2 was subjected to restraint.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual requires continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical records revealed no documentation to indicate whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview E1 acknowledged the medical record for R1 did not include the required documentation dated within 90 calendar days before the R1 was accepted by the assisted living facility.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. 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 specified 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)." 3. A review of R1's medical record revealed documentation of R1's freedom from infectious TB was documented using a chest x-ray. However, no tuberculosis screening test that is recommended by the CDC, and no signs and symptoms screening was available for review. Based on R1's date of admission, this documentation was required. 4. In an interview, E1 acknowledged CDC recommended documentation of R1's freedom from infectious TB was not available for review.

Based on documentation review and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration for one of two residents sampled. Findings include: 1. A review of facility documentation revealed an Adult Protective Services (APS) submission documenting "the resident became upset and began swinging [R2's arms at the employee. The employee restrained [R2's] arms by placing them on [R2's] lap. As a result, the resident sustained bruising." 2. A review of facility documentation revealed a witness statement dated February 25, 2025. The statement documented E5 attempted to de-escalate while E6 was "yelling" "Don't Baby [R2]!" and "arguing" with R2. The statement reported the statements caused R2 to react more aggressively and crying "You're a baby." The statement reported E6 then took R2 to R2's room. 3. In an interview, R2 reported that E6 had beat R2 up. 4. In an interview, E1 reported that E6 was placed on suspension pending termination. E1 acknowledged R2 was not treated with dignity, respect, and consideration.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a current service plan dated in September 2023. The service plan indicated R2 received medication administration. 2. A review of R2's medical record revealed a signed medication order dated in October 2022 for the following medications: -Atorvastatin Calcium -40 MG tab (bedtime) -Carbidopa-Levo-10/100 MG tab (noon) -Carbidopa-Levo-25/100 MG tab -Lisinopril-2.5 MG -Prazosin-1MG (bedtime) 3. A review of facility documentation revealed R2's medication administration record (MAR) for October 2023. The MAR revealed the following: Atorvastatin Calcium Oral Tablet 40 MG was administered at 7 PM on the following days: -October 1-12 -October 15-18 However, there were exceptions listed to indicate the medication was not available on the following dates: -October 13, 14, 19 4. A review of R2's medical record revealed a medication order was not available for the following medication: -Dicyclomine 10 MG capsule 5. A review of facility documentation revealed R2's MAR for October 2023. The MAR revealed the following: Dicyclomine 10 MG capsule was administered at 7:30 AM on the following days: -October 1, 6, 8, -October 13-20 However, there were exceptions listed to indicate the medication was not available on the following dates: -October 2-5 -October 7 -October 9-12 6. A review of facility documentation revealed R2's MAR for October 2023. The MAR revealed the following: Dicyclomine 10 MG capsule was administered at 4:30 PM on the following days: -October 1-4 -October 7-11 However, there were exceptions listed to indicate the medication was not available on the following dates: -October 5-6 -October 12 6. In an interview, E1 and E3 acknowledged the medications were documented as administered, though the MAR indicated the medications were not available. E1 also acknowledged the facility was unable to provide some medication orders for medications administered to a resident.

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 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 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 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 Officer observed a cabinet beneath the kitchen sink. The cabinet was not locked. The cabinet contained the following poisonous or toxic material: -Ecolab ZephAir Mountain Mist Tough Odor Remover The bottle contained a warning label. 2. The Compliance Officer observed numerous ambulatory residents on premises. 3. In an interview, E1 and E2 acknowledged the poisonous or toxic material was left unlocked and accessible to residents.