Park Senior Villas at Houghton - Villa Hh

Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. The deficient practice posed a risk if a report was not made as required to adequately protect residents involved. Findings include: 1. A.R.S. \'a7 46-454(A) stated "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.110 stated "Immediate" means without delay. 3. A review of facility documents revealed two documents, titled "Accident/Incident Report", dated June 28, 2024. These documents detailed an incident of possible sexual abuse between two residents on June 28, 2024. Based on the documented reports, the incident required a report for possible sexual abuse. 4. In an interview, E1 reported the incident was not reported to adult protective services (APS) until Monday, July 1, 2024. E1 acknowledged the suspected abuse was not reported according to A.R.S. \'a7 46-454. E1 reported the delay was due to a misunderstanding of the reporting timeframe and R2 was moved to another facility on July 5, 2024.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a signed medication order for "Fluticasone-Salmeterol (Advair Diskus) 250-50 MCG/ACT", "Inhale 1 puff BID", dated May 3, 2023. 3. A review of R1's medication administration record (MAR) dated February 2024. The MAR revealed on February 15, 2024, the medication was unavailable and waiting for a refill. Between February 15, 2024 and February 28, 2024, the medication was documented as not available and waiting for a refill, however on some occasions it was documented as administered. 4. A review of R1's medication revealed the medication was not available. 5. In an interview E1 acknowledged the medication administered to a resident was not accurately documented.