Park Senior Villas at La Canada - Villa L

Based on record review, and interview, the health care institution failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of two personnel records reviewed. Findings Include: 1. A review of E5's personnel file did not include documentation of continued competency training covering fall prevention and fall recovery in 2024. 2. In an exit interview, the findings were reviewed with E1. E1 acknowledged the facility failed to provide continued competency training on fall prevention and fall recovery despite having a training program available.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed by the resident or resident's representative, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a "14-day" service plan dated October 7, 2024, for directed care services. However, the service plan was not reviewed by R2's representative. 2. A review of R2's medical record revealed a "90 day" service plan dated December 20, 2024, for directed care services. However, the service plan was also not reviewed by R2's representative. 3. In an interview, E1 acknowledged the service plans provided for R2 did not include a review by R2's representative when the plans were developed or updated.

Based on documentation review, observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential elopement dangers to residents. Findings include: 1. The Compliance Officer observed the backyard, accessible to residents, with a shaded sitting area. The Compliance Officer observed the backyard was fenced, and the gate secured by a keypad. 2. A review of an incident report regarding R1 revealed, on August 5, 2023, R1 became upset at lunch and went to the backyard. E3 went to check on R1, and discovered R1 was no longer in the backyard. E3 discovered the gate was left open by landscapers and R1 had eloped. 3. A review of report # 230805131, by the Pima County Sheriff's Department, revealed R1 was located more than two hours after R1 was last seen. The report stated R1 appeared dehydrated and suffering from heat exhaustion. R1 was transported to the hospital, where R1 died. 4. In an interview, E1 reported the landscapers were scheduled to come on Wednesday's and should not have been on the property on a Saturday. E1 acknowledged the landscapers were provided the code to the backyard gate. 5. In an interview, E1 acknowledged the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.