Park Senior Villas - Chandler

Based on record review, documentation review, and interview, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered and the effect of the opioid administered, for two of three residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R2’s medical record revealed a Medication Administration Record (MAR) for the month of February 2026. This MAR included the documentation for the opioid Hydrocodone-Acetaminophen 5/325 mg tablet by mouth three times a day as needed. According to this MAR, R2 received this opioid three times a day, every day, at 8am, 12pm and 4pm from February 1-19, 2026. However, there was no documentation of the patient's response and the effect of the opioid administered for each administration during the month of February 2026. R2 did not have an end-of-life condition or an active malignancy. 2. A review of R3’s medical record revealed a MAR for the month of February 2026. This MAR included the documentation for the opioid Tramadol HCL 50 mg tablet by mouth twice daily as needed for pain. According to this MAR, R3 was administered this opioid on February 14, 2026 and February 19, 2026. However, there was no documentation of the effect on the patient on these days. R3 did not have an end-of-life condition or an active malignancy. 3. A review of facility documentation revealed an opioid policy created on August 1, 2019 titled "Opioid Policy & Procedure". The policy stated "Administration of Opioid: It is the responsibility of the Certified Caregiver, Licensed Nurse, Primary Physician, and or Medical Director to administer opioids per the Primary Physician or Medical Director's order. Before administering an opioid that is regulated by R9-10-Article 1, the Certified Caregiver and/or others that are responsible for administering Opioids per this policy, will be responsible for the following: Identify and document the resident's pain through the following tools: a) Universal Pain Scale Evaluation-use for residents able to communicate their level of pain or b) Advanced Dementia (AD) PAINAD Pain Scale-use for residents with cognitive deficit or that are unable to communicate their level of pain. c) Document the pain scale number on the respective evaluation sheet i. Beföre Time Given ii. up to 1 Hour After iii. Document the resident's response to the opioid given in the respective pain scale evaluation iv. Document the effectiveness of the opioid given on the respective pain scale". 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the administrator failed to document the actions taken to prevent an alleged incident of abuse from occurring in the future, according to Arizona Revised Statutes (A.R.S.) § 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for a resident who resided in the assisted living facility. Findings include: 1. A review of R1’s medical record revealed an incident report dated March 04, 2025, that detailed an alleged abuse. However, it did not document the actions taken by the manager to prevent the suspected abuse from occurring in the future. 2. During an interview, E1 acknowledged that the facility did not document actions taken by the manager to prevent the suspected abuse from occurring in the future.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident if toxic materials were accessible. Findings include: 1. During an environmental inspection with E1, the Compliance Officer observed Villa A, Villa B, and Villa G. A bottle of disinfectant spray was stored in an unlocked cabinet in the common area on Villa A. A similar bottle of disinfectant spray was stored in an unlocked kitchen cabinet on Villa B. Villa G had an unlocked storage unit "garage," that contained several cans of paint; multiple sizes. 2. During an interview, E1 acknowledged the toxic materials were not stored in a locked area and inaccessible to residents. This is a repeat deficiency from the compliance inspection conducted on January 24, 2023 and the compliance/complaint inspection conducted on September 19, 2024.

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 one of three sampled residents 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 R2's medical record revealed service plans for directed care services dated March 6, 2024 and September 9, 2024. No service plan between March 6, 2024 and September 9, 2024 was available for review at the time of the inspection. 2. In an interview, E1 acknowledged there was no updated service plan for R2 between March 6, 2024 and September 9, 2024 available for review at the time of the inspection.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a health and safety risk to residents with access to the poisonous or toxic materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed in an unlocked laundry room in Villa B "Lysol pet odor eliminator spray", "Heavy Duty Alkaline Bathroom Cleaner and Disinfectant", "Peroxide Multi and Cleaner and Disinfectant", and "Scrubbing Bubbles Disinfectant Restroom Cleaner" stored in an unlocked cabinets in an unlocked laundry in Villa B and accessible to residents. The laundry room door did have a locking mechanism on the door handle, however the mechanism was unlocked at the time of the inspection. 2. During the environmental inspection of the facility, the Compliance Officer observed in an unlocked laundry room in Villa A two bottles of "Lysol Power Clinging Gel" and a bottle of " Fabuloso Multi-Purpose Cleaner" stored in an unlocked in an unlocked laundry in Villa A and accessible to residents. The laundry room door did have a locking mechanism on the door handle, however the mechanism was unlocked at the time of the inspection. 3. In an interview, E1 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and accessible to residents. This is a repeat deficiency from the compliance inspection conducted on January 24, 2023.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed in Villa B, Villa A, and Villa G, in the common bathroom for residents, the pull alerts were not working. 2. In an interview, E1 acknowledged the manager had failed to ensure equipment used at the assisted living facility was maintained in working order.