PARK SENIOR VILLAS - CHANDLER

<p>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.</p><p> </p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>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.</p><p> </p><p><br></p><p>2. During an interview, E1 acknowledged that the facility did not document <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">actions taken by the manager to prevent the suspected abuse from occurring in the future.</span></p>

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.

Based on record review, documentation review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of four current residents sampled. The deficient practice posed a risk as the Department was provided false and misleading information.

Findings include:

1. A review of R4's (admitted in 2023) medical record revealed a service plan, dated in February 2023. The service plan revealed R4 was to receive medication administration.

2. A review of facility documentation revealed a medication administration report (MAR) for March 2023. The MAR revealed R4 was to receive the following medication:
-Alogliptin 25 mg at 8 AM

3. Further review of the March 2023 MAR revealed Alogliptin 25 min was administered on the following dates:
-March 1-12, 2023
-March 17-18, 2023
However, the boxes for March 13-16, 2023 and March 19-22 were red, indicating an exception. The exception boxes were filled in stating the medication was not administered due to the facility waiting for the pharmacy to deliever the medication/medication not being available to administer.

4. In an interview, E2 reported to be unsure why the boxes were initialed as the medication had been administered as R4's Alogliptin had not yet been received from the pharmacy.

5. In an interview, E1 reported E1 attempted to contact the caregiver whose initials were documented as administering the medication on March 17 and 18, 2023. E1 reported the caregiver was unavailable. E1 reported the medication had not been administered to R4 because the facility did not have the medication on hand to administere and R4's insurance would not pay for the medication to be filled. E1 acknowledged the MAR indicated the medication had been administered and this was considered false and misleading documentation.

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.

Findings include:

1. The Compliance Officers observed, in Villa A, unlocked kitchen cabinets. The cabinets contained the following toxic materials:
-Ajax
-Sure Scents air freshener
Both containers contained toxic warning labels.

2. The Compliance Officers observed several ambulatory residents on the premises.

3. In an interview, E7 acknowledged the unlocked toxic material.

4. In an interview, E1 acknowledged the unlocked toxic material.

Based on observation and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents.

Findings include:

1. The Compliance Officers observed, in Villa B, an unlocked cabinet in the dining area. The cabinet contained the following flammable materials:
-Two cans of 6 hour Diethylene fuel
The cans contained flammable warning labels.

2. The Compliance Officers observed several ambulatory residents on the premises.

3. In an interview, E7 acknowledged the flammable material was not locked and was accessible to residents.

4. In an interview, E1 acknowledged the flammable material was not locked and was accessible to residents.

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Orientation, On-going Training and Skills Check" dated August 1, 2019. However, the policy did not include a training program regarding fall prevention and fall recovery.

2. A review of the facility's policies and procedures revealed an undated document, titled "Park Senior Villas Fall Management Program." However, the policy did not include the initial training and continued competency training requirement.

3. A review of facility documentation, provided by E1, revealed a document, dated July 20, 2022 and titled "Inservice Form, Topic: Falls Prevention Training." However, E2's, E3's, E4's, E5's and E6's names were not on the in-service training roster.

4. In an interview, E1 acknowledged the facility's policy and procedure did not discuss the facility's training program or the frequency required for personnel to be trained. E1 reported E1 "instructed" the inservice and acknowledged E2, E3, E4, E5 and E6 were not present for this in-service training.

Based on documentation review, record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the following was not provided for review: activities of daily living documentation in compliance with three resident's service plans, and the facility's training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training.

Findings include:

1. The Compliance Officers requested, at 10:00 AM, documentation to be provided for the facility's complaint investigation and compliance inspection.

2. The Compliance Officers conducted the exit interview with E1 and E7 at 5:30 PM and the following documentation had not been provided to the Department for review:
-Fall prevention and fall recovery training program
-Activities of daily living documentation in compliance with three resident's service plans

3. In an interview, E1 acknowledged the aforementioned documentation was not provided to the Department within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided assistance with activities of daily living according to the resident's service plan, for three of four residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's (admitted in 2022) medical record revealed a service plan dated in November 2022. The plan stated R1 was to receive the following services:
-Bathing assistance - 2 times per week
-Housekeeping and laundry - 2 times per week

2. A review of R1's medical record revealed a document titled "Care Tracking Sheet" dated November 2022. However, the document revealed R1 received bathing assistance on the following dates:
-November 10
-November 13
-November 20
-November 27

3. A review of R1's medical record revealed a document titled "Care Tracking Sheet" dated November 2022. However, the document revealed R1 received housekeeping assistance on the following dates:
-November 6
-November 10
-November 13
-November 20
-November 27

4. A review of R1's medical record revealed a document titled "Care Tracking Sheet" dated December 2022. However, the document revealed R1 received bathing assistance on the following dates:
-December 1
-December 4
-December 8
-December 11

5. A review of R1's medical record revealed a document titled "Care Tracking Sheet" dated December 2022. However, the document revealed R1 received housekeeping assistance on the following dates:
-December 1
-December 4
-December 8
-December 11

6. A review of R3's (admitted in 2021) medical record revealed a service plan dated in September 2022. The plan stated R3 was to receive the following services:
-Bathing assistance - 2 times per week
-Housekeeping and laundry assistance - 2 times per week
-Skin integrity assistance - 2 times per week

7. A review of R3s medical record revealed a document titled "Care Tracking Sheet" dated January 2023. However, the document revealed R3 received bathing assistance on the following dates:
-January 3
-January 6
-January 13
-January 20
-January 24

8. A review of R3's medical record revealed a document titled "Care Tracking Sheet" dated January 2023. However, the document revealed R3 received housekeeping assistance on the following dates:
-January 3
-January 6
-January 13
-January 20
-January 24

9. A review of R3's medical record revealed a document titled "Care Tracking Sheet" dated January 2023. However, the document revealed R3 received skin integrity assistance on the following dates:
-January 3
-January 6
-January 13
-January 20
-January 24

10. A review of R4's (admitted in 2020) medical record revealed a service plan dated in August 2022. The plan stated R4 was to receive the following services:
-Bathing assistance - 2 times per week
-Housekeeping and laundry assistance - 2 times per week
-Skin integrity assistance - 2 times per week

11. A review of R4's medical record revealed a document titled "Care Tracking Sheet" dated January 2023. However, the document revealed R4 received bathing assistance on the following dates:
-January 2
-January 5
-January 16
-January 23

12. A review of R4's medical record revealed a document titled "Care Tracking Sheet" dated January 2023. However, the document revealed R4 received housekeeping assistance on the following dates:
-January 2
-January 5
-January 16
-January 23

13. A review of R4's medical record revealed a document titled "Care Tracking Sheet" dated January 2023. However, the document revealed R4 received skin integrity assistance on the following dates:
-January 2
-January 5
-January 16
-January 23

14. In an interview, E1 acknowledged R1's, R3's and R4's activities of daily living were not documented as provided according to the residents' service plans.