The governing authority failed to ensure compliance with A.R.S. § 36-411.  The deficient practice posed a risk-was a danger to a vulnerable population.

A.R.S. § 36-411 states, "A... as a condition of licensure or continued licensure of a residential care institution...  A fingerprint clearance card was available for X but was expired. Review of the DPS fingerprint clearance card database revealed Employee fingerprint clearance cards were "invalid". During an interview, X reported X did not have a fingerprint card. During a facility tour the surveyor observed X working alone at the facility with residents on the premises.

A review of  personnel record revealed Employee was hired as an Assistant Caregiver. A review of facility documentation revealed a staff schedule revealed Employee worked shifts alone.

 In an interview X reported Employee works as an assistant caregiver. X reported employee does not have a caregiver training certificate. X reported employee does work alone in the facility. X reported they were the only staff on-site. 

In an interview, X reported employee worked as an assistant caregiver. X acknowledged the personnel schedule did not reflect a caregiver for the shifts identified with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident.

In an interview, employee acknowledged the manager failed to ensure at least one manager or caregiver was present at the assisted living center when a resident was on the premises.

Based on documentation review, record review, and interview, the manager failed to ensure a policy and procedure was developed, documented, and implemented to establish a process for checking on a resident receiving directed care services to ensure the resident's health and safety.

Based on documentation review, record review, and interview, the manager failed to ensure the assisted living facility had caregivers with the qualifications, Fingerprint Clearance, experience, skills, and knowledge necessary to meet the needs of a resident. 

The surveyors arrived at the facility and requested to review medical records for residnets.

A review of Residents activities of daily living (ADL) sheet revealed pre-filled boxes, with a caregivers initials, for the following:

-BM Tracking (1:30 PM)

-Eating/Nutrition Limited Assistance (12:00 PM)

-Hydration Tracking (1:30 PM)

-Meal Tracking (12:30 PM)

-Monitoring Wellness and Medication Dependent (12:00 PM)

 -Toileting Dependent (11:00 AM and 1:00 PM). 

In a joint interview, Employees acknowledged the pre-filled documentation of services provided had occurred before the services had actually been provided for Residents.

Review of Residents record revealed a current written service plan for directed care services. Service plan revealed no documentation of offering sufficient fluids to maintain hydration, documentation of incontinence care that ensured the resident maintained the highest practicable level of independence when toileting, activities to maximize functioning; strategies to ensure personal safety; encouragement to eat meals and snacks; and coordination of communications with Residents representative. Employee acknowledged service plans did not include documentation of cognitive stimulation and activities to maximize functioning; strategies to ensure personal safety; encouragement to eat meals and snacks; and coordination of communications with the representative. Employee acknowledged service plans did not include offering sufficient fluids to maintain hydration and documentation of incontinence care that ensured the resident maintained the highest practicable level of independence when toileting.

Based on documentation review, record review, and interview, the manager failed to ensure the assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. 

Missing documentation of Bathing, Grooming. Resident's left in soiled clothing, unclean bedding, unkempt appearance. No documentation for residents with assistance of Aids such as Glasses, Dentures, Incontinence items. Nutrition documentation incomplete.

A review of facility documentation revealed a document titled "Disaster Plan." The disaster plan contained an annual review date however, the time was not filled in for the review. In an interview, X acknowledged no annual disaster plan review.

A review of Resident medical record revealed a form titled "Determination of Admission into Park Senior Villas Prior to Admission Form." The form was signed, however, the signature did not indicate if the individual who signed the form was a physician, registered nurse practitioner, registered nurse, or physician assistant; and the document was dated three days after date of admission. In an interview, the Employee did not submit the required documentation within 90 calendar days before admission.

Based on documentation review, record review, and interview, the manager failed to ensure a policy and procedure was developed, documented, and implemented to establish a process for checking on a resident receiving directed care services to ensure the resident's health and safety.

Based on documentation review, record review, and interview, the manager failed to ensure the assisted living facility had caregivers with the qualifications, Fingerprint Clearance, CPR Certifications, experience, skills, and knowledge necessary to meet the needs of Direct Care residents. 

Review of the personnel schedule revealed no caregiver was scheduled to work. During an interview,  Employee reported the resident care coordinator filled in when needed. Employee acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked by each.

Review of the facility's policy and procedure revealed a policy titled "CPR & First Aid Policy & Procedure". 

This policy stated "...1. Before providing personal or directed care services to a resident, a manager, caregiver, or volunteer provides documentation of CPR and First Aid training that: CPR a. Is current at all times...First Aid a. Is current at all times...3. The CPR and/or First Aid training cannot be done Online..." Review of the facility's policy and procedure revealed a policy titled "CPR & First Aid Policy & Procedure" with an effective date of August 2, 2022. This policy stated "...3. The CPR and/or First Aid training cannot be done Online..."

Personnel record revealed CPR cards obtained from NationalCPRFoundation, which was an online course. There was no other current documentation of CPR training available for review that would document an approved CPR training course that included hands on demonstration of employee's ability to perform CPR.

The surveyors arrived at the facility and requested to review personnel record. The personnel record revealed a first aid training card and a CPR training care were not available for review.

In a telephonic interview, Employee would speak with the instructor of the courses completed and provide additional documentation and information to the Department.

A signature indicating Employee's first name and last name, however, the signature on the roster did not match the signature on the TB documentation signed by Employee on 2020 or 2021 referenced in Tag C6DO in this statement of deficiencies. Falsified Documents.

During an interview, X acknowledged Residents service plans did not include the required rule areas identified.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

A review of Residents medical record revealed a document titled, "Physician Orders for Patient Admission to Park Senior Villas" signed and dated by a physician. The document revealed an order for Clozapine morning and at night. Medication administration record (MAR) revealed Clozapine dispenses were not documented.

In an interview, Employee reported the Clozapine had not been filled despite being admitted to the facility. Employee reported the facility had issues getting the medication filled. However, acknowledged the medication had not been administered in compliance with an order.

MAR was incomplete and duplicate medication orders found for Residents through Pharmacy cross reference. 

Tracking of OTC, Incontinence Care Products were delivered to facility but not dispensed to recipient.

Records revealed service plans indicating the residents' receive directed care services. 

 The surveyors requested to review the facility's policies and procedures for establishing a process for checking on a resident receiving directed care services during nighttime hours to ensure the resident's health and safety.  X presented the surveyors with a document titled "Check list of Nightly Duties". During an interview, X reported the checklist of nightly duties was posted in each building, however the facility did not have a written policy establishing a process for checking on a resident receiving directed care services during nighttime hours.

Review of the personnel schedule revealed no caregiver was scheduled to work. During an interview, X reported the resident care coordinator filled in when needed.  X acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked by each.

Based on documentation review, record review, and interview, the manager failed to ensure the assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. 

Based on documentation review and interview, the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under A.R.S. § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. The deficient practice posed a risk if the assisted living facility was unable to ensure compliance with applicable Rules.1. A review of www.az.tmuniverse.com revealed E2 passed the AL Facility Manager training on October 21, 2021 though Platinum Training. Yet Employee acted as Manager for much longer.

A review of www.elicense.az.gov revealed no manager's license for Employee 2.

A review of www.az.tmuniverse.com revealed no evidence Employee 3 passed a manager's training program.

A review of www.elicense.az.gov revealed no manager's license for Employee 3.

In a interview the Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board) reported Employee 2 did not have a valid manager's license.

In a interview, Employee 1 acknowledged Employee 1 emailed the Department indicating, as of August 24, 2021, they were no longer the manager of AL9512. Employee 1 reported to be under the impression Employee 3 was the acting manager in between the departure as manager and the hiring of Employee 2 as manager. Employee 1 reported to be unaware neither Employee 2 or Employee 3 had valid manager's license.

In a telephonic interview, Employee 2 acknowledged neither themselves or Employee 3 had valid manager's licenses. Employee 2 reported Employee 3 believed Employee 3 was an active manager when they served as interim manager, between Employee 1 departure and when Employee 2 was hired as the manager. Employee 2 acknowledged they never took the NCIA Board's manager test to become a state licensed manager through the NCIA Board. 

Intent to revoke License filed by ADHS.

(This is all ironic as the employees referenced are all related)

R9-10-101.32. 32. "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors.

A review of resident's medical records revealed a document titled " Physician orders for a patient admission..." The order stated "Diagnoses: Bipolar Disorder, Current Episode Mixed Mild." No additional diagnoses were documented. Resident's service plan for directed care services, revealed "Primary Diagnosis: Bipolar." No secondary or additional diagnoses were documented. Staff reported they were aware Residents primary diagnosis is a behavioral health diagnoses. X acknowledged the "manager" accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue.

The Department was provided false and misleading information.

R9-10-101.32. "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors.

A review of Resident's medical record revealed a document titled, "Physician Orders for a Patient Admission to Park Senior Villas" signed and dated by a medical practitioner. The document stated, "Primary Diagnosis... Schizophrenia, unspecified... "A review of Resident's medical record revealed a service plan for directed care services Bathing: ... limited assistance... Dressing & Grooming:...limited assistance... Toileting:... extensive assistance... continent of bladder, has occasional episodes of incontinence with bowels... Incontinence:... extensive assistance... occasional bowel incontinence on furniture...". 

Facility is not licensed for Behavior Health Care which posed risk to Vulnerable adult population.

A review of Residents medical record revealed a Residency Agreement with the assisted living facility. However, the residency agreement contained a cut out copy of Residents signature taped on top of the signature line.

In an interview, E1 reported E1 believed Resident struggled to write their name and therefore a copy of their signature was copied, cut, and taped on the residency agreement form. E1 acknowledged residents residency agreement did not include valid signature.

Based on record review and interview, the manager failed to ensure, a manager receives a documented agreement with a signature from the resident. The Department was provided false and misleading information.

A review of Residents medical record revealed a document titled "Resident Emergency Procedures & Evacuation Orientation." The form states ", Policy: Each resident shall receive an orientation to the emergency procedures of this facility within twenty-four (24) hours admission. The form identified a signature section that contained a photocopy of Residents signature that had been cut out and taped to the form.

In an interview, E1 reported they believed Resident struggled to write, therefore a copy of Residents signature was copied, cut, and taped on the Resident Emergency Procedure & Evacuation Orientation. E1 acknowledged orientation did not include valid signature.

 A review of Resident medical record revealed a service plan. The service plan indicated Resident was to receive directed level of care. Medical record revealed a residency agreement. The residency agreement was signed by the resident, however, the residency agreement was not signed by Residents representative. The signature space for the "Resident Representative" was signed by E4.

In an interview, E3 and E4 acknowledged residency agreement was not signed by the resident's representative as required. E4 reported E4 signed on this line in error.

Registered Complaint an report filed regarding odd activity on residents Credit Report.

Based on observation and interview, the manager failed to ensure the premises were cleaned. 

During the facility tour, the surveyors observed bedrooms. Bedroom had a strong urine odor and dried urine stains on the floor.       

In an interview, X reported the dried liquid on the floor was urine. 

The surveyors observed the following poisonous or toxic materials in an unlocked cabinet beneath the kitchen sink:

-Windex Glass Cleaner

-A box of Automatic dish machine detergent packs

-A bottle of odor eliminator spray

The materials contained warning labels.

In an interview, Employee acknowledged the materials were left unlocked and were accessible to residents.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95º F and 120º F in areas of the assisted living facility used by residents.

The Compliance Officers observed the water temperature from a hallway bathroom sink to be 122.9º F. The temperature was measured using a Department-issued thermometer.

In a joint exit interview, E4 and E5 acknowledged the water temperature in the villa kitchen sink and hallway bathroom were not maintained between 95º F and 120º F.