Villas at Green Valley, Villa J.

“Based on documentation review and interview, the healthcare institution failed to provide appropriate first aid to an injured resident who had fallen or appeared to be injured. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. A review of facility documentation revealed an incident report, dated, October 16, 2024, which described an incident which had occurred on October 15, 2024. The report indicated E4"heard R1 yelling, and [E4] walked into [R1's] room and found [R1] on the floor. The report also indicated E4 "gave [R1] a pillow and blanket," but did not indicate E4 provided appropriate first aid to a resident who had fallen, appears to be uninjured and is unable to reasonably recover independently. 2. In an interview, E1 acknowledged the facility failed to provide appropriate first aid to an resident who had fallen and appeared to be uninjured.”

“Based on documentation review, and interview the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk if a resident was subjected to ridicule or demeaning remarks, and removal of an assistive device which posed a health risk to the resident. Findings include: 1. A review of facility documentation revealed an incident report, dated, October 16, 2024, which described an incident which had occurred on October 15, 2024. The report indicated E4 "heard R1 yelling, and [E4] walked into [R1's] room and found [R1] on the floor. The report reflected E3 completed the report on October 16, 2024 as E4 had failed to complete the report the day prior. 2. A review of facility documentation revealed a had written note, dated October 15, 2024 and signed by E3. The report indicated E4 "heard [R1] screaming and heard the bed alarm go off. When E4 got to resident's room [E4] found [R1] on the floor. [E4] gave [R1] a pillow and blanket." The report reflected E3 instructed E4 to check R1 for injuries and "call paramedics for evaluation." 3. A review of facility documentation revealed an internal investigation dated October 15, 2024 through October 17, 2024. The investigation included the following allegations residents had not been treated with dignity, respect, and consideration: -"...[E4] made [R1] walk without [R1's] wheelchair and wouldn't let [R1] use [R1's] walker."; -"...[E4] gave [R1] a blanket and pillow after [R1] fell, left [R1] on the floor and walked out of the room on the phone with someone."; and -"...[E4] didn't come back until [R1] was screaming and that...[E4] said 'see you wanted to go to work.'" The documentation indicated E1 reviewed video provided by O1, which corroborated allegations noted above. The documentation also indicated E1 explained to E4 "as a trained caregiver you need to treat the residents with dignity and respect and that removing [R1's] wheelchair (her assistive device away from [R1]) is neglect and could be a contributing factor to [R1's] fall." Further, the documentation reflected E4 was terminated and "would be reported to APS." 4. A review of a video segment provided by E1 revealed E4 enter [R1's] bedroom and turn on the light. R1 was observed on their bed, with a wheelchair immediately to R1's left. R1 expressed their desire to go to work, and E4 was observed redirecting R1 and explaining R1 did not work, but lived "in an elderly home." E4 was also observed to instruct R1 to "stand up and walk. If you can stand up and walk I'll let you go to work." When R1 reached for their wheelchair, E4 stated, "Nope, you can't use this. Stand up and walk," and E4 was observed pulling the wheelchair away from R1 and out of R1's reach. 5. In an interview, E1 acknowledged these allegations were deemed credible and include allegations residents had not been treated with dignity, respect, or consideration by E4.”

“Based on documentation review and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to initiate an investigation and document the information required in R9-10-803.J.5.a-d, within five working days. Findings include: 1. A review of facility incident reports filed between August 2023 and November 2023 revealed one investigation report, dated November 16, 2023, which detailed an investigation initiated by Adult Protective Services (APS) on November 2, 2023 regarding concerns of abuse, neglect or exploitation of a resident while the resident was receiving services at the facility. The report indicated APS returned to the facility twice more, on November 6 and November 9, 2023. The facility's investigation report, signed on November 21, 2023, reflected documented requirements in R9-10-803.J.5.a-d. However, it did not reflect the facility initiated their own investigation and document the information in R9-10-803.J.5.a-d within five working days as required. 2. In an interview, E1 acknowledged an internal investigation was not initiated and information required in R9-10-803.J.5.a-d was not documented within five working days as required.”

“Based on documentation review, record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of facility documents revealed a staff schedule which indicated the facility operated on two shifts, days "7a-7p," and nights "7p-7a." 2. A review of R1's medical record revealed a service plan dated December 13, 2023, for Directed care services. The service plan included provision of numerous daily services required, such as "Oral Care, Morning and Night, set up," "Hydration, Offer 8oz of sufficient fluids..." "Encourage to eat meals," and "Needs Encouragement to Participate in Activities." 3. A review of R1's medical record revealed a form documenting services provided to R1 during the month of February 2023. Evidence of documentation of services provided to R1 during the night shift was not available for review. Further, evidence of documentation of services provided during either shift on February 9, 2023 was not available for review. 4. A review of R2's medical record revealed a service plan dated January 12, 2024, for Directed care services. The service plan included provision of numerous daily services required, such as "Oral Care, Morning and Night, Complete Assist," "Ambulation, Assist of one, Walker, Wheelchair, Complete Assist," "Toileting, Complete Assist," "Hydration, Offer 8oz of sufficient fluids..." "Encourage to eat meals," and "Attends Group Activities." 5. A review of R2's medical record revealed a form documenting services provided to R1 during the month of February 2023. Evidence of documentation of services provided to R2 during the night shift was not available for review. Further, evidence of documentation of services provided during either shift on February 9, 2023 was not available for review. 6. In an interview, E1 acknowledged the services provided to R1 and R2 were not documented.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than three ambulatory residents, and the following: In an unlocked laundry room, a cabinet above a washer and dryer containing two cans of "Ajax" cleaner and an unlabeled plastic bottles containing a viscous, red in color fluid; and On a closet shelf, inside an unlocked residential unit, a bottle of "Tide PODS," with a warning label stating "HARMFUL IF PUT IN MOUTH OR SWALLOWED," a spray bottle of "Lysol Laundry Sanitizer," with a warning label stating "Corrosive. Causes irreversible eye damage," and a spray bottle of "Tide Antibacterial Fabric Spray," with a warning label stating "KEEP OUT OF REACH OF CHILDREN." 2. In an interview, E2 advised the unlabeled bottle containing the red in color liquid contained "Fabuloso" all purpose cleaner. E2 agreed the poisonous toxic cleaners were not stored in labeled containers, in locked areas. 3. In an interview, E1 acknowledged the poisonous and toxic materials were not kept in a locked area, inaccessible to residents.”