Inspection Reports for
Woodland Palms Memory Care Community

A.R.S. § 36-420.01.A — The facility failed to administer a training program for all staff regarding fall prevention and fall recovery, including initial training, as documentation was not available for one of four sampled caregivers.

R9-10-806 — The manager failed to ensure that caregivers and assistant caregivers had documented qualifications, experience, skills, and knowledge necessary to meet residents' needs and ensure their health and safety, as personnel files for E3 and E4 lacked such documentation.

R9-10-808 — The manager failed to ensure caregivers were only assigned to provide assisted living services for which they had documented skills and knowledge, as E3 and E4 provided services without verified competency documentation.

A.R.S. § 36-420.01.A — The facility failed to administer a training program for all staff regarding fall prevention and fall recovery, including initial training, for three of eight sampled caregivers. Documentation of this training was not available for review.

R9-10-819 — The manager failed to ensure a caregiver immediately notified the resident's emergency contact and primary care provider after a resident emergency requiring medical services. Incident reports showed notifications were documented over two hours after the emergency, and documentation of earlier contact was not provided.

R9-10-803 — The manager failed to ensure policies and procedures were established to protect the health and safety of a resident by covering methods to be aware of the resident's whereabouts based on their level of assisted living services.

R9-10-803 — The governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm, as evidenced by a staff member mistakenly letting a resident out the gate unsupervised.

R9-10-803 — The manager failed to report suspected abuse, neglect, or exploitation of residents according to A.R.S. § 46-454, despite documented incidents involving resident altercations. This failure posed potential safety risks and rights violations due to lack of required notification and documentation.

R9-10-803 — The manager failed to maintain a separate record for each resident's personal funds account, including receipts, with missing receipts for expenditures and lack of signatures for money retrieved.

R9-10-808 — The manager failed to ensure a resident's written service plan included required details of psychosocial interactions, psychotropic medications, planned strategies, and goals for behavioral care.

R9-10-812 — The manager failed to ensure a behavioral health professional or medical practitioner completed and signed a written determination that the resident's behavioral care needs could be met by the facility at required intervals.

R9-10-816 — The manager failed to ensure medications were administered in compliance with orders, including holding medications based on blood pressure or pulse parameters, for two residents.

36-420.04 — The assisted living center failed to maintain a copy of the documentation provided to an emergency responder for one sampled resident after an emergency incident.

Care documentation — The manager failed to ensure caregivers documented services provided in residents' medical records for four of five sampled residents, risking unverified service provision and misleading information.

36-420.01 — The facility failed to administer a training program for all staff regarding fall prevention and fall recovery, as training documentation for employee E5 was not available for review.

Fingerprint clearance compliance — The governing authority failed to ensure documented, good faith efforts to contact previous employers and verify fingerprint clearance card status for three of four employees sampled, including false or misleading verification dates.

CPR training policy implementation — The manager failed to implement policies and procedures ensuring cardiopulmonary resuscitation training included a demonstration of ability, as employee E2's CPR training did not include such demonstration.

Policy review — The manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed; the last documented review was dated February 7, 2017.

R9-10-113 — The manager failed to ensure two of four employees provided evidence of freedom from infectious tuberculosis, lacking documentation of risk assessments, symptom screens, and second step testing.

Orientation documentation — The manager failed to ensure documentation indicating orientation was provided before assisted living services for one caregiver (E5).

First aid and CPR certification — The manager failed to ensure one caregiver (E5) provided current documentation of first aid training; the personnel file contained only CPR and defibrillator training.

Employment start date documentation — The manager failed to ensure personnel records included the individual's starting date of employment for one employee (E5).

R9-10-808 — The manager failed to ensure two of five residents provided complete documentation of freedom from infectious tuberculosis, missing risk assessments and symptom screenings.

Medication administration compliance — The manager failed to ensure medications were administered in compliance with orders for two residents (R1 and R5), resulting in medication errors and adverse events.

Dietary needs — The manager failed to ensure one resident (R5) was provided a diet meeting nutritional needs as specified in the service plan, which inaccurately stated no special diet was required.

Notification of emergencies — The manager failed to ensure immediate notification of emergency contacts and primary care providers when residents had accidents or injuries requiring medical services, with delays noted in notifications for residents R2 and R3.

Incident documentation — The manager failed to ensure documentation of accident descriptions for a resident (R5), missing important details such as medications administered in error, time of incident, and involved staff.

R9-10-120 — The manager failed to ensure documentation of resident need and effect of opioid administration for two residents (R2 and R5), lacking timely and complete assessments as required by policy.