Camino De Oro Senior Living

Based on observation and interview, the manager failed to ensure that poisonous or toxic material stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour, the Compliance Officer observed a bottle of Oven, Grill, and Fryer Cleaner, Simple Green Dilution, and a container of dishwasher pods in an unlocked cabinet under the kitchen sink. 2. In an interview, E1 acknowledged the cabinet under the sink that contained cleaning products was unlocked. 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently and required information could not be verified. Findings include: 1. A review of E2’s personnel record revealed no documentation of initial fall prevention and fall recovery training. Based on E2’s hire dated this was required. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the chief administrative officer failed to implement tuberculosis control activities initial training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by the health care institution, for one of two sampled employees. Findings include: 1. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 2. A review of E2’s personnel record revealed E2 did not receive initial training in identifying the signs and symptoms of tuberculosis. Based on E2’s hire date this was required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411, for two of two personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population and the department was provided falsified and misleading information. Findings include: 1. A.R.S. § 36-411(C)(1)(2)(4) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card… 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee.” 2. A review of E2’s personnel file revealed one previous employer reference. However the sections titled, “Date verified” and “Comments” were left blank. 3. In an interview, The Compliance Officers asked E1 if E2 had documentation of an APS registry check. E1 left for another room and came back later with the APS registry check for E2. The Compliance Officers were able to smudge what was written in ink on the APS registry check. On this check was the signature of the person who verified the registry and a date for December 5, 2025. The Compliance Officers asked if this was just printed and verified. E1 admitted that it was and that E1 had never done falsified documents before. 3. A review of E3’s personnel file revealed a fingerprint clearance card issued in August 2025. However there were no documented verification attempts to verify E3’s fingerprint clearance card status. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2’s medical record revealed R2’s current service plan dated December 2025 revealed R2 received medication administration. 2. A review of R2’s medical record revealed a medication administration record (MAR) for the month of January 2026. On this MAR it revealed Senna 8.6 mg was administered at 8 pm on the 4th, 5th, 6th, 7th, and on the 10th. 3. A review of R2’s medical record revealed no medical orders for Senna 8.6 mg. 4. The Compliance Officers observed a Senna 8.6 mg pill bottle in R2’s name. The Compliance Officers observed in R2’s medication organizer Senna 8.6 mg tablets in the organizer’s compartments. 5. In an interview, E1 was asked if there was an order for Senna 8.6 mg. E1 did not provide any documentation showing R2 takes Senna 8.6 mg at 8 pm. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and documentation review, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. During an environmental tour, the Compliance Officer observed an unlocked kitchen cabinet that contained multiple bins of medication for six residents. 2. A review of the facility’s policies and procedures revealed a policy titled “Medication Management”. The policy stated, “All residents’ medications brought to the facility will be received by the caregiver on duty. Medications will be locked in the medication storage area.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, when initially developed and when updated, signed and dated by the resident's representative, for one of two residents sampled. The deficient practice posed a risk if the resident's representative was unaware of the services to be provided to the resident at the facility. Findings include: 1. A review of R1's medical record revealed a written service plan dated March 28, 2023, for directed care services. However, the service plan was not signed and dated by R1's representative. 2. In an interview, E1 acknowledged R1's service plan was not signed and dated by R1's representative.

Based on observation and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. Findings include: 1. Upon arriving at the facility, the Compliance Officer was greeted by two caregivers, E2 and E3, working at the facility. The Compliance Officer observed the manager was not present at the facility. 2. During a facility tour, the Compliance Officer observed a posting which stated, "Manager's Designee". The designation listed employees, however E2 and E3 were not listed. 3. In an interview, E1 reported E2 and E3 were both newly hired caregivers. E1 acknowledged the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present.

Based on record review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services, for two of three personnel sampled. The deficient practice posed a risk if E2 or E3 were unable to complete their required duties or meet the needs of the residents. Findings include: 1. A review of E2's personnel record revealed no evidence of documentation that E2's skills and knowledge were verified and documented before E2 provided physical health services. 2. A review of E3's personnel record revealed no evidence of documentation that E3's skills and knowledge were verified and documented before E3 provided physical health services. 3. In an interview, E1 acknowledged E2 and E3's personnel records were missing documentation of skills and knowledge, verified and documented, before E2 and E3 provided physical health services.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of three caregivers. The deficient practice posed a risk if the employees were unable to meet resident's needs. Findings include: 1. The Compliance Officer was greeted by E2 and E3 upon arrival to the facility. 2. Review of the facility's policy and procedure revealed a policy titled "Orientation and in-service training" reviewed and signed by E1 March 1, 2023. This policy stated "New employee orientation is required to be completed by all new employees and volunteers 3. Review of E2's personnel record revealed E2 was hired as a caregiver and had a hire date of March 18, 2023. The personnel record revealed no documentation showing E2 had received orientation specific to the duties to be performed. 4. Review of E3's personnel record revealed E3 was hired as an assistant caregiver and had a hire date of March 18, 2023. The personnel record revealed no documentation showing E3 had received orientation specific to the duties to be performed. 5. During an interview, E1 acknowledged documentation was not available showing E2 and E3 had received orientation specific to the duties to be performed.