Las Palmas Assisted Living 2, LLC

Based on record review, documentation review, and interview, the manager failed to ensure that a personnel record for each employee included documentation of compliance with the requirements in A.R.S. § 36-411(C). The deficient practice posed a risk if E3 was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411.C states: "C. Owners 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. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 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. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A review of E3's personnel record revealed an APS Central Registry check was not available for review. 3. An online check by the Compliance Officer on August 12, 2025, of the Arizona Department of Public Safety (DPS) web portal at https://psp.azdps.gov/services/cardStatusRequest revealed that E3 was not on the APS Central registry. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a caregiver received orientation that was specific to the duties to be performed by the caregiver before they provided assisted living services to a resident for one of the three personnel records reviewed. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E3's personnel record revealed there was no documented orientation prior to E3 providing services to the residents. 2. A review of the facility's staff schedule revealed E3 was listed to work three days per week in July 2025 and August 2025. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted August 25, 2022.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance for one of three resident records reviewed. The deficient practice posed a risk as there was no completed service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed an initial service plan for personal care level services, with the following information: - Facility nurse signed and dated the document on April 4, 2025; - Facility manager signed and dated April 4, 2025; and - Resident/Resident’s Representative, April 30, 2025. Based on R1's date of acceptance, the service plan was not completed within 14 calendar days of R1's date of acceptance. 2. In an interview, E1 acknowledged the service plan was not completed within 14 calendar days of the resident’s date of acceptance.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of three resident records reviewed. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed a Medication Administration Record (MAR) dated July 2025. 2. A review of R1's MAR revealed R1 was being administered “NYSTATIN 100,000 U/GM POW APPLY 1 GM TOPICALLY TO GROIN TWICE DAILY”. The MAR revealed the powder was applied twice per day. 3. A review of R1's medical record revealed no order for the Nystatin. 4. A review of R2's medical record revealed a MAR dated July 2025. 5. A review of R2's MAR revealed R2 was being administered “LOSARTAN POTASSIUM Tab(s) 25 MG (COZAR) TAKE 1 TABLETBY MOUTH DAILY”. The MAR revealed the medication was administered one time per day. 6. A review of R2's medical record revealed no order for the Losartan Potassium. 7. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the compliance and complaint inspection conducted August 31, 2023.

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked self-contained unit used only for medication storage. The deficient practice posed a health and safety risk, if medications were accessible to residents. Findings include: 1. During a facility inspection, the Compliance Officer observed a refrigerator in the dining room. The refrigerator contained a silver box with a lock which required a key. The box was unlocked and contained three Lantus insulin prefilled pens, a box of Tresiba FlexTouch insulin prefilled pens, and a box of Fiasp FlexTouch prefilled insulin pens. 2. In an interview E1 acknowledged the medication was in a self-contained unit,; however, it was not locked and was accessible to residents and others. E2 immediately locked the medication box.

Based on observation and interview, the manager failed to ensure that equipment used at the assisted living facility was maintained in working order. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed a common bathroom near the laundry room, which had a vent fan that did not work. E1 reported E1 would have it repaired. 2. The Compliance Officers observed a smoke detector in a resident room, which was covered with tape. The Compliance Officers observed the ceiling had recently been painted. 3. During a tour of the facility, the Compliance Officer observed a sliding glass door leading to the backyard. When the Compliance Officer attempted to open the door, it would not open. E2 was able to open the door; however, it was very hard to open. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a signed list of medications dated May, 1, 2023. The medication list included "Bisacodyl 5MG PO 1Cap BID". 2. A review of R2's medical record revealed a Medication Administration Record (MAR) dated July 2023. The MAR indicated Bisacodyl 5 MG" was being administered "PRN". 3. In an interview, E1 acknowledged medication had not been administered to R2 in compliance with the medication orders. E1 reported R2's guardian wanted the medication administered PRN due to the possibility of accidents when off-site or in transport. E1 acknowledged an order for the medication to be administered as needed should have been obtained.