Las Palomas Senior Living

Based on documentation review,record review, and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of three sampled caregivers. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-ii) states: "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution…and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of i. Assessing risks of prior exposure to infectious tuberculosis, [and] ii. Determining if the individual has signs or symptoms of tuberculosis." 2. A review of E6's personnel record revealed E6 had been hired as a caregiver. However, the review revealed no baseline screening consisting of assessing risks of prior exposure to infectious tuberculosis and determining if E6 had signs or symptoms of TB. 3. A review of facility documentation revealed a series of personnel schedules which indicated E6 worked in July and August of 2025. 4. In an interview, when the Compliance Officer asked if E6 had documentation of the aforementioned baseline screening, E1 stated, “No.” This is an uncorrected citation from the complaint and compliance inspection conducted on January 9, 2025; and a repeat citation from the compliance inspection conducted on November 29-30, 2023.

Based on documentation review and interview, the health care institution failed to provide appropriate first aid before the arrival of emergency medical services to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. Findings include: 1. A review of facility documentation revealed an incident report dated July 16, 2025. The report stated: “[R3] slipped out of [R3’s] chair on to [R3’s] stomach hitting [R3’s] left elbow leaving a small skin tear…[Personnel member] cleansed it and radio[ed] for help to get resident back up…[Personnel members] were unable to get [R3] back in [R3’s] chair with 2 caregivers [and] gaitbelt [so] medtech called 911 to help get [R3] back into [R3’s] chair.” 2. In an interview, E1 confirmed 911 was called for a lift assist. When the Compliance Officer informed E1 of this statute, E1 stated, “Makes sense” and acknowledged facility personnel failed to provide appropriate first aid before the arrival of emergency medical services to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for one of five sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(3) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459.” 2. A review of E5's personnel record revealed E5 was hired after January 1, 2025. The review revealed a printout from the Adult Protective Services (A.P.S.) registry dated June 7, 2025. The printout revealed E5 was not on the A.P.S. registry. However, the review revealed facility personnel did not check the A.P.S. registry until after E5’s starting date of employment. 3. In an interview, when the Compliance Officer asked why facility personnel did not check the A.P.S. registry for E5 until after E5 was hired, E1 stated, “I don’t know why.”

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver’s skills and knowledge were verified and documented before the assistant caregiver provided physical health services, for two of two sampled assistant caregivers. The deficient practice posed a risk if an assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Team Member Training/Orientation - Arizona Specific” dated as last revised on August 29, 2023. The P&P stated, “The resident care, Caregiver and Assistant Caregiver team member’s skills and knowledge will be verified and documented.” The P&P continued, “Caregiver and Assistant Caregiver Team Members will be checked off and documented on training, skills and knowledge prior to providing services to residents.” 2. A review of E4’s and E5’s personnel records revealed E4 and E5 were hired as assistant caregivers. However, the review revealed no documentation of E4’s and E5’s verified skills and knowledge. 3. A review of facility documentation revealed a series of personnel schedules which indicated E4 and E5 worked in July and August of 2025. 4. In an interview, E1 reported E1 did not know verifying and documenting an assistant caregiver’s skills and knowledge was required like it was for a caregiver. This is an uncorrected citation from the complaint inspection conducted on June 17, 2025.

Based on documentation review and interview, the manager failed to ensure an assisted living facility had caregivers and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety of a resident. The deficient practice posed a risk if the employees were unable to ensure the health and safety of a resident. Findings include: 1. A review of facility documentation revealed an incident report dated July 16, 2025. The report stated: “[R3] slipped out of [R3’s] chair on to [R3’s] stomach hitting [R3’s] left elbow leaving a small skin tear…[Personnel member] cleansed it and radio[ed] for help to get resident back up…[Personnel members] were unable to get [R3] back in [R3’s] chair with 2 caregivers [and] gaitbelt [so] medtech called 911 to help get [R3] back into [R3’s] chair.” 2. In an interview, E1 confirmed 911 was called for a lift assist. When the Compliance Officer informed E1 of Arizona Revised Statutes (A.R.S.) § 36-420(B)(2), E1 stated, “Makes sense” and acknowledged facility personnel failed to be in compliance with that statute, therefore not meeting the needs and ensuring the health and safety of R3.

Based on documentation review, interview, and record review, the manager failed to maintain a personnel record which included all items required by this rule, for one of five sampled employees. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of facility documentation revealed a series of personnel schedules which indicated E6 worked in July and August of 2025. 2. In an interview, E1 reported E6 no longer worked at the facility. 3. A review of E6’s personnel record revealed no documentation of E6’s ending date of employment. 4. In an interview, E1 reported E1 would have to look at E6’s timecards to determine E6’s ending date of employment. E1 confirmed E6’s personnel record did not include E6’s ending date of employment.

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 to the health and safety of a resident. Findings include: 1. A review of facility documentation revealed an incident report dated July 28, 2025. The report stated: “I acknowledged a bruise under [R3’s] right eye. When I asked [R3] what happened [R3] said that a [personnel member] did it but it was not a big deal. Then I took [R3] to the bathroom and noticed that [R3] had a skin tear on the front of [R3’s] right leg I then proceeded to ask again what happen[ed] and [R3] said the same [personnel member] hit [R3] with a stool.” The review further revealed a report to Adult Protective Services (A.P.S.) dated August 13, 2025, which identified the personnel member as E2. 2. In an interview, E1 reported E1 was made aware of the allegations of abuse on August 13, 2025, and reported it to A.P.S. the same day. E1 reported E1 suspended E2 pending investigation. E1 reported E1 reached out to E2 for comment but E2 gave none. E1 further reported E1 terminated E2’s employment as of the date of the inspection. 3. A review of facility documentation revealed a “CORRECTIVE ACTION FORM” dated August 13, 2025. The form listed the “Reason for Corrective Action” as “Resident Abuse” and stated E2 was “Suspended for allegations of resident abuse” effective August 13, 2025.

Based on the record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for one of the seven caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E6's personnel record revealed no documented verification of E6's skills and knowledge. 2. A review of R1's medical record revealed an incident report dated June 13, 2025, which reflected that E6 was a staff member who witnessed the incident with R1. 3. In an interview, E1 reviewed E6's personnel record and acknowledged that the personnel record did not include documented verification of skills and knowledge at the time of the survey.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 before the individual began providing services, for two of six personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin T est) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of the facility's personnel schedule revealed E2 was scheduled to work and provided services on the following dates: - August 23, 2024, from 2:00 PM - 10:00 PM; - August 27, 2024, from 2:00 PM - 10:00 PM; - August 28, 2024, from 2:00 PM - 10:00 PM; and - August 29, 2024, from 2:00 PM - 10:00 PM. 4. A review of E2's personnel record revealed a TB signs and symptoms screening and risk assessment signed by a registered nurse (RN). However, the screening was signed after E2 began providing services. 5. A review of the facility's personnel schedule revealed E4 was scheduled to work and provided services on the following dates: - November 27, 2024, from 2:00 PM - 10:00 PM; - November 28, 2024, from 2:00 PM - 10:00 PM; - November 29, 2024, from 2:00 PM - 10:00 PM; and - November 30, 2024, from 2:00 PM - 10:00 PM. 6. A review of E4's personnel record revealed two negative TB skin tests. However, the tests were read after E4 began providing services. 7. In an interview, E1 reported the facility was unaware of the new TB policies as specified in R9-10-113. E1 acknowledged E2 and E4 did not provide evidence of freedom from infectious TB as specif

Based on record review and interview, the manager failed to ensure one of nine sampled employees' records contained current medical documentation of freedom from infectious tuberculosis (TB), as specified in R9-10-113; which posed a health and safety risk. Finding Include: 1. Review of the randomly selected sampled personnel records revealed that E6's record contained no medical documentation of a skin test or any other test that determined if the E6 was free from infectious TB at the time of hire nor anytime since. Based on the date of hire this was required. 2. In an interview, E1 and E2 acknowledged there was no documentation of TB screening for E6 as required.

Based on observation, document review, and interview, the manager failed to ensure there were pre-planned snacks posted with the posted pre-planned meal menu. Findings include: 1. During a facility tour, E1, E3, and the Compliance officer observed there were no pre-planned snacks posted on the day menu nor the week at a glance menu. The menu observed was dated November 26-December 2, 2023. 2. In an interview, E1 and E3 acknowledged there were no pre-planned snacks stated on the posted pre-planned menu.

Based on documentation review and interview, the manager failed to ensure there was documentation of the required annual disaster plan review meeting. Findings included: 1. At the beginning of the compliance inspection E2 received a list of the required documents that would be reviewed during this inspection. Later in the compliance inspection, the compliance officer requested and was not provided with the required documentation of the annual disaster plan review. 2. In an interview, E1 reported "we talk about it" however, acknowledged the disaster plan meeting was lacking the required documentation.

Based on documentation reviewed and interview, the manager failed to ensure an employee disaster drill was conducted at least once every three months on each shift and documented which posed a safety risk. Findings include: 1. During an interview, E3 reported the facility had three shifts: First shift from 6:00 AM to 2:00 PM, the second shift from 2:00 PM to 10:00 PM, and the third shift was from 10:00 PM to 6:00 AM. 2. In the past twelve months, the first shift employee disaster drills were not conducted from May 26, 2023 to present date. 3. In the past twelve months, the third shift employee disaster drills were not conducted in 2023 until May 20, 2023. 4. In an interview, E1 acknowledged the required employee disaster drills had not been conducted at least once every three months on the first and third shifts.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of the facility's documentation revealed one evacuation drill, dated November 2, 2023 was conducted during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during this 12-month time period. 2. In an interview, E1 acknowledged an evacuation drill for employees and residents was not conducted at least every six months, as required, during the past 12 months.

Based on observation, documentation review, and interview, the manager failed to ensure that on the day that a resident used the swimming pool, an employee tested the swimming pool's water quality at least once for compliance with chemical disinfection standards. Findings include: 1. During a facility tour, E1 and the compliance officer observed a resident using the facility's outdoor swimming pool. 2. E1 and the compliance officer reviewed the documentation for the testing of the swimming pool water and found the pool water had not been tested as required since June of 2023. 3. In an interview, E1 acknowledged the required documentation for the testing of the swimming pool water had not been done as required.