Paradise Cove

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of two personnel members sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population. Findings include: 1. A review of E3's personnel record revealed E3 was hired on March 25, 2024 as a caregiver. The record included a photocopy of a valid fingerprint clearance card, which was issued on November 30, 2021. Further review of the record revealed an employment application which identified three previous employers with dates of employment as noted, Employer 1, April 2023 to present, Employer 2, November 2019 to April 2022, and Employer 3, March 2019 to November 2019. However evidence of documentation indicating E3 submitted a new set of fingerprints and a new application for fingerprint clearance card to the Arizona Department of Public Safety was not available for review. Further, evidence of documentation of good faith efforts to contact prior employers to obtain information or recommendations relevant to E3's fitness to work in a health care institution were not available for review. 2. In an interview, E1 acknowledged E3's employment history contained a six month gap in employment history after the issue date of E3's fingerprint clearance card. E1 also agreed E3's personnel record did not contain evidence of good faith efforts to contact all prior employers.

Based on record review and interview, the manager failed to ensure medication administered to a resident is administered in compliance with a medication order for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan which indicated R1 received directed care services and administration of medication. The medical record contained a doctor's order, dated July 8, 2024, directing R1 take "Metformin HCL F/C 500MG, Take 1 tab by mouth 2 times a day for DM Type 2." 2. A review of R1's Medication Administration Record (MAR) for August 2024 revealed a section for documenting the administration of "Metformin HCL F/C 500MG, 8:00 AM, 8:00 PM." The record reflected Metformin was not administered to R1 on August 27, 28, 29, 30 or 31, 2024. 3. A review of R2's medical record revealed a service plan which indicated R2 received directed care services and administration of medication. The medical record contained a doctor's order, dated July 29, 2024, directing R2 take "Latanoprost 0.005%, instill 1 drop in each eye everyday at bedtime for Glaucoma." 4. A review of R2's MAR for September 2024 revealed a section for documenting the administration of "Latanoprost 0.005%, 8:00 PM." However, the record indicated R2 was not administered the medication from September 1 through September 28, 2024. 5. In an interview E2 advised the medication had been discontinued by R2's medical provider. Upon further review of R2's medical record, evidence of documentation of either a verbal or written order to discontinue administration of Latanoprost was unavailable for review. 6. In an interview, E1 acknowledged R1 and R2 were not being administered their medication as ordered.