Assisted Living at Mountain Vista

Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver documented the services provided in the resident’s medical record, for two of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated December 28, 2025. After further review, it was revealed that R1 received the following services: A complete shower, three per week; and Shaving, three times per week. 2. A review of R1's medical record revealed documentation of activities of daily living for R1. After further review, it was revealed R1 had shower and shaving services completed on March 2, 2026, and March 5, 2026. However, additional documentation of shower and shaving services was not available for review. 3. A review of R2's medical record revealed a service plan dated December 28, 2025. After further review, it was revealed that R2 received the following service: Shaving, three times per week. 4. A review of R2's medical record revealed documentation of activities of daily living for R2. After further review, it was revealed R2 had shaving services completed on March 1, 2026, and March 4, 2026. However, additional documentation of shaving services was not available for review. 5. A review of the facility’s policies and procedures revealed a policy titled "Resident Records/Medical Records”. The policy stated, “Care or services to residents are to be documented as they are provided as much as possible.” 6. In an interview, E1 and E2 reported that all services were provided to R1 and R2. 7. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as the Department was provided false and misleading information. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Medication”. The policy stated, “I. Medication administration is documented after the resident has actually taken the medication." 2. A review of R1's medical record revealed a current medication order dated May 22, 2025, for the following medications: Brimonidine .15%, 1 drop in both eyes, three times daily (tid); Divalproex 250 milligram (mg), 1 tablet by mouth (po), two times daily (bid); Lactulose Sol 15 milliliters (mL), po, 45mL daily (qd); Levetiracetam 500 mg, 1 tablet po, bid; Quetiapine 300 mg, 1 tablet po, every night (qhs); Amlodipine 2.5 mg, 1 tablet po, qhs; Acamprosate 333 mg, 2 tablets po, tid; Mirtazapine 7.5 mg, 1 tablet po, qhs; and Latanoprost .005%, 1 drop in both eyes, tid. 3. A review of R2's medication administration record (MAR) for March 2026 was conducted at 1:04pm. The MAR revealed the following medications were documented as administered on the date of the inspection: Brimonidine .15%, 1 drop in both eyes, three times daily (tid), documented as administered on March 12, 2026, at 10:00 pm; Divalproex 250 milligram (mg), 1 tablet by mouth (po), two times daily (bid), documented as administered on March 12, 2026, at 7:00 pm; Lactulose Sol 15 milliliters (mL), po, 45mL daily (qd), documented as administered on March 12, 2026, at 7:00 pm; and Levetiracetam 500 mg, 1 tablet po, bid, documented as administered on March 12, 2026, at 7:00 pm. 4. A review of R2's medication administration record (MAR) for March 2026 revealed the following medications were not documented on MAR: Quetiapine 300 mg, 1 tablet po, every night (qhs), documented as administered on March 10, 2026, at 7:00 pm. However, documentation for March 11, 2026, was not available for review. Amlodipine 2.5 mg, 1 tablet po, qhs, documented as administered on March 10, 2026, at 7:00 pm. However, documentation for March 11, 2026, was not available for review. Acamprosate 333 mg, 2 tablets po, tid, documented as administered on March 11, 2026, at 8:00 am. However, documentation for March 11, 2026, at 12 pm and 7 pm was not available for review. Mirtazapine 7.5 mg, 1 tablet po, qhs, documented as administered on March 10, 2026, at 7:00 pm. However, documentation for March 11, 2026, was not available for review. Latanoprost .005%, 1 drop in both eyes, tid, documented as administered on March 10, 2026, at 7:00 pm. However, documentation for March 11, 2026, was not available for review. 5. In an interview, E2 reported the medication was administered every day, but forgot to add it to the MAR. 6. In an exit interview, the findings were discussed with E1 and E2, a

Based on observation, record review, and documentation review, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were 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 Dawn dish soap, Lysol Toilet Cleaner, and dishwasher detergent pods in a kitchen cabinet under the sink. The cabinet did not have a lock. 2. A review of R1’s medical records revealed a service plan dated December 28, 2025. After further review, it was revealed that R1 was ambulatory. 3. A review of R1’s medical records revealed a service plan dated December 28, 2025. After further review, it was revealed that R2 was ambulatory. 4. A review of the facility’s policies and procedures revealed a policy titled "Environmental Safety”. The policy stated, “Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas…” 5. In an exit interview, the findings were discussed with E1 and E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver provided assistance with activities of daily living according to the resident's service plan, for one of two current residents sampled. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(5) states "Activities of daily living" means "ambulating, bathing, toileting, grooming, eating, and getting in or out of a bed or a chair." 2. A review of R2's medical record revealed a service plan dated in June 2023 for personal care services. The service plan stated "Assistance required: Full assist of 1 caregiver...Oral care: 2x/day...brush teeth...upper denture." 3. A review of R2's medical record revealed an activities of daily living (ADL) document dated July 2023. The document stated "Brush teeth". The document include a line through the dates of July 1-17, 2023, indicating the service was not provided. 4. In an interview, E2 reported the line indicated R2 is independent for the activity and does not require assistance brushing R2's teeth. E2 acknowledged the service was not provided as specified in R2's service plan.