Cedar Care at Lagos Vistoso

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R2's medical record revealed a signed medication list, dated November 15, 2025, which included the following medications: Glipizide 10 milligrams (mg), 1 tablet by mouth (po) twice a day (bid); and Metformin 1000 mg, 1 tablet po bid. 2. A review of R2's medication administration record (MAR) for January 2026 revealed R2 was administered Glipizide 10 mg, 1 tablet po at 8:00 AM, January 1, 2026 - present. 3. A review of R2's MAR for January 2026 revealed R2 was administered Metformin 1000 mg, 1 tablet po at 8:00 AM, January 1, 2026 - present. 4. The Compliance Officers observed Glipizide 10 mg, 1 tablet prefilled in R2's medication organizer in the 8:00 AM and 8:00 PM slots. However, the MAR documentation did not indicate administration at 8:00 PM, as ordered. 5. The Compliance Officers observed Metformin 1000 mg, 1 tablet prefilled in R2's medication organizer in the 8:00 AM and 8:00 PM slots. However, the MAR documentation did not indicate administration at 8:00 PM, as ordered. 6. In an interview, E1 reported that the MAR documentation was an error in transcription rather than administration. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of Department documentation revealed O1 was the assisted living manager as of March 30, 2023. 2. The Compliance Officer observed E1's license, issued by the Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), posted on the premises and was issued on April 12, 2023. 3. In an interview, E1 acknowledged the governing authority did not notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager.

Based on documentation review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for one of four residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's (admitted in April 2023) medical record revealed a service plan was not available for review. 2. A review of R2's (admitted in April 2023) medical record revealed a service plan was not available for review. 3. A review of R3's (admitted in April 2023) medical record revealed a service plan was not available for review. 4. In an interview, E1 reported R1's, R2's, and R3's service plans were not completed. 5. In an interview, E1 acknowledged a written service plan for R1, R2, and R3 was not completed within 14 calendar days after acceptance.