Hacienda De Luna Assisted Living

Based on record review and interview, the manager failed to ensure a service plan was signed and dated by the resident or the resident's representative when the service plan was initially developed or when updated, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan, dated November 1, 2025, for personal care services. However, the service plan had not been signed by the resident or the resident's representative. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure the service plan, for one of one sampled resident receiving directed care services, included the requirements in R9-10-814(F)(2). R9-10-814(F)(2) states; "In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: Offering sufficient fluids to maintain hydration;" Findings include: 1. A review of R1's medical record revealed a service plan, initiated November 1, 2025, for directed care services. However, the service plan did not include offering sufficient fluids to maintain hydration. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan, dated November 1, 2025, for personal care services including medication administration. 2. A review of R2's medical record revealed a list of medication orders, dated October 3, 2025, which included the order, "Rosuvastatin Calcium 5 MG Oral Tablet, Give 1 tablet by mouth every day. Start 5/12/2025." 3. A review of R2's medical record revealed a Medication Administration Record (MAR) dated November 2025. The MAR indicated Rosuvastatin had not been administered to R2 in November 2025. The MAR indicated the medication was not available and was waiting for doctor's orders. 4. In an interview, E1 reported the medication had run out of refills. E1 reported R2's doctor was contacted, however, R2's doctor stated they were going to consult the original prescriber. E1 acknowledged Rosuvastatin had not been held, discontinued, or refilled and further clarification from R2's doctor was not available for review. E1 reported R2 was prescribed both Atorvastatin and Rosuvastatin and that is why there was a question about continuing the Rosuvastatin. 5. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.