La Sonora at Dove Mountain

Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order. Findings include: 1. A review of R2’s medical record revealed a medication order for “Amlodipine Besylate 5 MG TAB Take 1 tablet by mouth daily, check Bp q day, and hold if SBP < 115.” Further review revealed a medication administration record (MAR) for documenting the administration of medications during September 2025, including “Amlodipine Besylate 5 MG TAB Take 1 tablet by mouth daily, check Bp Daily, and hold if Sbp Less Than 115.” The record reflected R2 refused administration of Amlodipine every day, from September 2 through September 19, 2025. In addition, R2’s medical record contained an order to discontinue Amlodipine, which was dated September 19, 2025. 2. A review of facility documentation revealed a written request from E2 to R2’s primary care provider, dated September 15, 2025. The request was for an order to discontinue R2’s Amlodipine due to R2’s refusal to take the medication. 3. In an interview, E2 advised efforts were not made to contact R2’s primary care provider regarding R2’s refusal to take Amlodipine as ordered until September 15, 2025. E2 acknowledged Amlodipine had not been administered to R2 as ordered for eighteen days before the facility received an order from R2’s primary care provider to discontinue administration of Amlodipine. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure an employee provided documentation 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 R9-10-113, for two of nine employees sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E4’s personnel record revealed evidence of documentation of baseline assessment of risk of exposure to active TB; however, the risk assessment was not signed by a registered nurse, medical provider, or local health authority. Further review revealed evidence of a baseline assessment of E4’s signs and symptoms of active TB was unavailable for review. 2. A review of E5’s personnel record revealed evidence of documentation of a two-step skin test for TB. The documentation indicated the second step skin test was initiated on May 19, 2025, but the reading was conducted on June 13, 2025, more than 72 hours after the test was initiated. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. E1 agreed E4’s personnel record did not contain evidence of baseline screening, and E5’s second step skin test was not evaluated within between 48 and 72 hours after being initiated. E1 acknowledged E4 and E5 did not provide appropriate documentation of freedom from infectious TB, as specified in R9-10-113, on or before the date E4 or E5 began providing services at or on behalf of the assisted living facility.

Based on record review and interview, for four of seven residents sampled, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident’s date of occupancy. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(A)(2)(a)(i-ii) states: “a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, baseline 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 [TB], ii. Determining if the individual has signs or symptoms of [TB].” 2. A review of R6’s medical record revealed evidence of documentation of a negative TB skin test. However, evidence of baseline screening for signs, symptoms, and risk of exposure to TB was unavailable for review. 3. A review of R3’s, R4’s, and R7’s medical records revealed evidence of baseline screening for signs, symptoms, and risk of exposure to TB. However, evidence of documentation of a negative skin or blood test for TB was unavailable for review. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. In an interview, E1 advised R3, R4, R6 and R7 had all been accepted into the facility by the facility's former manager, and before E1's date of hire. E1 acknowledged R3, R4, R6, and R7 had not provided evidence of freedom from infectious TB as specified in R9-10-113, before or within seven calendar days of their respective dates of occupancy.

Based on documentation review and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a risk as it violated a resident's rights. Findings include: 1. A review of E5’s personnel record revealed a document titled “Disciplinary Action Record.” The document included a section titled “Detailed Description:” which alleged a resident reported a caregiver had “pushed,” “slapped,” and “grabbed both…arms” of the resident. The report also indicated the resident had a bruise on their right lower arm, above the wrist. In addition, the document included a section titled “Employee Statement” to document the employee’s response to any allegation. The section indicated E5 “put my arm as weight on [the resident’s] wrist,” because the resident was not allowing E5 to clean the resident. 2. In an interview, E2 advised R4 had told a caregiver on September 18, 2025, that E5 had beaten R4 while bathing R4 on September 16, 2025. E2 stated the caregiver had been determined to be E5. According to E2, E5 had verbally admitted to grabbing R4’s wrist, and E4 had written the statement noted in the Employment Statement of the Disciplinary Action Report, admitting E5 had used their arm as a weight to restrain R4, who was resisting care. E2 advised E5 was placed on suspension, pending E1’s investigation into the allegation. 3. In an interview, E1 advised E4’s employment was terminated, in part, based on E4’s admission of restraining R4. E1 acknowledged R4 had been subject to restraint by E5’s own admission.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed a caregiver work area that was open and unoccupied. The Compliance Officer freely entered the work area and observed multiple cabinets, each affixed with locking mechanisms which required a key to secure and open. Several of the cabinets were left unsecured, and the Compliance Officer was able to open them with little effort. Inside one of the cabinets, the Compliance Officer observed a can of “Raid Ant Killer” and a clear plastic bottle containing a blue liquid. The bottle and liquid were reminiscent of mouthwash; however, when removed from the cabinet, the Compliance Officer discovered the bottle was labeled “Mr. Clean Multi-Surface Cleaner.” Each of the containers was marked “CAUTION KEEP OUT OF REACH OF CHILDREN.” Upon discovery, E1 had all of the cabinets in the work area secured by a caregiver who was passing by, and had a key. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided. E1 acknowledged the poisonous or toxic materials were not kept in a secure area, inaccessible to residents.

Based on documentation review and interview, after having a reasonable basis to believe abuse, neglect, or exploitation of a resident had occurred, the manager failed to immediately report the incident according to A.R.S. § 46-454. The deficient practice posed a potential safety risk for residents and a potential rights violation due to a delay in reporting alleged abuse, neglect, or exploitation. Findings include: 1. A review of facility documentation revealed an incident report, dated July 16, 2025, at “11:28 PM” which documented an incident of alleged physical abuse and resident rights violation involving E6 and R1. The report indicated R1 had “repeatedly told [E6] that [E6] was hurting [R1]. The report also indicated R1 felt E6 was trying “…to make [R1] feel ashamed of being incontinent.” 2. A review of facility documentation revealed an investigative report, mostly compliant with R9-10-803(J)(1-6). The documentation included a report to Adult Protective Services (APS); however, the report to APS included documentation which indicated the report was not made until “July 17, 2025,” at “3:54 PM.” 3. In an interview, E1 acknowledged the report to APS was not made immediately as required per R9-10-803(J)(2), according to A.R.S. § 46-454. This is a repeat citation from a complaint investigation conducted on February 27, 2025.

Based on documentation review, 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 eight caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of facility policy and procedures, last reviewed October 1, 2024, revealed a policy titled “Employee Training & In-Service.” The policy read, in part, “The community will ensure that caregivers are able to demonstrate competency in skills and techniques necessary to care for residents’ needs…” 2. A review of staff schedules for July 2025 revealed E4 worked numerous shifts throughout the month. 3. A review of E4’s personnel record revealed E4 was hired as a caregiver. Further review revealed evidence E4’s skills and knowledge were verified and documented before E4 provided physical health services were unavailable for review. 4. In an interview, E1 acknowledged evidence of documentation of verification of E4’s skills and knowledge was unavailable for review. This is a repeat citation from a complaint investigation conducted on February 7, 2025.

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 of injury and violated a resident's rights. Findings include: 1. A review of facility documentation revealed an incident report, dated July 16, 2025, at “11:28 PM” which documented an incident of alleged physical abuse and resident rights violation involving E6 and R1. The report indicated R1 had “repeatedly told [E6] that [E6] was hurting [R1]. The report also indicated R1 felt E6 was trying “…to make [R1] feel ashamed of being incontinent.” 2. A review of facility documentation revealed an investigative report, which included a report to Adult Protective Services (APS). The investigative report included an untitled and unsigned document, dated July 16, 2025, which indicated the facility Health and Wellness Director notified the Executive Director of the incident at 9:09 AM on July 16, 2025. The report included a typed and signed statement from R1, dated July 16, 2025. which indicated R1 felt E6 was cleaning R1 “…really rough…”, was “hurting” R1 and E6 continued treating R1 this way after R1 “…told [E6] to stop…” The statement also indicated R1 felt E6 was punishing R1 for being incontinent. 3. A review of the facility report to APS revealed the report regarding the incident involving E6 and R1 was not made until July 17, 2025, at 3:54 PM. 4. In an interview, E1 acknowledged E6 had not treated R1 with dignity, respect, or consideration. E1 also acknowledged the mandatory report was not made immediately, but rather more than 24 hours after the executive director was made aware. This is a repeat citation from a complaint investigation conducted on February 27, 2025.

Based on document review and interview, the manager failed to ensure policies and procedures were established and implemented to protect the health and safety of a resident, which covered how a caregiver will respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual The deficient practice posed a potential risk to the health and safety of residents. Findings include: 1. A review of facility policies and procedures, last reviewed June 20, 2024, revealed a policy titled “2.H. Emergency Response.” The policy stated, in part, “1. Medical Emergencies – Call 911. 2. Psychiatric Emergency - Call 911; and to the extent possible, keep the resident experiencing the emergency, and other residents and staff safe by: a. One on one monitoring of the resident experiencing the psychiatric emergency by: Moving the resident to a familiar, quiet place if they are willing to do so. C. Remove/relocate other residents to a point distant from the resident experiencing the psychiatric emergency such as to their own apartment, the dining room etc. …4. Criminal Situation – To the extent possible, ensure safety of residents and staff, Call 911.” 2. The Compliance Officer requested a more specific policy pertaining to how a caregiver will respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. However, evidence of documentation of another policy was unavailable for review. 3. A review of facility “Charting Notes,” pertaining to R1 and entered between June 5, 2024, and January 7, 2025, revealed the following entries on the dates noted: -June 20, 2024, “[R1] attempted to touch another resident inappropriately in the elevator. Writer redirected resident and separated them from other resident;” - June 25, 2024, “After multiple reports of inappropriate conduct, ED spoke with resident who acknowledged [R1's] behavior and states [R1] will stop making suggestive comments and touching residents and staff. Additionally, ED discussed [R1’s] desire to pleasure [R1's self] while being showered and [R1] states this will also cease. POA aware;” -July 10, 2024, “[Employee] reported [R1] grabbed [employee's] bottom while [employee] was in the hallway. [R1] was immediately told it was inappropriate and to not do that in the future. [R1] did it a second time about 30 minutes later. ED notified. [ED] stated it was reported the previous evening by [another employee] that [R1] tried to grab [another employee's] chest. IR was completed and POA was informed. [POA] will have a discussion with [R1] again, as will ED, PCP also notified;” -July 13, 2024 “ALERT CHARTING: [R1] placed on Alert Charting after a phone call from MT reporting [R1] expressed inappropriate sexual behaviors to another resident. [R1] said [R1] was ‘going to go to [other resident’s] room to sleep with [other resident] and if [other resident] didn’t want it, [R1] would be taking it or or (sic) doing it

Based on document review, record review and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the report made to a peace officer or to the adult protective services central intake unit. The deficient practice posed a potential safety risk for residents and a potential rights violation if alleged abuse, neglect, or exploitation was not documented as required. Findings include: 1. A review of a facility incident report dated February 23, 2025 revealed an incident of "inappropriate touching" of R2 by R1. The incident report reflected R2 was in the hallway and R1 was walking back to R1's apartment when R1 touched R2 on [R2's] buttocks and groin area. The report indicated the incident occurred at approximately 4:20 p.m., was not "immediately reported to local law enforcement," and the incident was not "a result of abuse or neglect." 2. A review of R2's medical record revealed a progress note, entered on February 23, 2025, at 9:10 p.m., which read, "Resident reported that [R2] was inappropriately touched by another resident and may feel the need for increased safety reassurance. A second entry on February 24, 2025, at 6:04 p.m., read, "resident was upset when [R2] found out [R2] lives a couple of doors down from [R1] it made resident upset to the point that [R2] wanted to call the police and [R2's sibling] did go try to talk to [E1] before [E1] left for the day resident did seem to calm down but was still upset about the situation." 3. In an interview, E1 reported being advised of the incident between R1 and R2 on February 23, 2025 at approximately 8:00 p.m. E1 advised E1 reported the incident to Adult Protective Services (APS) and conducted an investigation into the matter. E1 stated they spoke with R1, R2, R3, and R1's representative, and other witnesses regarding the incident; however, E1 did not document those actions or interviews. E1 said R1's representative was given a verbal notice of termination of residency without notice, on February 24, 2025, and R1 was placed on observation every two hours. 4. A review of R2's medical record revealed progress notes entered on February 24, 2025, at "6:04 PM," which read, "resident was upset when [R2] found out [R2] lives a couple of doors down from [R1] it made [R2] upset to the point that [R2] wanted to call police and [R2's] sister [R2] did try to talk to [E1] before [E1] left for the day resident did seem to calm down but was still upset about the situation." 5. A request was made to review the documented report E1 had made to APS, which E1 produced. The documentation indicated the report was made to APS on February 24, 2025, at "9:01 PM." 6. In an interview, E1 advised that R1 had been placed on hourly checks after the incident. E1 advised R1 was also made to dine in R1's residential unit to prevent further interaction with [opposite sex] residents. E1 indicated R1's p

Based on record review, document review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a resident rights violation if the resident was subjected to abuse. Findings include: 1. A review of R1’s medical record revealed a document titled “Physician’s Report,” dated May 10, 2024, which indicated R1 was experiencing “Mild Cognitive Impairment.” The document also indicated R1 required “Personal care services,” rather than Directed care services. Further, the document contained a section for documenting R1’s “Mental Condition.” The section reflected R1 was “Able to follow Instructions,” and “Able to Communicate Needs.” In addition, the section indicated R1 was not, “Confused/Disoriented,” and did not display “Inappropriate Behavior.” Further review of R1’s medical record revealed a document titled “Interim Service Plan,” dated May 15, 2024. The document identified a “Concern/Need” for R1 of “Inapprop Behavior.” The document, created and signed by E6, listed interventions as “Resident can get ‘handsy’ and touch other residents & staff; Redirect him – discourage behavior; Place @ meal table w/ [same sex] residents only,” and Monitor that [R1] doesn’t go into [opposite sex] resident’s rooms (has asked for one’s room #).” 2. A review of R1’s service plan, dated May 27, 2024, revealed R1 received personal care services. The plan included a section titled “Dining,” which contained a note reading, “[R1] will dine with other [same sex] residents to limit opportunities for inappropriate touching.” The plan included another section titled “Redirection,” which stated, “…[R1] will be redirected for inappropriate touching of staff and other residents by using gentle reminders to not touch others. [R1] will dine with [same sex] residents to limit opportunities.” 3. A review of facility “Charting Notes,” pertaining to R1 and entered between June 5, 2024 and January 7, 2025 revealed the following entries on the dates noted: -June 20, 2024, “[R1] attempted to touch another resident inappropriately in the elevator. Writer redirected resident and separated them from other resident;” - June 25, 2024, “After multiple reports of inappropriate conduct, ED spoke with resident who acknowledge [their] behavior and states [they] will stop making suggestive comments and touching residents and staff. Additionally, ED discussed [R1’s] desire to pleasure [R1's self] while being showered and [R1] states this will also cease. POA aware;” -July 10, 2024, “[Staff member] reported [R1] grabbed [staff member's] bottom while [staff member] was in the hallway. [R1] was immediately told it was inappropriate and to not do that in the future. Resident did it a second time about 30 minutes later. ED notified. [ED] stated it was reported the previous evening by a [staff member] that [R1] tried to grab [staff member's] chest. IR was completed and POA was informed. [POA] will have a discussion with [R1] agai