Solterra Senior Living

Based on record review and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to health and safety. Findings include: 1. Review of the R2’s medical record revealed an incident report dated November 11, 2025. This incident report stated, “Resident accidently drove [R2’s] electric wheelchair into the door frame, which caused the controller to move forward unexpectedly. This resulted in the wheelchair accelerating and colliding with [R2’s] dresser and then [R2’s] bed, pinning [R2’s] left foot between the bed and wheelchair. Resident was assisted and the wheelchair was powered off assessment completed: bruising swelling, redness, pain level- 8, unable to bear weight. Vital signs obtained. Ice applied/ elevated as appropriate. Resident instructed to report any increased pain of changes. Provider hospice per protocol. Will continue to monitor.” 2. Review of R2’s medical record revealed a document titled, “Progress Note” which stated the following: - “11/12/25 - Resident is bedridden right now from [R2’s] leg injury. [R2] needs to be fed meals and changed every 2 hours.” - “11/13/25 - … Resident just wanted jello and lemonade for lunch and [R2] refused breakfast due to not wanting to move. Resident needs help with drinking water and food.” - “11/14/25 - Resident was feeling unwell this morning [R2] was very confused with where [R2] was, [R2] was also very scared about why [R2] can’t move. Resident was reassured that is safe is in Solterra senior living. Resident did eat breakfast but small portions. Water was being given every 30 minutes through morning shift. Resident family has requested [R2] and encourage [R2] to go to the hospital for x ray for [R2’s] legs. Resident has left to the hospital to chandler regional at 12:45 pm.” - “12/09/2025 - Talked to staff at Tempe Post Acute. They mentioned this resident is unable to stand and using a hoyer lift. I (E1) told them that is out of our scope.” 3. In an interview, E1 reported R2’s hospice provider was called and the facility was given instructions on what to do. E1 reported that after R2’s visit to the hospital R2 was admitted into rehab. E1 reported R2 required a hoyer lift and that R2 is now out of the facility’s scope of services and will not be able to return to the facility. E1 acknowledged R2 was in pain before being sent to the hospital. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to immediately report suspected exploitation according to A.R.S. § 46-454. The deficient practice posed a risk as a peace officer or the adult protective services (APS) central intake was unable to assess if there was an immediate health and safety concern for the resident and other residents residing in the assisted living facility. Findings include: 1. A.R.S. § 46-454(A) stated "A. A health professional, emergency medical technician, home health provider, hospital intern or resident, speech, physical or occupational therapist, long-term care provider, social worker, peace officer, medical examiner, guardian, conservator, fire protection personnel, developmental disabilities provider, employee of the department of economic security or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit. The guardian or conservator of a vulnerable adult shall immediately report or cause reports to be made of such reasonable basis to the superior court and the adult protective services central intake unit. All of the above reports shall be made immediately by telephone or online..." 2. R9-10-101.111 stated "Immediate" means without delay. 3. Review of E1’s text messages showed R3’s family member contacted E1 on November 26, 2025 at 3:49 pm which stated, “Call me, one of your employees stole my [R3’s] credit card and went to town. There’s an active investigation.” 4. Review of the facility’s email, provided by E1, revealed an email with the sent date November 27, 2025 at 11:12 AM, which stated, “Thank you for contacting Adult protective services on 11/27/2025”. 5. In an interview, E1 acknowledged R3’s family member contacted E1 on November 26, 2025 and APS was contacted on November 27, 2025. 6. 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 a written service plan included documentation of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for three of the three residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. Review of R1’s current service plan dated October 2025 did not include a list of R1's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. Review of R2’s current service plan dated October 2025 did not include a list of R2’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 3. Review of R3’s current service plan dated October 2025 did not include a list of R3's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 4. In an interview, E1 acknowledged the current service plans provided did not include a list of R1’s, R2’s, and R3’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 5. 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 a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of three sampled residents. The deficient practice posed a health and safety risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R2’s current service plan dated, October 2025 revealed the following services were provided to R2: - “Level of Assistance- Bathing: Total Resident is dependent on others to provide bath, including shampoo” - “Level of Assistance- Grooming/ Personal Hygiene: Total Resident is dependent on others to provide all grooming/ personal hygiene needs/ 1 time(s) per day, everyday. - “Level of Assistance- Dressing: Total Resident is dependent upon others to do all dressing/ undressing/ 2 times(s) per day, everyday.” - “Level of Assistance- Toileting: Total Resident requires physical assistance with all tasks related to toileting. May require assistance with closed drainage system/ catheter. / 2 time(s) per day, every day.” 2. Review of R2’s activities of daily living (ADL) for the month of November 2025 revealed the following services were marked with “INF” for the entire month of November: - Bathing - Grooming/ Personal Hygiene - Dressing - Toileting It is unclear if a caregiver has completed this service. 3. Review of R3’s current service plan dated October 2025 revealed the following services were provided to R3: - “Monitor resident for desires to leave community/ 3 time(s) per day, every day. 4. Review of R3’s ADL revealed for the month of November 2025 revealed the following services were marked with “INF”. - “Monitor resident for desires to leave community” is marked “INF” from 18th to the 30th. It is unclear if a caregiver has completed this service. 5. In an interview, E1 reported that “INF” means Info only. E1 also reported its a glitch in the system not allowing the caregivers to chart the services that were completed. 6. 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 that a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2’s medical record revealed a medication order dated April 16, 2025, for Midodrine HCl 2.5 milligrams (mg), 1 tablet by mouth (po) twice a day (bid) if systolic blood pressure (SBP) is less than 105 millimeters of mercury (mmHg). 2. A review of R2’s medication administration record (MAR) for June 2025 and July 2025 revealed R2 was administered Midodrine HCl 2.5 mg, 1 tablet po on the following dates and times: June 24, 2025, at 8:00 AM; June 26, 2025, at 8:00 AM; June 29, 2025, at 8:00 AM and 6:00 PM; June 30, 2025, at 6:00 PM; July 6, 2025, - July 8, 2025, at 8:00 AM; July 9, 2025, at 6:00 PM; July 12, 2025, at 8:00 AM; July 14, 2025, at 6:00 PM; July 15, 2025, at 8:00 AM; July 19, 2025, at 8:00 AM; and July 20, 2025 - July 22, 2025 at 8:00 AM and 6:00 PM. 3. A review of R2's medical record revealed the following SBP readings: 156 / 63 mmHg on June 24, 2025, at 8:00 AM; 172 / 84 mmHg on June 26, 2025, at 8:00 AM; 167 / 70 mmHg on June 29, 2025, at 8:00 AM; 209 / 85 mmHg on June 29, 2025, at 6:00 PM; 144 / 82 mmHg on June 30, 2025, at 6:00 PM; No SBP reading was documented on July 6, 2025, at 8:00 AM; 193 / 69 mmHg on July 7, 2025, at 8:00 AM; 112 / 82 mmHg on July 8, 2025, at 8:00 AM; 165 / 61 mmHg on July 9, 2025, at 6:00 PM; 192 / 66 mmHg on July 12, 2025, at 8:00 AM; 165 / 79 mmHg on July 14, 2025, at 6:00 PM; 186 / 95 mmHg on July 15, 2025, at 8:00 AM; 195/80 mmHg on July 19, 2025, at 8:00 AM; 153 / 66 mmHg on July 20, 2025, at 8:00 AM; 180 / 66 mmHg on July 20, 2025, at 6:00 PM; 139 / 69 mmHg on July 21, 2025, at 8:00 AM; 150 / 86 mmHg on July 21, 2025, at 6:00 PM; 149 / 75 mmHg on July 22, 2025, at 8:00 AM; and 159 / 76 mmHg on July 22, 2025, at 6:00 PM. However, the aforementioned SBP readings did not indicate the administration of Midodrine HCl 2.5 mg to R2. 4. In an interview, the finding was reviewed with E1 and E2, and no additional information was provided.

Based on observation and interview, the manager failed to ensure heating and cooling systems maintained the assisted living facility at a temperature between 70°F and 84°F at all times, unless individually controlled by a resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a thermostat on the wall in the dining room area. The thermostat read 90°F. 2. In an interview, O1 acknowledged the facility's temperature was not maintained between 70°F and 84°F at all times.