Sonoran Adult Care, LLC

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 April 1, 2025, for the following medications: Asprin 1 milligram (mg) 1 tablet by mouth (po) daily (qd); Atorvastatin 10 mg, 1 tablet po at bedtime (qhs); Furosemide 40 mg, 1 tablet po qd; Methimyole 10 mg, 2 tablets po qd; Pantoprazole 40 mg, 1 tablet po qhs; Terazain 10 mg,1 tablet po qhs; Docusate 100 mg, 1 tablet po twice a day (bid); and Senna 8.6 mg, three tablets po bid. 2. A review of R2’s medication administration record (MAR) for June 2025 revealed missing documentation of the following medications on June 1, 2025: Asprin 1 mg, 1 tablet by po qd; Atorvastatin 10 mg, 1 tablet po qhs; Furosemide 40 mg, 1 tablet po qd; Methimyole 10 mg, 2 tablets po qd; Pantoprazole 40 mg, 1 tablet po qhs; Terazain 10 mg,1 tablet po qhs; Docusate 100 mg, 1 tablet po bid; and Senna 8.6 mg, three tablets po bid. 3. In an interview, E1 acknowledged medication administered to R2 was not accurately documented in R2’s medical record.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if the employees were unable to meet resident's needs. Findings include: 1. A review of facility policies and procedures revealed a policy and procedure titled "Fall Prevention and Recovery" (dated unavailable). However, the policy did not include a training program to include initial training and continued competency training in fall prevention and fall recovery. 2. A review of E1's personnel record revealed documentation of initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported E1 provided the training. E1 acknowledged E1 did not document E1's initial training in fall prevention and fall recovery. 4. In an interview, E1 acknowledged the policy did not include a training program to include initial training and continued competency training in fall prevention and fall recovery. This is a repeat deficiency from the compliance inspection conducted on May 23, 2022.

Based on documentation review and interview, the manager failed to implement the facility's quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Quality Management". The policy stated "...Frequency for Submitting Report: Report of incidents, investigations and evaluation will be submitted to manager/owner for approval, input, questions, and further evaluation. Manager/owner will file in SS binder... Reports will be maintained for 12 months after the report is submitted to the governing authorities". 2. The Compliance Officers requested to review documentation of the facility's quality management summary report. However, the documentation was not provided for review. 3. In an interview, E1 acknowledged a quality management summary report was not available for review.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date of the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. During a facility tour, the Compliance Officers observed E1 working on the premises. The Compliance Officers observed no other personnel members working on the date of the inspection. 2. A review of facility documentation revealed a calendar for the months of February 2023, March 2023, April 2023, May 2023, and June 2023. 3. A review of the calendars for February 2023 and March 2023 revealed documentation of the caregivers or assistant caregivers who worked each day, including the hours worked by each, was not available for review. 4. A review of the calendar for April 2023 revealed documentation of the caregivers or assistant caregivers who worked each day, including the hours work by each was not available for review for the following dates: -April 3-6, 2023; -April 10-13, 2023; -April 17-20, 2023; and -April 24-27, 2023. 5. A review of the calendar for April 2023 revealed handwritten documentation E2 worked on the following dates: -April 1-2, 2023; -April 7-9, 2023; -April 14-16, 2023; -April 21-23, 2023; and -April 28-30, 2023. However, documentation of the hours worked by E2 was not available for review. 6. A review of the calendar for May 2023 revealed documentation of the caregivers or assistant caregivers who worked each day, including the hours work by each was not available for review for the following dates: -May 1-4, 2023; -May 8-11, 2023; -May 15-18, 2023; -May 22-25, 2023; and -May 29-31, 2023. 7. A review of the calendar for May 2023 revealed handwritten documentation E2 worked on the following dates: -May 5-7, 2023; -May 12-14, 2023; -May 19-21, 2023; and -May 26-28, 2023. However, documentation of the hours worked by E2 was not available for review. 8. A review of the calendar for June 2023 revealed documentation of the caregivers or assistant caregivers who worked each day, including the hours work by each was not available for review for the following dates: -June 1, 2023; -June 9, 2023; and -June 11-30, 2023. 9. A review of the calendar for June 2023 revealed handwritten documentation E1 worked on the following dates: -June 3-8, 2023. However, documentation of the hours worked by E1 was not available for review 10. In an interview, E1 reported E1 was the only one working because there was only one resident. E1 reported E2 only worked as needed. 11. In an interview, E1 reported the calendar was used as the personnel schedule. E1 acknowledged the facility's work schedule did not include documentation of the caregivers or assistant caregivers working each day and the hours w

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services to be provided to the resident, for two of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan for directed care services dated June 3, 2023. However, the service plan did not indicate the amount, type, and frequency of assisted living services to be provided to R1. 2. A review of R2's medical record revealed a service plan for directed care services dated April 1, 2023. However, the service plan did not indicate the amount, type, and frequency of assisted living services to be provided to R2. 3. In an interview, E1 acknowledged the resident's service plans did not include the amount, type, and frequency of assisted living services to be provided to the residents. This is a repeat deficiency from the compliance inspection conducted on May 23, 2022.

Based on record review and interview, the manager failed to ensure a written order verifying the verbal order was obtained from the medical practitioner within 14 calendar days after receiving the verbal order if a verbal order for a resident's medication was received from a medical practitioner by the assisted living facility, for two of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan (dated June 3, 2023) for Directed care services. The service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed a verbal physician's order signed by an RN on March 17, 2022 and included the following medications: - D/C Tylenol 500 mg caps; - Continue Tylenol 500 mg caps; 1 tab PO BID; - D/C megesterol 40 mg, tabs; 1 tab PO QID; - D/C diclofenic 1.3 % Topical; - D/C CBD oil/cream 500 mg - 250mg; - D/C Vitamin D3 - D/C Docusate - D/C cranberry tablets - D/C multivitamin - D/C Digestive advantage daily probiotics However, the document was not signed by a medical practitioner within 14 calendar days after receiving the verbal order. 3. In an interview E1 acknowledged the verbal order identified in R1's medical record was not signed by a medical practioner within 14 days.

Based on observation, documentation review, 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 residents sampled. Findings include: 1. During a tour of the facility conducted on June 27, 2023 the Compliance Officers observed a medication container of "Lovastatin tab 40 MG" labeled for R1. The label stated, "Take 1 tablet by mouth every night at bedtime." 2. A review of the facility's policies and procedures revealed a policy titled "Medication Services"(not dated). The procedure stated "Administration of medication and self-administration/Error Prevention... 1. Check medication with order and MAR for right medication.; 2. Make sure it's the right patient; 3. Make sure it's the right dose. Double check calculations.; 4. Make sure it's right route..." 3. A review of R1's medical record revealed a medication order dated May 3, 2023 signed by a medical practioner for "Lovastatin 40 MG" everyday at bedtime. 4. A review of R1's medication administration record (MAR) for June 2023 revealed documentation of "Lovastatin 50 MG 1 tab, PO QD." 5. In an interview, E2 acknowledged the medication "Lovastatin 50 MG 1 tab" listed on the MAR was administered in compliance with the dosage instructions listed on the medication container and medication order of "Lovastatin 40 MG." E1 reported E1 made an error when E1 transcribed the medication dosage onto R1's MAR.

Based on documentation review and interview, the manager failed to ensure a disaster plan review was documented. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Disaster Planning" (date unavailable). The policy stated " ... Of course there is room for improving these plans and they will be reviewed once a year. The review must be dated and the time will be posted. All employees names helping in the review will also be posted. Plus the recommendations." 2. A review of facility documentation revealed a current disaster plan review was not available for review. 3. In an interview, E1 reported and acknowledged a current disaster plan review was not available for review. This is a repeat deficiency from the compliance inspection conducted on May 23, 2022.