Sonoran Hills Assisted Living

Based on record review and interview, the manager failed to ensure one of two sampled resident's medication was administered in compliance with a medication order. Findings include: 1. A review of R1's medical record revealed a medication order dated January 5, 2024 for Morphine sulfate 15 mg one tablet every eight hours, and a medication order dated December 26, 2023 for Morphine 30mg one tablet every eight hours. 2. A review of R1's September 2024 medication administration record (MAR) reflected R1's Morphine 15 mg 8am dose was not administered from February 13, 2024 through February 15, 2024. R1's Morphine 15 mg 4 pm dose was not administered from February 10, 2024 through February 12, 2024. There was no medication order to hold R1's Morphine 15mg. 3. In an interview, E1 reviewed and acknowledged R1's Morphine was not administered as documented, and acknowledged there was no documented medication order to hold R1's Morphine.

Based on interview and record review, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider and emergency contact. The deficient practice posed a risk if the resident did not receive adequate follow-up care. Findings include: 1. In an interview, E1 reported on March 3, 2024, R2 had a seizure and stopped breathing and emergency medical services (EMS) was called to take R2 to the hospital. 2. In an interview, E1 revealed on April 16, 2024, R2 stopped breathing in R2's bedroom during the night and EMS was called and R2 was taken to the emergency room. 3. A review of R2's medical record revealed a document titled "After summary visit" dated March 3, 2024. There was no documentation that met the above requirement. 4. A review of R2's medical record revealed there was no documentation that covered the above requirement regarding the incident on April 16, 2024. 5. In an interview, E1 acknowledge there was no documentation available for reviewed that covered the above requirement regarding the incidents on March 3, 2024 and April 16, 2024.