Sonoran Senior Care, LLC

Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer opioids identified the resident's need for an opioid before administering the opioid and monitored the resident's response to the opioid for residents who did not have an active malignancy or an end-of-life condition. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled, “Medications,” which stated, “3. Document in the resident's medical record: a. Identification of pain before administration using the pain scale 0-10 or face scale for nonverbal residents (See Pain Diary Form) b. The effect of the opioid administration on Pain Diary Form,” 2. Review of R1’s medical record revealed a current service plan dated September 2025. This service plan revealed R1 receives medication administration. 3. Review of R1’s medical record revealed signed medication orders dated December 2025 which stated, “Start Tramadol 50 mg 1 tab three times daily,” 4. Review of R1’s medical record revealed a December 2025 medication administration record (MAR) which revealed Tramadol 50 mg was administered three times a day from December 1 to present day. 5. Review of R1’s medical record revealed a document titled, “PRN Flowsheet” which revealed pain and the effectiveness of Tramadol 50 mg was being recorded up to December 3, 2025. Recording the pain and effectiveness of Tramadol was not documented on December fourth to present day. 6. In an interview, E1 acknowledged R1’s pain and effectiveness of Tramadol 50 mg was not recorded December fourth to present day. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individual was not qualified to provide the required services. Findings include: 1. The facility was licensed at the Directed Care Level. 2. Review of A.R.S. § 36-401.A.49. revealed "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 3. The Compliance Officers observed E2 and E3 working at the time of the inspection. 4. The Compliance Officers observed E3 walk into a resident’s room unsupervised. E2 was accompanying the Compliance Officers during the environmental inspection. The Compliance Officers observed E3 sitting next to a resident bed and hand feeding a resident without E2 present in the room. 5. Review of E3’s personnel record revealed E3 was hired as an assistant caregiver. 6. In an interview, E1 acknowledged E3 was hired as an assistant caregiver and E3 cannot interact with the resident unsupervised. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, interview, and observation 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 receiving medication administration. Findings include: 1. Review of R1’s medical record revealed a current service plan dated September 2025. This service plan revealed R1 receives medication administration. 2. Review of R1’s medical record revealed a signed medication list dated September 2025. The list revealed the following: - Atorvastatin 10 mg 1 tablet QHS - Propranolol 10 mg 1 tablet BID - Topiramate 50 mg 2 tablets QHS - Trazodone 100 mg 1 tablet QHS 3. Review of R1’s medical record revealed a signed medication order dated December 2025 which revealed R1 takes, “Tramadol 50 mg 1 tablet TID”. 4. Review of R1’s medical record revealed a Medication Administration Record (MAR) for the month of December 2025. The following medications were not documented as administered on December 29th: - Atorvastatin 10 mg at 8pm - Propranolol 10 mg at 8 pm -Topiramate 50 mg at 8 pm - Trazodone 100 mg at 8 pm - Tramadol 50 mg at 2 pm and 8pm 5. In an interview, E1 reported the medications were administered to R1 however it was not documented. Based on the time of the inspection this was required. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. Review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed ambulatory residents. 3. The Compliance Officers observed the following medications in a kitchen cabinet with a broken lock: - A pill bottle of Geri-Kot natural laxatives standardized Senna concentrate 8.6 mg - A pill bottle with no label which contained circular red pills. - A box of Musinex 600 mg tablets 4. In an interview, E1 acknowledged the lock on the kitchen cabinet was broken and medications were inside. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed in an unlocked kitchen cabinet the following: - Clorox disinfecting wipes - A spray bottle of Odoban 2. The Compliance officers observed a cabinet with a broken lock in the unlocked laundry room which contained the following items: - A bottle Tandil essentials laundry detergent - A can of Comet bleach - A squeeze bottle of Lysol toilet bowl cleaner - A spray bottle of The Invisible Shield Marble and Granite Cleaner - A bottle of Robec garbage disposal cleaner - A spray bottle of Odoban pet oxy stain remover - A bottle of Ecolab acidic toilet bowel cleaner - A 1.2 gallon bottle of Gain detergent - A spray bottle of Great value cleaner with bleach - A spray canister of Sprayway glass cleaner 3. In an interview, E1 acknowledged the lock for the laundry room cabinet was broken and the toxic materials were accessible. 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 a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for two of two sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(2)(a)-(b) states: "B. A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101." 2. A review of R1's and R2's medical records revealed documentation of freedom from TB. However, documentation of TB screening was not available for review at the time of inspection. 3. In an interview, E1 acknowledged failure to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis.