Via Elegante, Tucson Mountains

Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered and the effect of the opioid administered or for which assistance in the self-administration of medication for a prescribed opioid was provided for one of nine residents sampled. Findings include: 1. A review of facility documentation revealed a opioid policy last revised December 13, 2024. The policy stated "Employees will periodically check on the resident over the next hour and note on the MAR (by means of the EMAR follow up feature) the resident’s response to the medication”. 2. A review of R8's medical record revealed a service plan for personal care services and received medication administration. A review of R8's medication orders dated June 25, 2025 stated, “Oxycodone HCL 5 MG Tablet, take 1 tablet by G-tube twice daily”. A review of R8's medication administration record (MAR) revealed Oxycodone was administered as ordered between September 1, 2025 and September 23, 2025, however, documentation of monitoring of the effect of the opioid was not available for review. 3. In an exit interview, the findings were reviewed with E1, E2, E3, and E4. E4 reported the facility only tracks the effectiveness of “as needed” medications.

Based on record review and interview, the manager failed to ensure medication administered to a resident is administered in compliance with a medication order for one of nine residents sampled. The deficient practice posed a risk of an adverse health condition for one resident due to medication not being administered. Findings include: 1. A review of R1's medical record revealed a service plan which indicated R1 received personal care, and administration of medication. The medical record contained a doctor's order, dated August 6, 2024, directing R1 take "Finasteride 5 MG Tablet, Take 1 Tablet by mouth at bedtime." 2. A review of R1's Medication Administration Record (MAR) for September 2024 revealed evidence of documentation to indicate R1 was administered "Finasteride 5 MG Tablet, Take 1 Tablet by mouth at bedtime" as ordered was unavailable for review. 3. In an interview, E4 advised the pharmacy had not received a valid order for "Finasteride 5 MG," from R1's medical provider until October 10, 2024. 4. In an interview, E1 agreed R1 had not been administered Finasteride as ordered.