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.”