Via Elegante, Sierra Vista Highlands.

“Based on record review, documentation review, and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one of four resident records reviewed.  Findings include: 1. A review of R2’s medical record revealed R2 received personal care services and medication administration.   2. A review of R2’s medical record revealed a signed list of medication orders, which included: - Acetaminophen 500 MG Tablet, “TAKE 1 TABLET BY MOUTH EVERY 8 HOURS FOR PAIN”.  - Lamotrigine 100 mg Tablet, “TAKE 1 TABLET BY MOUTH TWICE DAILY FOR DEPRESSION”. - Atorvastatin 10 MG Tablet, “TAKE 1 TABLET BY MOUTH AT BEDTIME FOR LIPID CONTROL”. 3. A review of R2’s medical record revealed a medication administration record (MAR), dated March 2025. The MAR revealed R2 was not administered Acetaminophen, as ordered, on March 3, 4, 5, 14, 15, and 16, 2025; Lamotrigine, as ordered, on March 8, 9, and 10, 2025; and Atorvastatin, as ordered, on March 8, 9, and 10, 2025. The exception report for the MAR stated the medications were not given because the medication was not available.   4. A review of the facility's policy titled "MEDICATION POLICY", revised "2/25", revealed "... Weekly, two qualified Caregivers will perform a full inventory of all medications. This includes medications from all sources… and will reorder any medications not on cycle fill that are expected to run out within the next 10 days or less.” The document further instructs what to do in various circumstances to resolve the issue, including documenting all steps taken to resolve the issue in the resident’s medical record. 5. A review of facility documentation revealed an incident report and investigation regarding E2. The documentation revealed E2 left the facility unexpectedly, without management approval, on June 8, 2024, while working as a medication tech. The documentation revealed all 8:30 am medications were given between 2 pm and 5:30 pm on June 8, 2024. The documentation revealed all prescribers and emergency contacts were notified and a report was made with Adult Protective Services.   6. In an interview, E1 acknowledged the medications for R2 and for the facility on June 8, 2024, were not administered as ordered.”

“Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. The deficient practice posed a risk if a report was not made as required to adequately protect residents involved. Findings include: 1. A.R.S. \'a7 46-454(A) stated "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.110 stated "Immediate" means without delay. 3. A review of facility documents revealed a document titled "Incident Statement" dated April 25, 2024 and multiple written witness statements. These documents detailed a possible sexual encounter between two residents on April 19, 2024. Based on the level of understanding by R1 and R2, the incident required a report for possible sexual abuse. 4. In an interview, E1 reported an internal investigation was conducted and ongoing, however the incident was not reported to adult protective services (APS) until April 22, 2024. E1 acknowledged the suspected abuse was not reported according to A.R.S. \'a7 46-454.”