Sierra del Sol.

“Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for two of ten resident records reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R4's medical record revealed a signed medication order dated December 5, 2025 for "Colace 100mg 1 tablet bid”, with a start date of November 20, 2025.   2. A review of R4’s Medication Administration Record (MAR) dated December 2025 revealed Docusate Sodium, the drug name for Colace, was being administered as needed. Further review revealed Docusate Sodium had been administered only on December 4, 2025. 3. A review of R6’s medical record revealed a signed medication order dated November 30, 2025 for "Levothyroxine 75MCG Tab sig: 1 PO qam…”.  4. A review of R6’s MAR revealed Levothyroxine 50 MCG was being administered. E3 confirmed that the center only had Levothyroxine 50 MCG available to administer to R6. 5. 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 before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of ten resident records reviewed.  Findings include:  1. A review of R6's medical record revealed a documented residency agreement. However, the residency agreement did not include the manager's signature.  2. In an interview, E1 acknowledged R6's residency agreement did not include the manager’s signature.”

“Based on documentation review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk of physical and/or psychosocial harm. Findings include: 1. A review of facility documentation revealed an incident report and documentation of an investigation into the incident. The documentation revealed an interaction involving R1 and E8, which occurred on February 4, 2025 at 10:57 am. The documentation revealed E8 was engaged in an interaction with R1 in the dining room and was observed, “sticking out [E8’s] tongue at [R1], pushing [R1’s] wheelchair, irritating [R1], mocking [R1] …”. The documentation revealed R1 did not suffer any physical injuries, however did have a verbal outburst and showed signs of fear. The documentation revealed other caregivers immediately intervened to deescalate and calm R1.   2. The documentation further revealed the facility had a zero-tolerance policy for such behavior and that E8 was no longer employed with the facility.   3. In an interview, E1 acknowledged R1 was treated without dignity, respect and consideration by E8. E1 further acknowledged the incident was reported to Adult Protective Services.”

“Based on record review and interview, the manager accepted an individual requiring continuous medical services, for one of eight residents sampled. The deficient practice posed a risk as an assisted living facility cannot provide continuous medical services. Findings include: 1. A review of R7's medical record revealed a document titled "Physician's Initial Report and Orders" The document stated "Please also indicated (sic) and list any of the following services needed while in the community: Continuous Medical Services..." A box next to "Continuous Medical Services" was marked to indicate R7 required continuous medical services. The document was signed by a medical practitioner. 2. In an interview, E1 reported R7 does not receive continuous medical services. E1 reported the box indicating R7 required continuous medical services should not have been marked.”

“Based on observation, record review, and interview, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive, for four of eight residents sampled. Findings include: A.R.S. \'a7 36-401.48 "Supervisory care services" means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications. A.R.S. \'a7 36-401.39 "Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. A.R.S. \'a7 36-401.16 "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. A review of R1's medical record revealed a service plan, dated June 7, 2023, for personal care services. However, the service plan included only general supervision and did not include assistance with activities of daily living or medication administration. 2. A review of R2's medical record revealed a service plan, dated July 12, 2023, for personal care services. However, the service plan included only general supervision and did not include assistance with activities of daily living or medication administration. 3. A review of R3's medical record revealed a service plan, dated May 22, 2023, 2023, for personal care services. However, the service plan included only general supervision and did not include assistance with activities of daily living or medication administration. 4. A review of R5's medical record revealed a service plan, dated October 11, 2023. However, the service plan did not include the level of service R5 was expected to receive. 5. In an interview, E1 and E2 acknowledged some of the resident service plans provided for review had not accurately identified if each resident was expected to receive Supervisory care services, Personal Care services, or Directed care services.”

“Based on record review, and interview, for one of five sampled residents reviewed, who received personnel care services, the manager failed to ensure a written service plan was reviewed and updated at least once every six months. Findings include: 1. A review of R6's medical record revealed a service plan, dated March 6, 2023, for personal care services. However, an updated service plan dated on or before September 6, 2023, was not available for review. 2. In an interview, E1 acknowledged a current service plan had not been provided for R6 during the on-site inspection.”

“Based on documentation review, record review, and interview, the manager failed to establish, document and implement policies and procedures for administering an opioid as part of treatment or providing assistance in the self-administration of medication for a prescribed opioid, to protect the health and safety of a patient. Findings include: 1. A review of the facility's policies and procedures revealed a policy and procedure for opioid administration was not available for review.. 2. In an interview, E1 acknowledged a policy and procedure which covered all items required by R9-10-120(F)(1)(a-e) had not been provided for review during the on-site inspection.”