Inspection Reports for
La Sonora at Dove Mountain

R9-10-817 — The manager failed to ensure medication was administered to a resident in compliance with a medication order, including a delay of eighteen days before contacting the primary care provider regarding medication refusal.

R9-10-806 — The manager failed to ensure two employees provided documentation of freedom from infectious tuberculosis on or before their start dates, including incomplete baseline assessments and delayed TB skin test reading.

R9-10-807 — The manager failed to ensure four residents provided evidence of freedom from infectious tuberculosis within seven calendar days of occupancy, with missing or incomplete TB screening documentation.

R9-10-810 — The manager failed to ensure a resident was not subjected to restraint; a caregiver admitted to using their arm as weight to restrain a resident resisting care, resulting in suspension and termination.

R9-10-820 — The manager failed to ensure poisonous or toxic materials were stored in locked, labeled containers separate from food and medications; cabinets were found unsecured with accessible toxic substances.

R9-10-803 — The manager failed to immediately report suspected abuse, neglect, or exploitation to Adult Protective Services, causing a delay in reporting that posed a potential safety risk and rights violation.

R9-10-806 — The manager failed to ensure a caregiver’s skills and knowledge were verified and documented before providing physical health services, posing a risk to residents' needs.

R9-10-810 — The manager failed to ensure a resident was treated with dignity, respect, and consideration, and the mandatory report of alleged abuse was delayed more than 24 hours.

R9-10-803 — The manager failed to ensure policies and procedures were established and implemented to protect residents from sudden, intense, or out-of-control behavior, posing a potential risk to resident health and safety.

R9-10-803 — The manager failed to document the report made to a peace officer or Adult Protective Services after having a reasonable basis to believe abuse or neglect occurred, risking resident safety and rights.

R9-10-810.B.1 — The manager failed to ensure a resident was treated with dignity, respect, and consideration, violating resident rights due to allowing inappropriate sexual behaviors to continue.

No evidence was provided to support the deficiency regarding emergency responder documentation requirements.

No evidence was provided to support the deficiency regarding governing authority compliance with A.R.S. § 36-411.

No evidence was provided to support the deficiency regarding verification and documentation of caregiver or assistant caregiver skills and knowledge before providing services.

No evidence was provided to support the deficiency regarding documentation of first aid and CPR training certification before providing assisted living services.

No evidence was provided to support the deficiency regarding means of exiting the facility for residents without keys or special knowledge for egress.

No evidence was provided to support the deficiency regarding the annual review of the disaster plan.

No evidence was provided to support the deficiency regarding conducting evacuation drills for employees and residents at least every six months.

No evidence was provided to support the deficiency regarding documentation of accidents, emergencies, or injuries requiring medical services.

R9-10-113 — No evidence was provided to support the deficiency regarding tuberculosis screening and infection control activities.

36-420.04 — The facility failed to provide required documentation to emergency responders for four residents transported to the hospital, lacking a standardized form and copies of documentation given to responders.

The governing authority failed to ensure good faith efforts to contact prior employers to verify fitness for work for three of eight personnel sampled.

The manager failed to ensure verification and documentation of a caregiver's skills and knowledge before providing physical health services for one of four certified caregivers sampled.

The manager failed to ensure a caregiver provided current documentation of first aid and adult CPR training before providing assisted living services for one of ten personnel sampled.

The manager failed to ensure the facility's exit door alerted employees when residents egressed, posing a risk of unmonitored resident whereabouts.

The manager failed to ensure the disaster plan was reviewed at least once every 12 months; no documentation of a 2024 review was available.

The manager failed to ensure an evacuation drill for employees and residents was conducted and documented at least once every six months; no documentation of a July 2024 drill was available.

The manager failed to ensure documentation of notification to the resident's primary care provider following an accident requiring medical services was complete.

R9-10-113 — The chief administrative officer failed to implement tuberculosis infection control activities including baseline screening for four of eight personnel sampled, lacking assessment of prior exposure risks.

The manager failed to ensure a resident was treated with dignity, respect, and consideration, resulting in potential resident rights violations including abuse and derogatory remarks. Incidents involved physical restraint and verbal abuse by staff, with multiple staff suspended and one terminated.

Misappropriation of personal and private property — The manager failed to ensure a resident was not subjected to misappropriation by a caregiver who used residents' credit cards for self-purchases, confirmed by police and facility video evidence.

R9-10-808 — The manager failed to ensure service plans for residents receiving personal care included skin maintenance, hydration, and incontinence care for three residents.

R9-10-808 — The manager failed to ensure service plans for residents receiving directed care included incontinence care, cognitive stimulation, personal safety strategies, encouragement to eat, and weight documentation for two residents.

The manager failed to ensure a current toxicology reference guide was available for use by personnel members, as none was provided for review.

J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation has occurred, the manager failed to document the suspected abuse, maintain documentation for at least 12 months, include actions taken to prevent recurrence, and maintain investigation documentation as required. Multiple allegations involving residents and staff lacked proper investigation documentation and preventive actions.

When a resident has an accident, emergency, or injury requiring medical services, the manager failed to ensure documentation included actions taken to prevent recurrence. Incident reports for residents with injuries were missing preventive action documentation or were unavailable for review.