Saguaro Gardens Assisted Living

Deficiency 1 · R9-10-816.B.3 — Medication Administration Log

The manager failed to ensure that medication administration records were completed at the time of administration for two of three sampled residents. The deficient practice posed a risk if staff were unable to determine whether a resident had received a scheduled medication.

Findings

A review of R2's medication administration record revealed three entries during the week of February 17, 2025 where the administering staff member's initials and time of administration had not been recorded. A review of R3's record revealed two similar unsigned entries during the same period. In an interview, E2 acknowledged the entries had not been completed at the time of administration and reported the omissions were due to shift handoff timing. No evidence of medication errors was identified. The facility's own written medication policy requires staff to initial and timestamp each entry at the time of administration.

Deficiency 2 · A.A.C. R9-10-814.A.4 — Resident Service Plan Review Frequency

The manager failed to ensure that a resident's service plan was reviewed and updated at least every six months, for one of three sampled residents. The deficient practice posed a risk as services may not reflect the resident's current needs.

Findings

R1's service plan was dated August 3, 2024. The inspection was conducted on March 6, 2025 — seven months after the last review. No updated service plan or documented interim review was found in R1's medical record. In an interview, E1 acknowledged the service plan had not been reviewed within the required six-month window and attributed the lapse to a staffing transition in October 2024.