HACIENDA DE LUNA ASSISTED LIVING

INSP-0163534

Complete

Date: 11/18/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-11-20

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on November 19, 2025:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

R9-10-808.A.5.a. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident’s representative;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a service plan was signed and dated by the resident or the resident's representative when the service plan was initially developed or when updated, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan, dated November 1, 2025, for personal care services. However, the service plan had not been signed by the resident or the resident's representative. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Temporary Solution:

Service Plan was immediately signed after Inspection.

Permanent Solution:

Moving forward when a service plan is updated Care Manager will review with personal care resident to sign immediately upon receiving. If the patient is Directed care, Care Manager will contact POA, review and add a note to the service plan with date on when they will sign in person.

Person Responsible:

Miranda Altamirano ALF Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-815.C.1. Directed Care Services C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 1. The requirements in R9-10-814(F)(1) through (3);

Evidence/Findings:

Based on record review and interview, the manager failed to ensure the service plan, for one of one sampled resident receiving directed care services, included the requirements in R9-10-814(F)(2). R9-10-814(F)(2) states; "In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: Offering sufficient fluids to maintain hydration;" Findings include: 1. A review of R1's medical record revealed a service plan, initiated November 1, 2025, for directed care services. However, the service plan did not include offering sufficient fluids to maintain hydration. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Temporary Solution:

Added Hydration section on current service plan while inspector was present.

Permanent Solution:

After speaking to Care Plan nurse, we reviewed all Directed and Personal care service plan to ensure all residents had Hydration Section. Which they all did minus the current service plan we corrected.

Person Responsible:

Miranda Altamirano ALF Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-817.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan, dated November 1, 2025, for personal care services including medication administration. 2. A review of R2's medical record revealed a list of medication orders, dated October 3, 2025, which included the order, "Rosuvastatin Calcium 5 MG Oral Tablet, Give 1 tablet by mouth every day. Start 5/12/2025." 3. A review of R2's medical record revealed a Medication Administration Record (MAR) dated November 2025. The MAR indicated Rosuvastatin had not been administered to R2 in November 2025. The MAR indicated the medication was not available and was waiting for doctor's orders. 4. In an interview, E1 reported the medication had run out of refills. E1 reported R2's doctor was contacted, however, R2's doctor stated they were going to consult the original prescriber. E1 acknowledged Rosuvastatin had not been held, discontinued, or refilled and further clarification from R2's doctor was not available for review. E1 reported R2 was prescribed both Atorvastatin and Rosuvastatin and that is why there was a question about continuing the Rosuvastatin. 5. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Temporary Solution:

Contacted Nurse Practitioner regarding medication and the order was an active order. The nurse who was responsible for implementing the order did not review with Nurse practitioner's office. After state inspection the owner of the provider group was made aware and was able to coordinate with Nurse Practitioner and got the discontinued order. The owner of the provider group communicated that, that particular nurse is no longer with the company.

Permanent Solution:

If the provider group does not have an answer within 24 hours we will contact the owner of the provider group for immediate action. In the future the manager will contact provider for verbal order to hold or discontinue.

Person Responsible:

Miranda Altamirano ALF Manager

HACIENDA DE LUNA ASSISTED LIVING

Facility Information

Inspection History

INSP-0163534

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0134791

Summary:

INSP-0070120

Summary: