LA SONORA AT DOVE MOUNTAIN

INSP-0160610

POC

Date: 9/29/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-11-12

Summary:

The following deficiencies were found during the on-site investigation of complaints 00145732, 00145700, 00104411, 00146051, 00146047, 00104285, and 00104208, conducted on September 29, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-817.B.3.a-c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under the direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident’s medical record.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order. Findings include: 1. A review of R2’s medical record revealed a medication order for “Amlodipine Besylate 5 MG TAB Take 1 tablet by mouth daily, check Bp q day, and hold if SBP < 115.” Further review revealed a medication administration record (MAR) for documenting the administration of medications during September 2025, including “Amlodipine Besylate 5 MG TAB Take 1 tablet by mouth daily, check Bp Daily, and hold if Sbp Less Than 115.” The record reflected R2 refused administration of Amlodipine every day, from September 2 through September 19, 2025. In addition, R2’s medical record contained an order to discontinue Amlodipine, which was dated September 19, 2025. 2. A review of facility documentation revealed a written request from E2 to R2’s primary care provider, dated September 15, 2025. The request was for an order to discontinue R2’s Amlodipine due to R2’s refusal to take the medication. 3. In an interview, E2 advised efforts were not made to contact R2’s primary care provider regarding R2’s refusal to take Amlodipine as ordered until September 15, 2025. E2 acknowledged Amlodipine had not been administered to R2 as ordered for eighteen days before the facility received an order from R2’s primary care provider to discontinue administration of Amlodipine. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Temporary Solution:

HSD [nurse] immediately reviewed medications to ensure no other resident had refusals that had not been address with healthcare provider and responsible parties.

Permanent Solution:

HSD [nurse] conducted training with all Med Techs instructing them to report all medication refusals. HSD is contacting health care providers and responsible parties (if applicable) when refusal happens on 3rd day in a row. Orders or instructions will be requested and followed up on.

Person Responsible:

Rebecca Allison, Executive Director

INSP-0160346

Enforcement

Date: 9/23/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-10-22

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00145543, conducted on September 23, 2025:

Deficiencies Found: 4

INSP-0137633

Complete

Date: 7/29/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-09-05

Summary:

No deficiencies were found during the on-site investigation of complaint 00137797 conducted on July 29, 2025.

✓ No deficiencies cited during this inspection.

INSP-0136905

POC

Date: 7/24/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-09-10

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00137001 conducted on July 24, 2025:

Rebecca Allison, Executive Director

INSP-0130851

Complete

Date: 5/30/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-07-07

Summary:

No deficiencies were found during the on-site investigation of complaint 00129545 conducted on May 30, 2025.

✓ No deficiencies cited during this inspection.

INSP-0099685

POC

Date: 2/27/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-04-04

Summary:

The following deficiencies were found during the on-site investigation of complaints 00120754 and 00120753 conducted on February 27, 2025:

Rebecca Allison, Executive Director

INSP-0076396

Complete

Date: 11/5/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-12-05

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaint AZ00217907 and AZ00217423 conducted on November 05, 2024:

Deficiencies Found: 9

INSP-0076394

Complete

Date: 7/22/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-07-29

Summary:

An on-site investigation of complaints AZ00202016, AZ00203812, AZ00211859, AZ00213003, were conducted on July 22, 2024, and the following deficiencies were cited :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

B. A manager shall ensure that:
1. A resident is treated with dignity, respect, and consideration;

Evidence/Findings:

Based on documentation review, observation and interview the manager failed to ensure a resident is treated with dignity, respect, and consideration. The deficient practice posed a potential resident rights violation if residents were subject to abuse and were subjected to ridicule, demeaning, or derogatory remarks.

Findings include:

A.R.S. 46-451 "Abuse" means: (a) Intentional infliction of physical harm; (b) Injury caused by negligent acts or omissions; (c) Unreasonable confinement; (d) Sexual abuse or sexual assault; (e) Emotional abuse.

Incident involving R3:

1. A review of documentation dated July 11, 2024, revealed the facility made the following report: "The reporting source (RS) states that the adult victim (AV) is abused by multiple alleged perpetrators (AP). The AV has bilateral injuries to both their left and right wrist. It is reported the AV was held by their wrist by the AP and stripped off their clothes and briefs by the overnight staff from 10 PM - 6 AM. The AP's have been suspended as of July 11, 2024". The Marana Police Department was notified on July 11, 2024.

2. A review of documentation provided by E1 revealed a timeline investigation of this incident. On July 11, 2024, E4 went to E1 and reported that E12 had shared the following information. E12 was concerned that R3 was being held down on the bed by caregivers by holding R3's wrists to change R3's brief. E1 reached out to E12 who confirmed the actions stating it's due to R3 being combative during care and they needed multiple care staff to assist with brief changes. E12 reported that E10 changed the brief while E12, and E11 held onto R3's wrists.

3. On July 11, 2024, O1 from the Marana Police Department arrived to see R3 and interview the caregivers. During the interviews, O1 had been told E7 was involved in holding R3 down. E7 then reported to O1 that E8, and E9 had also been involved.

4. O1 was escorted to R3's room in the memory care section of the facility. O1 reported R3 was pleasant and cooperative during conversation and willingly to allow O1 to view and take photographs of bilateral bruising areas. In the timeline, O1 observed the bruising on R3's wrists. O1 expressed concerns with the bruising on the right forearm-3 small bruises spaced approximately 1/4" to 1/2" and noting significant bruising.

5. E8, E9, E10, E11, and E12 have been put on suspension until the investigation is completed.

Incident involving R1:

6. A review of documentation provided by Adult Protective Services (APS) dated November 22, 2024, revealed the facility made the following report: "The client was yelled/cursed at by another staff member".

7. A review of documentation revealed a document dated November 19, 2023/November 20, 2023. The document was a statement prepared by E14. E14 reported overhearing E6 yell and curse the following to R1 "Get the [expletive] out of my face". During the investigation, E1 asked E13 about the incident. E13 reported overhearing the yelling and cursing of E6 to R1. Two other caregivers E4 and E15 reported overhearing E6 be unkind to R1 and other residents. E6 was suspended during the investigation. E6's employment was terminated.

8. In an interview, E1 and E2 acknowledged reporting, investigating, and documenting both of the incidents and cooperating with O1 in the Marana Police Department's investigation.

INSP-0076392

Complete

Date: 10/10/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-10-19

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00198721, AZ00199088, AZ00199411, AZ00199413, AZ00199414, AZ00199651, AZ00200011, and AZ00201696 were conducted on October 10, 2023:

Deficiencies Found: 4

INSP-0076390

Complete

Date: 7/24/2023

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2023-08-08

Summary:

An on-site investigation of complaints AZ00193437, AZ00193917, AZ00194972, AZ00193461, AZ00193600, AZ00193459, AZ00196831, AZ00198305, was conducted on July 24, 2023 and the following deficiencies were cited .

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall:
1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;
2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454;
3. Document:
a. The suspected abuse, neglect, or exploitation;
b. Any action taken according to subsection (J)(1); and
c. The report in subsection (J)(2);
4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2);
5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2):
a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition;
c. The names of witnesses to the suspected abuse, neglect, or exploitation; and
d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and
6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Evidence/Findings:

Based on record review, documentation review, and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises or while the resident was receiving services, the manager failed to document the suspected abuse, maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2), and include actions taken by the manager to prevent the suspected abuse, and maintain a copy of the documentation required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Findings include:

1. A review of documentation provided by Adult Protective Services (APS) revealed the following allegations of suspected abuse occurred involving R1, R2, R3, R7, and R8:

2. A review of documentation dated June 10, 2023 from APS revealed O1 had reasonable basis to believe abuse had occurred on the premises while a resident was receiving services from the assisted living facility and report it. O1 reported the following allegations involving R1, and E7. R1 reported E7 had been abrasive, insensitive, and rough when providing care to R1. The managers investigation of these allegations determined E7 was being rough with the resident. A review of the investigation document revealed the following was missing from the investigation document:

-actions taken by the manager to prevent the suspected abuse from occurring in the future.

3. A review of documentation provided by APS to the department dated March 31, 2023, revealed allegations of abuse between R2 and E7. The following was missing from the investigation document:

-actions taken by the manager to prevent the suspected abuse from occurring in the future.

4. A review of documentation provided by APS to the department dated April 4, 2023, allegations of abuse were reported that someone punched R2. R2 had a cut on the top of R2's hand and some bruises. A review of documentation provided by E1 revealed APS did an investigation on April 5, 2023, on these allegations. The following was missing from the investigation document:

- no documentation was provided to show an investigation of these allegation had taken place.

5. A review of documentation provided by APS to the department dated March 29, 2023, revealed allegations of abuse took place between R3 and E7. The following was missing from the investigation document:

-actions taken by the manager to prevent the suspected abuse from occurring in the future.

6. A review of documentation provided by APS to the department dated March 31, 2023, revealed allegations of abuse between R3 and E7. The following was missing from the investigation document:

- no documentation was provided to show an investigation of these allegation had taken place.

7. A review of documentation provided by APS to the department dated February 8, 2023, allegations of abuse, and neglect was reported. R7 had been left in the bathroom by a caregiver. R7 suffered a laceration on forehead and possible broken ribs. The following was missing from the investigation document:

- no documentation was provided to show an investigation of these allegation had taken place.

8. A review of documentation provided by APS to the department dated March 19, 2023, allegations of abuse were reported. R8 had bruises on body and arms. The following was missing from the investigation document:

- no documentation was provided to show an investigation of these allegation had taken place.

9. In an interview, E1 reported unable to locate investigation reports from APS investigations for R2, R3, R7, and R8, and acknowledged reports for R1, R2, and R3 were missing actions taken by the manager to prevent the suspected abuse from occurring in the future.

This is a repeat citation from the complaint survey conducted on March 27, 2023.

Deficiency #2

Rule/Regulation Violated:

D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver:
2. Documents the following:
a. The date and time of the accident, emergency, or injury;
b. A description of the accident, emergency, or injury;
c. The names of individuals who observed the accident, emergency, or injury;
d. The actions taken by the caregiver or assistant caregiver;
e. The individuals notified by the caregiver or assistant caregiver; and
f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure when a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver documents the date and time of the accident, emergency, or injury, a description of the accident, emergency, or injury, the names of individuals who observed the accident, emergency, or injury, actions taken by the caregiver or assistant caregiver, the individuals notified by the caregiver or assistant caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a health and safety risk.

Findings include:

1. A review of documentation provided by E1 revealed an incident report for R2 who received medical services for a cut on top of the hand and some bruises from a fall. The document is missing the following:

- any action taken to prevent the accident, emergency, or injury from occurring in the future.

2. A review of documentation provided by Adult Protective Services (APS) revealed R7 received medical services for a laceration on forehead and possible broken ribs. The document is missing the following:

- no documentation available to review on this incident resulting in an injury to a resident.

3. A review of documentation provided by Adult Protective Services (APS) revealed R8 received medical services for bruises on the body and arms. The document is missing the following:

- no documentation available to review on this incident resulting in an injury to a resident.

4. In an interview, E1 acknowledged the residents received medical services. R2's document was missing any action taken to prevent the accident, emergency, or injury from occurring in the future, and no documentation was provided for review on the incidents involving R7, and R8.

INSP-0076388

Complete

Date: 3/27/2023

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2023-04-10

Summary:

An on-site investigation of complaint AZ00190954 was conducted on March 28, 2023, and the following deficiencies were cited:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall:
1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;
2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454;
3. Document:
a. The suspected abuse, neglect, or exploitation;
b. Any action taken according to subsection (J)(1); and
c. The report in subsection (J)(2);
4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2);
5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2):
a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition;
c. The names of witnesses to the suspected abuse, neglect, or exploitation; and
d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and
6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Evidence/Findings:

Based on record review, documentation review, and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the suspected abuse, maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2), and include the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, and any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse, and maintain a copy of the documentation required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Findings include:

1. A review of documentation provided by The Adult Protective Services (APS) revealed an incident occurred involving R1, R2, and R3. The allegation was suspected abuse by E2. This document was sent to the Department on February 1, 2023.

2. A review of R1, R2, and R3's medical records revealed all residents were receiving directed care services.

3. In an interview, E1 reported APS, and the The Tucson Police Department came to the facility and did an investigation on this incident.

4. A review of two documents provided by E1 revealed a document titled "Incident Form" dated January 18, 2023, this document was an incident investigation report involving R1 and E2. This document had all the requirements in R9-10-803.J. A review of the second documented titled "Incident Form" dated January 26, 2023, revealed an incident investigation report involving R2 and E2. This document had all the requirements in R9-10-803.J.

5. The Compliance Officer asked E1 for the incident report for the investigation of R3 and E2. E1 reported doing an investigation however, did not do a incident report. No documentation was provided to show an investigation was completed on the incident involving R3 and E2, as required in R9-10-03.J.

6. In an interview, E1 acknowledged an investigation report was not completed for R3 as required in R9-10-803.J.

Facility Information

Inspection History

INSP-0160610

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0160346

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

INSP-0137633

Summary:

INSP-0136905

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-0130851

Summary:

INSP-0099685

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-0076396

Summary:

Deficiencies Found: 9

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2