Az Life Assisted Living Home LLC

Based on observation, record review, documentation review, and interview, for one of two residents reviewed, who received a controlled substance, the manager failed to ensure that policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility. Findings include: 1. In observation, R2 had Oxycodone HCL 5mg (a Schedule II controlled substance) and Lorazepam medication (a schedule IV controlled substance) on site. The Oxycodone medication indicated 14 tablets were dispensed on May 20, 2025, and 10 tablets remained. Five tablets of Lorazepam medication were observed. 2. In record review, R2's medical record (received personal care and medication administration services) included a medication order for the Oxycodone (take 1 tablet by mouth every day) and Lorazepam medication (take 1 tablet by mouth every 6 hours as needed). R2's medication administration record (MAR) dated June 2025, indicated R2 received the Oxycodone medication daily from June 1 - 9th, 2025; however, did not receive the Lorazepam medication in June 2025. 3. In record review, R2's medical record did not include documentation of an inventory for either the Oxycodone or Lorazepam medication. 4. In documentation review, the facility's medication policies, on page 3-4, documented, "... The opioids and narcotic medications will be inventoried and placed in the medication storage area... Daily narcotics or controlled substances administration will be recorded on each resident Narcotic Administration Record..." 5. During an interview, E1 acknowledged the facility did not maintain an inventory of controlled substances, according to the facility's policy and procedures.

Based on interview and record review, for one of two residents reviewed who was confined to a bed or chair and unable to ambulate, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a signed and dated determination from a primary care provider (PCP) or medical practitioner (MP), at the onset of the condition, and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services. The deficient practice posed a safety risk to a resident if a facility retained a resident without the required authorization. Findings include: 1. In record review, R1's medical record included service plans (received directed care services), dated from February 24, 2024, through April 25, 2025, which documented "bed/w/c (wheelchair)..Non-Ambulatory, requires positioning, Transfer assistance 1 person..." 2. In recrod review, R1's medical record did not include documentation of a signed and dated determination from a primary care provider (PCP) or medical practitioner (MP), at the onset of the condition, and every six months, that stated the resident's needs could be met by the facility. 3. During an interview, E1 reported R1's ambulation was impaired following a fall and a hip fracture in 2023, and acknowledged R1 was no longer able to walk, even with assistance and the required determination from the MP or PCP was not obtained.