Lincoln Heights Assisted Living

Based on documentation review, record review and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), when there was a change in the manager. Findings include: 1. In observation, E1's manager's certificate was posted at the facility. 2. In record review, E1's personnel record documented E1 was hired as the manager on December 12, 2021. 3. A review of Department documentation revealed O1 was the manager. The Department was not notified of the change in the manager. 4. During an interview, E1 reported [E1] became the manager in either December 2021, or January 2022.

Based on record review, documentation review, observation, and interview, for one of two residents reviewed and receiving controlled substances, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. Findings include: 1. In observation, R1 had Lorazepam medication (a schedule IV controlled substance), and Morphine (a schedule II controlled substance) on site, and stored by the facility. 2. In record review, R1's medical record included medication orders for Lorazepam 2 mg/ml oral concentrate, take 0.25ml po SL every night at 5 PM and at bedtime, and Morphine Sulfate (concentrate) 10 mg/ml take 0.25 ml po SL every night at 5 PM and at bedtime. R1's medication administration record (MAR) for August, 2023, included documentation R1 received the Lorazepam and Morphine medications as ordered, August 1, through August 20, 2023. The documentation did not include an inventory of the controlled substances. 3. In documentation review, a facility policy titled, "Assisting with Controlled Medications," documented, "... For every medication marked with a "C", a Narcotic Inventory Sheet (NIS) should be maintained. When a controlled medication is received from the pharmacy (or resident at time of admission), the Manager should count the number of tablets/capsules and enter this number on the NIS. The date, time and signature of the person should also be entered on this form... Maintain an NIS with the Resident's current MAR... When assisting a resident in taking a controlled medication, a staff member should a. Record the date, time and what medication was given to the resident on the NIS, as well as initial... b. Count the number of tablets/capsules available and enter that number in the "Amount on Hand" on the form. c. Draw a line through the "Amount Received" column. d. Write the number of tablets/capsules written in the "Amount Given" column from the number int the "Amount on Hand" column. Write the resulting number in the "Amount Remaining" column..." 4. During an interview, O1 reviewed the MARs for R1, and acknowledged an inventory had not been maintained for the controlled substances.