Litchfield Terrace Assisted Living Home, LLC

Based on record review, observation, documentation review, and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2’s medical record revealed R2’s current service plan dated July 26, 2025. The service plan revealed R2 received medication administration. 2. Review of R2’s Medication Administration Record (MAR) revealed R2 received Midodrine 5 MG two times a day at 8 am and 6 pm, September 1st - present. 3. Review of R2’s signed medication orders dated August 1, 2025, revealed a signed order for “Midodrine 5mg 1 tablet twice daily do not give if SBP is greater than 120.” 4. Review of R2’s medical record revealed a document titled “Vital Signs Measurements”. This document revealed R2's blood pressure was recorded once on September 7th, 16th, 21st, and 28th. 5. The Compliance Officer observed Midodrine 5 mg in R2’s medication organizer. 6. Review of the facility’s policies and procedures revealed a policy titled, “Medication Administration” which stated, “1. The manager or manager’s designee shall ensure that a medication administered to a resident is administered in compliance with a medication order.” 7. In an interview, E1 reported R2 was on hospice and requested a new order to remove the parameters. E1 continued to say that the nurse did not send over the new order. 8. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed the medication cabinets had clear see see-through windows. The cabinets had two interlocking padlocks that kept the cabinet doors from opening all the way. However, the Compliance Officer was able to open the cabinet door with just enough space to pull out a narcotic pill bottle. The padlock fell off when the bottle was retrieved and the Compliance Officer had access to all the other medications in the cabinet. The Compliance Officer was also able to open the second medication cabinet by pulling on one of the padlocks. The medication cabinets held medications for six residents, including narcotic medication. 2. The Compliance Officer observed the following medications in various resident rooms: - Triad Hydrophilic Wound Dressing - Idosorb Cadexomer Iodine Gel - Hydrogen peroxide - Antifungal cream miconazole nitrate - Dermaphor skin protectant moisturizing ointment - Perineal skin cleanser - Chamosyn with Manuka Honey - Mupirocin 2% 3. Review of R1’s, R2’s, R3’s, R4’s, and R5’s service plans revealed R1, R2, R3, R4, and R5, received medication administration. 4. Review of the facility’s policies and procedures revealed a policy titled, “Safe Storage of Medication” which stated, “All medications centrally stored by the facility must be maintained in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. 5. In an interview, E1 reported all residents received medication administration. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454, for one of one resident sampled. The deficient practice posed a risk as a peace officer or the adult protective services central intake was unable to assess if there was an immediate health and safety concern for the resident and other residents residing in the assisted living facility. Findings include: A.R.S.\'a7 46-454(A) "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit." R9-10-101.110 "Immediate" means without delay. 1. A review of R1's medical record revealed an incident report dated July 9, 2024 and July 29, 2024. The incident report dated July 9, 2024 revealed that a caregiver witnessed R1 kick R2's leg as R2's leg was hanging over the side of the bed. The incident report dated July 29, 2024 revealed a caregiver witnessed on the video monitor R1 trying to pull R2 out of bed and punched R2 on the leg. 2. A review of facility records revealed that there were no reports made to a peace officer or to the adult protective services central intake unit for the two incidents that occurred on July 9, 2024 and July 29, 2024. 3. A review of the facility policy and procedures revealed a policy titled, "Preventing Abuse, Neglect, or Exploitation and Reporting Requirements," which stated in section 1, "Abuse, neglect, or exploitation of residents may take many forms, including: Any physical injury to a resident not caused by an accident (eg., hitting, pinching, striking, or injury resulting from rough handling)..." 4. In an interview, E1 acknowledged the facility did not notify a peace officer or Adult Protective Services immediately as required in A.R.S. \'a7 46-454(A).