San Nicolas Assisted Living Home Nw, INC

Based on record review, documentation review, and interview, the manager failed to implement the facility’s policy on opioid administration to a resident. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of R4’s medical record revealed a document titled “Opioid As Needed Med Admin,” used for tracking the administration of hydrocodone. The record contained columns for documenting the “Dose,” “Reason,” and “Response” used for tracking the amount of medication administered to R4, R4’s need for the medication, and the medication’s effect on R4 after administration. Between January 15, 2025, and October 7, 2025, there were numerous gaps in documentation of the dose administered, R4’s need for the medication, and the effect of the medication. In cases where entries were made, the entries routinely read “pain.” Entries after February 13, 2025, included a column titled “Count,” used for tracking the amount of hydrocodone after administration to R4. Entries in the Count column after February 13, 2025, appeared to reconcile with the amount of hydrocodone administered, versus the amount on hand. However, between January 15 and February 12, 2025, evidence of documentation to reconcile the amount of hydrocodone on hand with the amount of hydrocodone administered to R4 was unavailable for review. 2. A review of facility policy and procedures, last reviewed 12/01/24, revealed a “Opioid Policy,” which read “The caregiver…will monitor the resident(s) by checking and documenting pain levels before administering scheduled and/or PRN opiates.” The caregiver…will check resident(s) 30 min after administering and document the response to the opiate…Staff will use pain level indicator 1-10…” The policy further indicated, “The manager will ensure that proper documentation is taking place.” 3. In an interview, E1 advised they discovered the improper documentation of R4’s opioid medication when reviewing R4’s controlled substance tracking sheet in February 2025. E1 said during the review, E1 discovered multiple doses of hydrocodone could not be accounted for, as caregivers were not regularly documenting the amount of medication administered, and not documenting the amount of medication on hand at all. E1 agreed the caregivers were not following the facility’s policy on documenting the resident's need for the medication, nor were they following policy on monitoring the resident and documenting the effects of the medication. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the Governing Authority failed to ensure compliance with A.R.S. § 36-411, for two of four caregivers sampled by failing to ensure a caregiver had a valid fingerprint clearance card and failing to verify the current status of a caregiver’s fingerprint clearance card. The deficient practice posed a risk if E4 and E5 were a danger to a vulnerable population. Findings include: 1. A review of E4’s personnel record revealed E4 was hired as a caregiver on November 13, 2014. Further review revealed a fingerprint clearance card with an expiration date of January 3, 2025. E4’s personnel record included an application for a new fingerprint clearance card, dated October 2, 2025. Evidence of documentation of the validity of E4’s fingerprint clearance card in 2025 was unavailable for review. 2. A review of E5’s personnel record revealed E5 was hired as a caregiver on May 16, 2024. Further review revealed a fingerprint clearance card with an expiration date of March 21, 2025. Evidence of documentation of the validity of E5’s fingerprint clearance card in 2025 was unavailable for review. 3. In an interview, E1 admitted E4 and E5 worked numerous shifts in 2025, after their respective fingerprint clearance cards had expired. E1 acknowledged E4’s and E5’s personnel records did not include verification of the validity of their fingerprint clearance cards as required in A.R.S. § 36-411. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R4’s medical record revealed a document titled “Opioid As Needed Med Admin,” used for tracking the administration of hydrocodone. The record contained a column for documenting the “Dose” used for tracking the amount of medication administered to R4. Between January 15, 2025, and October 7, 2025, there were numerous gaps in documentation of the dose administered. Entries after February 13, 2025, included a column titled “Count,” used for tracking the amount of hydrocodone after administration to R4. Entries in the Count column after February 13, 2025, appeared to reconcile with the amount of hydrocodone administered, versus the amount on hand. However, between January 15 and February 12, 2025, evidence of documentation to reconcile the amount of hydrocodone on hand with the amount of hydrocodone administered to R4 was unavailable for review. 2. In an interview, E1 advised they discovered the improper documentation of R4’s opioid medication when reviewing R4’s controlled substance tracking sheet in February 2025. E1 said during the review, E1 discovered multiple doses of hydrocodone could not be accounted for, as caregivers were not regularly documenting the amount of medication administered, and not documenting the amount of medication on hand at all. E1 stated R4 never ran out of medication, but admitted some of R4’s hydrocodone had been unaccounted for. E1 recalled in the weeks after February 13, 2025, E5 approached E1 and admitted to diverting R4’s hydrocodone. E1 advised R4 was never reimbursed for the missing medication, and R4 was not aware the medication was missing. 3. A request was made to review the incident report and supporting documentation of E1’s report to law enforcement or adult protective services, or E1's investigation into the matter, as required per R9-10-803(J)(4-5). However, evidence of required documentation was unavailable for review. 4. In an interview, E1 acknowledged they did not report the incident as required, according to A.R.S. § 46-454. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident was not subjected to misappropriation of personal and private property by the assisted living facility’s employees. The deficient practice posed a risk of injury and violated a resident's rights. Findings include: 1. A review of R4’s medical record revealed a document titled “Opioid As Needed Med Admin,” used for tracking the administration of hydrocodone. The record contained a column for documenting the “Dose” used for tracking the amount of medication administered to R4. Between January 15, 2025, and October 7, 2025, there were numerous gaps in documentation of the dose administered. Entries after February 13, 2025, included a column titled “Count,” used for tracking the amount of hydrocodone after administration to R4. Entries in the Count column after February 13, 2025, appeared to reconcile with the amount of hydrocodone administered, versus the amount on hand. However, between January 15 and February 12, 2025, evidence of documentation to reconcile the amount of hydrocodone on hand with the amount of hydrocodone administered to R4 was unavailable for review. 2. A review of facility policy and procedures, last reviewed 12/01/24, revealed a “Opioid Policy,” which indicated, “The manager will ensure that proper documentation is taking place.” However, the policy did not reflect a method for inventorying and tracking controlled substances. 3. In an interview, E1 advised they discovered the improper documentation of R4’s opioid medication when reviewing R4’s controlled substance tracking sheet in February 2025. E1 said during the review, E1 discovered multiple doses of hydrocodone could not be accounted for, as caregivers were not regularly documenting the amount of medication administered, and not documenting the amount of medication on hand at all. E1 stated R4 never ran out of medication, but admitted some of R4’s hydrocodone had been unaccounted for. E1 recalled in the weeks after February 13, 2025, E5 approached E1 and admitted to diverting R4’s hydrocodone. E1 advised R4 was never reimbursed for the missing medication, and R4 was not aware the medication was missing. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for one of five residents sampled. Findings include: 1. A review of R3's medical record revealed a service plan, dated December 16, 2022, for personal care services indicating R3 was to receive several services including, "Shower: Set-up, Standby, Staff washes [R3's] hair," "Basic Hydration 6-8 oz with every meal, snack, and throughout the day," and "Administer Medications." 2. A review of R3's medical record revealed a document dated September 2023, used for documenting services provided and activities of daily living. However, the document did not contain evidence demonstrating R3 received any services listed in [R3's] service plan on September 22, 23, 24, 28, 29 and 30, 2023." 3. In an interview, E1 acknowledged R3's services were not being documented appropriately.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of four residents sampled who received medication administration. Findings include: 1. A review of R3's medical record revealed a service plan, updated December 16, 2022, for personal care services including medication administration. 2. A review of R3's medical record revealed a signed list of medication orders dated September 13, 2023, which included: - "Sodium Bicarbonate 650 mg PO BID;" - "Tylenol 650 mg PO BID;" and - "Ambien 5 mg PO q hs." 3. A review of R3's medical record revealed a Medication Administration Record (MAR) dated September, 2023. The MAR indicated the following: - For the medications, "Sodium Bicarbonate 650 mg," "Tylenol 650 mg," and "Ambien 5 mg," the MAR indicated the medications had not been administered on September 22, 23 24, 18, 19 or 30, 2023. 4. A review of R4's medical record revealed a service plan, dated November 4, 2022, for personal care services including medication administration. 5. A review of R4's medical record revealed a signed list of medication orders dated September 13, 2023. The list included: - "Dry Eye Relief - Eye Drops 1 drop both eyes TID;" - "Eliquis 2.5 mg PO BID;" - "Hydralazine 50 mg PO TID;" -"Levothyroxine 50 mcg PO q day;" - "Lisinopril 30 mg 1 PO BID;" - "Omeprazole 20 mg PO q day;" - "ropinirole 0.25 mg PO QID;" - "Salonpas with Lidocaine apply cream to affected area 4x daily;" and -"Tramadol 50 mg PO QID." 6. A review of R4's medical record revealed a Medication Administration Record (MAR) dated October, 2023. The MAR indicated the following: - For the medications, - "Dry Eye Relief - Eye Drops," "Eliquis 2.5 mg," "Hydralazine 50 mg," "Levothyroxine 50 mcg," "Lisinopril 30 mg," "Omeprazole 20 mg," "ropinirole 0.25 mg," "Salonpas" and "Tramadol 50 mg," the MAR indicated the medications had not been administered at 7 AM or at 8AM on October 10, 17, 24 and 31, 2023. - For the medications, "Dry Eye Relief - Eye Drops," "Hydralazine 50 mg," "ropinirole 0.25 mg," "Salonpas" and "Tramadol 50 mg," the MAR indicated the medications had not been administered at 12 PM on October 13, 14, 15, 20, 21, 22, 27, 28 and 29, 2023. - For the medications, "Dry Eye Relief - Eye Drops," "Eliquis 2.5 mg," "Lisinopril 30 mg," "Hydralazine 50 mg," "ropinirole 0.25 mg," "Salonpas" and "Tramadol 50 mg," the MAR indicated the medications had not been administered at 5 PM on October 13, 14, 15, 20, 21, 22, 27, 28 and 29, 2023. - For the medications, "ropinirole 0.25 mg," "Salonpas" and "Tramadol 50 mg," the MAR indicated the medications had not been administered at 8 PM on October 13, 14, 15, 20, 21, 22, 27, 28 and 29, 2023. 7. In an interview, E1 acknowledged the medications administered to R3 and R4 had not been accurately documented in each resident's medical record.