The Watermark at Oro Valley

Based on record review, documentation review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. Findings include: A review of R1's medical record revealed a service plan, dated February 7, 2026, for directed care services. The service plan indicated R1 was "an elopement risk r/t dementia, but does not wander." A review of the facility's policies and procedures revealed a policy titled "Elopement Policy - Assessing Risk, Drills, and Handling an Elopement," last revised November 29, 2023. This policy stated: "Memory care residents need not be assessed as they have already been determined to be appropriate for a secured area. Residents should be monitored for exit-seeking behaviors and additional interventions should be implemented, as well as updating the Individual Service Plan." "The community will verify that alarmed exit doors are working properly each shift..." "Routine checks should be documented on the nursing Medication Administration Record (MAR) or the Task Administration Record (TAR) and nursing will sign off on placement and functionality each shift." A review of the facility's policies and procedures revealed a policy titled "Preventing unsafe wandering or exit seeking Arizona only." This policy stated: "Never provide alarm or secure entry codes to family members, visitors, or others. Only associates should have access to alarm/entry codes. Codes should be monitored and changed as necessary." A review of the facility's policies and procedures revealed a policy titled "Systems to Accommodate Visitors, Associates, and Residents Who do not require controlled egress Arizona Only." This policy stated: "Communities who do not use Wanderguard, accommodate visitors and resident who do not require Directed Level Care in and out of the secured neighborhood by escorting visitors and residents through the secured doors." "Associated are trained to enter and exit secured neighborhoods with provided access via assigned entry code or fob with an awareness of securing entry for residents who reside in a secured neighborhood." A review of facility documentation revealed an incident report dated January 31, 2026. The incident report stated, "On Saturday, January 31, 2026, at approximately 1315, while case associates were completing assurance checks, care associates became aware that resident [R1] was not in the anticipated location. [R1] was observed at lunch and was escorted to [R1's] room at approximately 12:25 pm....While care associates were attempting to locate the resident, it was noted that an alarm was not functioning as expected. At the time of the incident, the community was experiencing increased traffic related to another resident moving out. The main egress door was open intermittently to accommodate move-out activity, resulting in higher-than-usual foot traffic in the area. The resident was located...at approximately 1400... .3 miles from the facility.... EM

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's medical record, for two of five sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R3's medical record revealed a service plan, dated September 19, 2025, for personal care services, which detailed the services the facility would provide to R3, including: - “Focus: Safety checks – assurance checks will be completed every 4 hours for safety related to fall risk. Desired outcome: [R3] general and specific whereabouts and well being will be verified. Actions/Support Actions: Assurance checks will be completed every 4 hours for safety related to fall risk.” 2. A review of R3's medical record revealed a document titled "Documentation Survey Report v2," dated November 2025. The report documented the services provided to R3 on each day in November 2025. The report documented the following: • “Assurance Checks: Assurance checks will be completed every 4 hours for safety related to fall risk” were scheduled on the “Day (6a-2p)…” shift and the “Evening (2p-10p)…” shift and had been marked as completed one time per shift. However, documentation of assurance checks on the overnight shift were not available for review. 3. A review of R5’s medical record revealed a service plan, dated May 19, 2025, for personal care services, which detailed the services the facility would provide to R5, including: - “Socialization…Care associated will remind/encourage/supervise attending social events for cognitive and social stimulation”; - “Continence: Care associate will remind resident to go to bath room as needed….”; - “Bathing: Care associates will check skin with bath/shower and report any open areas, bruises, injuries, or signs of infection for example, swelling redness, pain , odor, pus like drainage to nurse. Care associated will provide set up bathing supplies per resident bathing schedule. Care associates will provide stand by assistance for safety during shower”; - “Eating/Meals/Hydration: Care associates will cue resident for meals and encourage independence in dining. Eating: The resident requires assistance for eating, reminding to go to meals.”; - “Level of awareness: Care associate to take resident for a walk.”; - “Vision: Ensure glasses are on and that the glasses are clean.”; - “Hearing: Care associates will remind resident to wear hearing aid(s).”; - “Care associate will provide laundry services 2 times weekly with showers.”; - “Dentures: Care associate will provide assistance with the resident’s dentures including cleaning and storing each morning, each evening, and as needed.”; and - “Assurance Checks: observe resident for safety/needs one time per shift.” 4. A review of R5’s medical record revealed a service plan, dated July 24, 2025, for directed care services, which detailed the services the facility would provide to R5,

Based on record review, documentation review, and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed potential dangers to residents who were unsupervised. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 6, 2025, for directed care services. The service plan included the following services: "strategies to ensure personal safety include frequent rounds for awareness of the resident's general or specific whereabouts and instruction on utilizing call pendant as appropriate...," and, "Mid-Day preferences...After lunch, prefers to rest and enjoys sitting outside and watching birds." 2. A review of the facility's policies and procedures revealed a policy titled, "General or Specific Whereabouts of Residents - AZ Only," last revised February 14, 2024, which stated, "...memory care residents need not be assessed for elopement risk as they have already been determined to be appropriate for a secured area...Associates should continuously monitor residents for knowledge of their general or specific whereabouts and exit-seeking strategies." 3. A review of facility incident reports revealed an incident report dated August 5, 2025 at 02:45. The incident report stated, "staff doing rounds and safety checks, observe [R1] is not in [R1's] room, staff located [R1] sitting outside by the patio. Observe [R1's] arms are red, [R1's] head and [R1's] back. staff escorted [R1] inside, checked vitals...[R1] is able to verbalize [R1] is not in pain..." and, "Immediate Action Taken: First aid provided, staff hydrated [R1] with lots of fluids intake, applied cold wash cloth on [R1's] head, back and [R1's] arms..." 4. A review of R1's medical record revealed a progress note, dated August 6, 2025 at 22:04. The progress note stated, "...hospice nursing on site to assess wounds as well. The blisters are thought to be related to [R1] receiving prolonged sun exposure on the 5th. The blisters were discovered on the 6th in the AM. Please note that per [E9], that [R1] may have a medical condition known at bulbous pemphigoid. It was noted in [R1's] admission H and P notes, although was never transcribed to [R1's] Watermark EMR...." 5. A review of R1's medical record revealed a progress note, dated August 7, 2025 at 11:07. The progress note stated, "...[E3] accompanied [Hospice nurse] to assess [R1]. [Hospice nurse] removed bandages, assessed, measured and documented wound. [Hospice Nurse] observed that the previous blisters were now open wounds. [E3] and [Hospice nurse] discussed the change in condition..." 6. In an interview, E2 reported the doors to the patio area from the memory care dining room are alarmed and were found to be functioning, however, E2 acknowledged the incident report indicated the memory care staff were not aware R1 was outside. E2 reported based on interviews with staff regarding when R1 left their room and ate, R1 was not outside

Based on record review and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program or documentation of employment as a manager or caregiver of an unclassified residential care institution or adult foster care home before November 1, 1998, for one of four sampled caregivers. The deficient practice posed a risk if an individual was not qualified to provide the required services. R9-10-806.A.1.a-b states: A. A manager shall ensure that:: 1. A caregiver: a. Is 18 years of age or older; and b. Provides documentation of: i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers; ii. For supervisory care services, employment as a manager or caregiver of a supervisory care home before November 1, 1998; iii. For supervisory care services or personal care services, employment as a manager or caregiver of a supportive residential living center before November 1, 1998; or iv. For supervisory care services, personal care services, or directed services, one of the following: (1) A nursing care institution administrator’s license issued by the Board of Examiners; (2) A nurse’s license issued to the individual under A.R.S. Title 32, Chapter 15; (3) Documentation of employment as a manager or caregiver of an unclassified residential care institution before November 1, 1998; or (4) Documentation of sponsorship of or employment as a caregiver in an adult foster care home before November 1, 1998; Findings include: 1. A review of E5's personnel record revealed E5 had been hired as a caregiver on April 18, 2025. 2. A review of E5's personnel record revealed a caregiver certificate issued by "ALTP0019" on September 19, 1996. 3. A review of E5's personnel record revealed documentation of verification of E5's caregiver certificate, which stated ALTP0019 had been an authorized caregiver training program starting on February 10, 1999, and ending on August 2, 2013. 4. A review of E5's personnel record revealed a work history which covered employment between January 2013 and April 2025. 5. A review of E5's personnel record revealed a caregiver certificate issued by an approved training program or documentation of employment as a manager or caregiver of an unclassified residential care institution or adult foster care home, before November 1, 1998, was not available for review. 6. In an exit interview with E1, E2, E3, E4, the findings were reviewed and no additional information as provided.

Based on record review and interview, the manager failed to ensure, for one of four sampled residents, a service plan included the level of service the resident was expected to receive. Findings include: 1. A review of R2's medical record revealed a service plan, dated June 30, 2025. However, the service plan did not state the level of care R2 was expected to receive. 2. In an interview, E3 reported R2 was in the memory care unit and received directed care services. 3. In an exit interview with E1, E2, E3, and E4, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan, when initially developed and when updated, was signed by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for one of four sampled residents. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R4's medical record revealed a service plan, updated June 25, 2025, and printed during the on-site inspection. However, the service plan did not include any signatures. 2. In an exit interview with E1, E2, E3, and E4, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on April 15, 2025, and from the on-site monitoring inspection conducted on July 6, 2025.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's medical record, for one of four sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan, and false or misleading information was provided to the Department. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 6, 2025, for directed care services, which detailed the services the facility would provide to R1.. 2. A review of R1's medical record revealed a progress note, dated August 6, 2025 at 9:51 PM. The progress note stated R1 was sent to the hospital on August 6, 2025 at 21:15 (9:15 PM). 3. A review of R1's medical record revealed a progress note, dated August 7, 2025 at 12:35 PM. The progress note stated R1 returned to the facility at 8:55 AM. 4. A review of R1's medical record revealed a document titled, "Documentation Survey Report v2," (ADL) dated August 2025. The ADL documented the services provided to R1 on each day in August 2025. The ADL documented the following: On August 6, 2025 at 23:33 (11:33 PM), a caregiver on the 2200-0600 shift documented providing R1 with, "Continence: Assist resident to/from bathroom per schedule. Assist with hygiene and incontinence supplies." However, this entry was false or misleading, as R1 was at the hospital during this time period; On August 6, 2025 at 23:35 (11:35 PM), a caregiver on the 2200-0600 shift documented providing R1 with, "Continence: Assist to/from bathroom 1 Naya to assist [R1] with toileting task. Report increasing difficulty with toileting task to MCD and RCD." However, this entry was false or misleading, as R1 was at the hospital during this time period; On August 6, 2025 at 23:36 (11:36 PM), a caregiver on the 2200-0600 shift documented providing R1 with, "Continence: Assist with continence supplies." However, this entry was false or misleading, as R1 was at the hospital during this time period; On August 7, 2025 at 00:01 (12:01 AM), a caregiver on the 2200-0600 shift documented providing R1 with, "Assurance Checks: Observe resident for safety/needs every 4 hours." However, this entry was false or misleading, as R1 was at the hospital during this time period; and On August 7, 2025 at 04:03 (4:03 AM), a caregiver on the 2200-0600 shift documented providing R1 with, "Assurance Checks: Observe resident for safety/needs every 4 hours." However, this entry was false or misleading, as R1 was at the hospital during this time period. 5. In an exit interview with E1, E2, E3, E4, the findings were reviewed and no additional information as provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on April 15, 2025.

Based on record review and interview, for one of four sampled residents, the manager failed to ensure a service plan for a resident receiving directed care services included documentation of the resident's weight and of coordination of communications with the resident’s representative, family members, and, if applicable, other individuals identified in the resident’s service plan. Findings include: 1. A review of R2's medical record revealed a service plan, dated June 30, 2025. However, the service plan did not state R2's level of care and did not include documentation of R2's weight or coordination of communications with R2's responsible party and family members. 2. In an interview, E3 reported R2 was in the memory care unit and receiving directed care services. 3. In an exit interview with E1, E2, E3, and E4, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when initially developed and when updated, was signed and dated by the resident or resident’s representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for three of nine residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a current service plan, signed by a nurse. However, the service plan had not been signed by the resident or resident's representative, or the manager. 2. A review of R2’s, R6's, and R7’s medical records revealed each resident had a current service plan. However, for each resident, the service plans provided for review did not include any signatures. 3. In an interview, E1, E2, E3, and E4 acknowledged the service plans provided for R1, R2, R6, and R7 were not signed and dated by the resident or resident’s representative, the manager, and the nurse or medical practitioner who reviewed the service plan. This is an uncorrected deficiency from the on-site compliance and complaint inspection conducted on April 15, 2025.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of nine residents sampled receiving medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order, and if false or misleading information was provided to the Department. Findings include: 1. A review of R6's medical record revealed a signed medication order dated May 16, 2025. The medication order stated the following: “Add: Lomotil 2.5MG capsule Take 1 tablet by mouth four times daily until diarrhea subsides Depakote 125MG capsule sprinkles Take 2 capsule by mouth two times daily Discontinue: Depakote 125MG capsule sprinkles Take 1 capsule by mouth twice daily." 2. A review of R6's medical record revealed a verbal order, dated May 26, 2025, signed by a registered nurse, which stated, "Routine Visit. Switched Lomotil to PRN now that diarrhea has subsided." 3. A review of R6's medical record revealed a medication administration record (MAR), dated May 2025, which included the following: - Lomotil had been marked as administered at 0700, 1100, 1600 and 1900 starting at 1900 on May 16, 2025 through 0700 on May 23, 2025. - Lomotil had been held with the code, "9" (See nurses note) starting at 1100 on May 23, 2025 through 1900 on May 24, 2025; - Lomotil had been marked as administered at 0700 on May 25, 2025; - Lomotil had been held with the code, "9" at 1100 on May 25, 2025; - Lomotil had been marked as administered starting at 1600 on May 25, 2025 through 1900 on May 26, 2025; - Lomotil had been held with the code, "9" at 0700 and 1100 on May 27, 2025' - Lomotil had been marked as administered starting at 1600 on May 27, 2026 through 0700 on May 28, 2025; - Lomotil had been marked held with the code, "9" starting at 1100 on May 28, 2025 through 1100 on May 30, 2025; and - Lomotil had been marked as administered starting at 1600 on May 30, 3025 through 1900 on May 31, 2025. 4. A review of R6's medical record revealed medication hold notes as follows: - On May 23, 2025 at 10:20, Lomotil was held with the note, "The resident has not had diarrhea in the last 2 days"; - On May 24, 2025 at 07:29, Lomotil was held with the note, "Resident has not had loose bm in 2 days"; and - On May 24, 2025 at 12:06, Lomotil was held with the note, "Resident has not had loose bm in 3 days." 5. A review of R6's medical record revealed a controlled substance log for Lomotil. The controlled substance log indicated on May 30, 2025, one tablet had been signed out at 4:00 PM. However, the MAR indicated the medication had been administered at 1600 and 1900 on May 30, 2025, indicating the MAR was false and misleading for the 05/30/2025 entry at 1900. 6. A review of R6's medical record revealed a medication administration record (MAR), dated June 2025, which included the following: - Lomotil had been marked as administered at 07

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for four of seven personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. A.R.S. § 36-411 states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section

Based on record review and interview, the manager accepted an individual who required continuous nursing services. Findings include: A review of R4's medical record revealed a form titled, "Determination for Admission, AZ Only." The form had been signed and dated by a medical provider four days prior to R4's date of acceptance. This form stated, "2. Does this person require continuous nursing service? (i.e. skilled nursing, RN/LPN 24/7)," and had been marked, "Yes." In an interview, E2 reported R4 had not required continuous nursing services and R4's medical provider had not completed the form accurately prior to R4's acceptance. In an interview, E1, E2, E3, and E4 acknowledged the form, required per R9-10-807.B, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, had indicated R4 did require continuous nursing services at the time of acceptance, however, the facility had accepted R4 anyway, as they did not agree with this assessment.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when initially developed and when updated, was signed and dated by the resident or resident’s representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for three of seven residents sampled. Findings include: 1. A review of R2’s, R3's, and R5’s medical records revealed each resident had a current service plan. However, for each resident, the service plans provided for review did not include any signatures. 2. In an interview, E1, E2, E3, and E4 acknowledged the service plans provided for R2, R3, and R5 were not signed and dated by the resident or resident’s representative, the manager, and the nurse or medical practitioner who reviewed the service plan.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for four of seven residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1’s, R2’s, R3’s, and R7’s medical records revealed each resident had a current service plan describing the services which would be provided to each resident. 2. A review of R1’s, R2’s, and R3’s medical records revealed electronic documentation titled, “Documentation Survey Report,” (ADL) which documented the services provided to each resident on each day in March 2025 and April 2025. However, the ADLs included multiple gaps and omissions, for each resident, where required services had not been documented to have been provided. 3. A review of R7’s medical record revealed ADL’s dated December 2024 and January 2025 documenting the services provided to R7. However, the ADLs included multiple gaps and omissions, where required services had not been documented to have been provided. 4. In an interview, E1, E2, E3, and E4 acknowledged the services provided to each resident had not been accurately documented on the provided ADL forms. This is a repeat deficiency from the on-site complaint inspection conducted on March 3, 2022, the on-site compliance inspection conducted on March 14, 2023, and the on-site compliance and complaint inspection conducted on March 1, 2024.

Based on record review and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to a resident, for one of seven sampled residents. Findings include: A review of R6's medical record revealed a medication administration record (MAR) dated November 2024. The MAR indicated R6 was being administered the following medications, 'Lactulose, Haloperidol, Lorazepam, and Morphine. A review of R6's medical record revealed medication orders were not available for review. In an interview, E1, E2, E3 and E4 acknowledged the medical record provided for R6 had not included medical records.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for two of seven residents sampled receiving medication administration. Findings include: 1. A review of R2's medical record revealed a signed medication order dated April 9, 2025. The medication order stated the following: “Add: Lorazepam 1MG tablet, Take 1 tablet by mouth three times daily scheduled and every 4 hours as needed Discontinue: Lorazepam 0.5MG Tablet, Take one tablet by mouth three times a day Lorazepam 0.5 MG Tablet, Take one tablet by mouth every 6 hours as needed.” 2. A review of R2's medical record revealed a medication administration record (MAR), dated April 2025, which included the following: - “Lorazepam, 0.5MG Tablet…three times daily” had been marked as administered on April 9, 2025 at 0700, 1300, and 1900; - “Lorazepam, 1.0MG Tablet,” had been marked as administered on April 9, 2025 at 1600; - “Lorazepam, 0.5MG Tablet,” had been marked as administered on April 10, 2025 at 1900; - “Lorazepam, 1.0MG Tablet,” had been marked as administered on April 10, 2025 at 0700, 1100, and 1600; - “Lorazepam 0.5 MG tablet…every 6 hours as needed,” had not been administered in April 2025; and - “Lorazepam 1.0 MG tablet…every 4 hours as needed,” had not been administered in April 2025; 3. A review of R2’s medical record revealed a document titled, “Controlled Substance Declining Inventory record,” for the medication, “Lorazepam 0.5 MG.” The log documented the following: - On 04/09/2025 at 0923, 1 dose was given; - On 04/09/2025 at 1245, 1 dose was given; - On 04/09/2025 at 1725, 1 dose was given; - On 04/09/2025 at 2004, 1 dose was given; and - On 04/10/2025 at 7 AM, 1 dose was given. 4. A review of R2’s medical record revealed a “Controlled Substance Declining Inventory Record,” for the medication, “Lorazepam 1.0MG.” The log documented the following: - On 04/09/2025, no entries had been made; - On 04/10/2025 at 758 [AM], 1 amount was given; - On 04/10/2025 at 334 [AM], 1 amount was given; - On 04/11/2025 at 1134, 1 amount was given., however, an original mark in the date field had been obscured and was not legible. 5. A review of R5’s medical record revealed a MAR, dated March 2025, which revealed the following: - On March 7, 2025 at 1300, “Aspirin 81 MG, co Q10 50 MG Softgel, Fish Oil 1200MG Softgel, Folic Acid 1 MG tablet, and L-Lysine 500Mg tablet had been left blank; and - On March 15, 2025 at 1900, “Diflunisal 500 MG, Donepezil HCL 5 MG, and Gabapentin 300 MG had been left blank. 6. In an interview, E1, E2, E3, and E4 acknowledged the medication administered to R2 and R5 had not been accurately documented in the provided records.

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, in R3’s bedroom, the compliance officer observed a hygiene supply drawer in the attached bathroom had a lock, however, the lock appeared loose and the Compliance Officer was able to open the cabinet without the key. Inside the drawer, the Compliance Officer observed a tube of Diclofenac Gel. 2. During an environmental inspection of the facility, in R5’s bedroom, the compliance officer observed a medicine cabinet in the attached bathroom did not have a lock. Inside the cabinet, the Compliance officer observed containers of “Acyclovir,” and “Acetaminophen.” 3. A review of R3’s medical record revealed a service plan for directed care services including medication administration for all medications. 4. A review of R5’s medical record revealed a service plan for personal care services including medication administration for all medications. 5. In an interview, E1, E2, E3, and E4 acknowledged medications stored by the assisted living facility had not been stored in a separate locked area.