Acuna at Morning Sun

Based on observation, record review, and interview, the governing authority failed to designate a manager who had a certificate as an assisted living facility manager. Findings include: 1. During the facility tour, the compliance officer did not observe a manager's certificate posted in the facility. 2. A review of the facility’s documentation revealed there was no manager's delegation of authority available for review. 3. A review of personnel records revealed there was no personnel file for the current manager of the facility. 4. In an interview, E2 reported no longer being the manager for the facility as of June 23, 2025, and had been the manager for the facility for three months. 5. In an interview, E3 reported there was no personnel record available for review for a current certified manager for the facility at the time of the survey, and there was no documentation that designated a manager in writing. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on May 7, 2025.

Based on observation and interview, the manager failed to ensure the current assisted living facility’s license was conspicuously posted. Findings include: 1. During a facility tour, the compliance officer did not observe the facility’s current Assisted Living facility license posted. 2. In an interview, E3 reported being unaware of the Assisted Living facility’s license whereabouts and acknowledged that the license was not posted.

Based on record review and interview, the manager failed to ensure that two of four sampled employees had personnel records. Findings include: 1. During a facility tour, the compliance officer conducted room temperature checks for each bedroom. V1 was found residing in the master bedroom's closet. 2. In an interview, V1 reported being a volunteer who cooked meals for the residents in the facility and was responsible for cleaning R3’s briefs when R3 resided at the facility. 3. In an interview, E3 reported that E1 hired E3. 4. A review of E3‘s personnel record revealed a document titled “orientation” dated March 18, 2025, reflecting that E1 was the administrator to sign and date E3‘s orientation. 5. A review of E3’s personnel record revealed a document titled “employment application,” which was signed by E1 and reflected that E1 was the administrator. 6. In a request to review V1’s and E1’s personnel records, there were no personnel records available for review for V1 or E1. 7. in an interview, E3 acknowledged there was no personal record available for review for V1 and E1.

Based on record review and interview, the manager failed to ensure medical records were maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1. Findings include: 1. In an interview, E3 reported that at the time of the visit, R1 and R2 remained in the facility, and R4 and R3 had been discharged. According to E3, the residents had not been informed ahead of time of the termination of residency. 2. In a request to review R3’s and R4’s medical records, there was no documentation of a medical record available for review. 3. In an interview, E3 acknowledged R3’s and R4’s medical records were not available for review, and their records were no longer at the facility. This is a repeat deficiency from the compliance inspection conducted on August 10, 2023.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. Findings include: 1. During a facility tour, the compliance officer observed a dishwasher located in the kitchen that appeared to be rusted on the inside. 2. During a facility tour, the compliance officer observed the master bedroom light fixture to be nonfunctional. 3. In an interview, E3 acknowledged that the dishwasher and the light fixture in the master bedroom were not maintained in working condition.

Based on observation, documentation review, and interview, the manager failed to ensure a pest control program was implemented and documented. Findings include: 1. During the facility tour, the compliance officer observed insects that were brown with a flat and oval body shape, with thread-like antennas, and appeared to have six legs, located inside the kitchen cabinet drawers containing kitchen utensils. 2. A review of facility documentation revealed there was no documentation of pest control being implemented or documented. 3. In an interview, E3 reported that a pest control company had visited the facility to conduct service. However, E3 was unable to provide documentation that pest control was implemented during the survey.

Based on observation and interview, the manager failed to ensure heating and cooling systems maintained the assisted living facility at a temperature between 70° F and 84° F at all times. Findings include: 1. During a facility tour, the compliance officer observed the master bedroom that contained two resident beds to be at a temperature of 85.2°F. 2. In an interview, E3 acknowledged that the master bedroom was not maintained between 70° F and 84° F, and reported that there were problems with the facility's air conditioner.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation required by this rule, for two of four personnel sampled. The deficient practice posed a risk as required information for a personnel member could not be verified. Findings include: 1. A review of the Medication Administration Record (MARS) for R3 showed that E4 signed off on the medication record. 2. In an interview, E2 revealed that E3 use to be the owner of the facility and left a few months ago. E2 believed that E3 took employee and resident records when the employee left. 3. A review of personnel records revealed that records for E3 and E4 were not available for review at the time of the inspection. 4. In an interview, E1 acknowledged that there were no personnel records for E3 and E4 as required.

Based on documentation review and interviews, the manager failed to ensure that an incident report and ensuing investigation was conducted as per the requirements of R9-10-803.J. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. In an interview, E2 revealed that a potential abuse incident occurred involving R1 and an employee but E2 was not sure which employee. 2. The Compliance Officer requested an incident report for the incident involving R1, however, no documentation of the incident was provided. 4. E1 acknowledged that the manager failed to comply with requirements of R9-10-803.J by not completing an incident report nor investigation.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation required by this rule, for two of four personnel sampled. The deficient practice posed a risk as required information for a personnel member could not be verified. Findings include: 1. A record review of the Medication Administration Record (MARS) for R3 showed that E4 signed off on the medication record. 2. In an interview, E2 revealed that E3 use to be the owner of the facility and left a few months ago. E2 believed that E3 took employee and resident records when the employee left. 3. A review of personnel records revealed that records for E3 and E4 were not available for review at the time of the inspection. 4. In an interview, E1 acknowledged that there were no personnel records for E3 and E4 as required.

Based on observation and interview, the manager failed to ensure medical records were maintained for 2 of 4 residents reviewed. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. During the environmental inspection, the Compliance Officer was informed by E2, that R1, R2 and R3 had recently been, but were no longer residents of the facility. 2. The Compliance Officer requested to review the medical records for R1, R2, and R3. 3. The medical records for R2 and R3 were not provided for review. 4. In an interview, E1 acknowledged that medical records were not maintained for R2 and R3.

Based on observations, documentation review, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. During the environmental inspection, the Compliance Officer observed that when the patio door in the living room was opened, no alarm sounded to alert employees that a person was entering or exiting the facility. 2. A review of Department documentation revealed the facility was authorized to provide Directed Care services. 3. In an interview, E2 acknowledged that personnel would not be alerted to a resident exiting the facility due to the alarm or alert on the patio door not being operational.

Based on observation and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record for R2 and R3. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A request to review the medical records for R2 and R3 was made by the Compliance Officer during the compliance inspection. E2 verified that R1, R2, and R3 were previous residents of the facility. 2. The residents records were not available during the compliance inspection. 3. In an interview, E1 acknowledged a medication administered to a resident was not documented in the resident's medical record for R2 and R3.

Based on observation and interview, the manager failed to ensure the bathroom accessible from the common area contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control. Findings include: 1. During the environmental inspection, the Compliance Officer observed that a bathroom accessible from a common area did not have paper towels in a dispenser or a mechanical hand dyer. 2. In an interview, E2 revealed that the paper towels were removed from the bathroom because residents kept clogging the toilet with them. E2 acknowledged the bathroom accessible from the common area did not contain paper towels in a dispenser or a mechanical air hand dryer.

Based on record review and interview, the manager accepted a resident whose primary condition was a behavioral health issue. The deficient practice posed a risk as the health care institution was not authorized to provide behavioral health services. Findings Include: 1. Review of documents provided for R1 revealed a copy of a court order which stated that R1 "[...] as a result of a mental disorder [was] gravely disabled and in need of psychiatric treatment". 2. No documentation of a physical health condition was provided for R1. 3. E2 acknowledged the manager accepted a resident whose primary condition was a behavioral health issue.

Based on record review and interview, the manager failed to ensure a resident had a written service plan for 2 of 4 residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. During the environmental inspection the Compliance Officer verified with E2 that R2 and R3 were prior residents of the facility. 2. The Compliance Officer requested to review the service plans for R1, R2, and R3. 3. The service plans for R2 and R3 were not provided for review. 4. In an interview, E1 acknowledged R2 and R3 did not have written service plans.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the compliance inspection, the Compliance Officer observed a copy of the toxicology guide titled " Poisoning and Drug Overdose" 6th edition by Kent Olson that was last updated in 2012. 2. An online search of the toxicology guide titled " Poisoning and Drug Overdose" 7th edition by Kent Olson that was last updated in 2022. 3. In an interview, E1 and E2 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Based on documentation review and interview, the manager failed to ensure all required policies and procedures were established, documented and implemented. Findings include: 1. A review of facility documentation revealed no policies and procedures were available to review. 2. In an interview, E1 stated E1 did not have access to the policy and procedure manual, and acknowledged the required documentation was not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. The Compliance Officer requested the following at 10:10 AM: -Employee disaster drills; -Resident and employee evacuation drills; -Disaster plan and annual review; -Two personnel records; -Two medical records; -Policies and procedures; and -Fall Prevention and Fall Recovery training program. 2. In a telephonic interview, E2 stated E1 did not have access to the requested documents, and was unsure if E1 would be able to provide documents to the Compliance Officer within two hours of the request for the documentation. 3. The Compliance Officer conducted the exit interview with E1 at 12:15 PM. None of the aforementioned documentation was provided within two hours of the request. 4. In a telephonic interview, E2 acknowledged the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request.

Based on observation, record review, and interview, the manager failed to ensure a personnel record for an employee or volunteer was maintained throughout the individual's period of providing services in or for the assisted living facility, for two of two personnel members sampled. The deficient practice posed a risk as required information could not be verified. Findings include: 1. The Compliance Officer arrived at the facility at approximately 10:00 AM. At the time of arrival, the Compliance Officer observed E1 working on the premises, cleaning the facility and providing services to a resident. 2. The Compliance Officer requested to review E1's and E2's personnel records. However, personnel records were not provided for review. 3. In an interview, E1 reported E1 did not have access to personnel records and acknowledged the requested personnel records were not provided for review.

Based on observation and interview, the manager failed to ensure a calendar of planned activities was prepared at least one week in advance, posted in a location easily seen by the residents, and updated as necessary to reflect substitutions in the activities provided. The deficient practice posed a risk if residents were unable to participate in planned activities. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a posted activity calendar dated April 2022 on the side of the kitchen refrigerator. 2. In an interview, E1 acknowledged the manager failed to ensure a calendar of planned activities was prepared at least one week in advance, posted in a location easily seen by the residents, and updated as necessary to reflect substitutions in the activities provided.

Based on record review and interview, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for two of two residents sampled. The deficient practice posed a risk as required information could not be verified, and the Department was unable to determine substantial compliance as the documentation was not provided during the inspection. Findings include: 1. The Compliance Officer requested R1's and R2's medical records for review. However, the medical records were not provided for review. 2. In an interview, E1 reported E1 did not have access to the medical records, and acknowledged the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1.

Based on observation, documentation review, and interview, the manager failed to ensure a food menu was prepared at least one week in advance and was maintained at least 60 calendar days after the last day included in the food menu. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided at the exit interview. Findings include: 1. During the enviromental inspection of the facility, the Compliance Officer observed a posted food menu for seven days, labeled Sunday - Saturday. However, the document did not contain dates. 2. A review of the facility's documentation revealed food menus maintained for at least 60 calendar days after the last day included in the food menu were not available for review. 3. In an interview, E1 acknowledged the missing dates on the posted menu and reported the facility did not have any current menus, or menus maintained for the last 60 days.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was developed, documented, maintained in a location accessible to caregivers and assistant caregivers, and, if necessary, implemented, to include when, how, and where residents would be relocated, how a resident's medical record would be available to individuals providing services to the resident during a disaster, a plan to ensure each resident's medication would be available to administer to the resident during a disaster, and a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility's relocation site during a disaster. The deficient practice posed a risk as no plan to ensure the health and safety of residents in an emergency was provided for review. Findings include: 1. The Compliance Officer requested the facility's disaster plan and disaster plan review. However, the documentation was not provided for review. 2. In an interview, E1 reported E2 had the disaster plan documentation. E1 acknowledged the manager failed to ensure the facility's disaster plan was developed, documented, and maintained in a location accessible to caregivers and assistant caregivers.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility documentation revealed no disaster drills were available to review. 2. In an interview, E1 reported E1 was new and unsure if the disaster drills were completed. E1 acknowledged the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months; and included all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. A review of facility documentation revealed no employee and resident evacuation drills were available to review. 2. In an interview, E1 acknowledged documentation was not available showing an evacuation drill for employees and residents was conducted at least once every six months.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95 \'baF and 120 \'baF in areas of the assisted living facility used by residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the hot water temperature to be 142 \'b0F in the sink sink in the hallway bathroom between bedrooms 1 and 2. 2. In an interview, E1 acknowledged the hot water temperature was not maintained between 95 \'b0F and 120 \'b0F.