Arizona Sun Assisted Living 1, LLC

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility that 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. Review of Department documentation revealed the facility was licensed for directed level of care. 2. The Compliance Officer observed the door leading to the backyard had an alarm. However, when the door was opened, the alarm did not sound. There were no special locks on the door to control egress. 3. In an interview, E3 acknowledged the door alarm was off and the door was not controlled or able to alert employees of the egress of the resident from the facility. 4. Technical assistance was provided on this Rule during the inspection conducted on December 4, 2023.

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, for one of four residents sampled. 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 R1’s current service plan dated June 11, 2025, revealed that R1 received medication administration. 2. Review of R1’s signed medication order dated June 9, 2025, revealed “trazodone HCL Oral Tablet 50 MG take one tablet by mouth at HS.” 3. Review of R1’s June 2025 medication administration record (MAR) revealed Trazodone 50 MG was not documented as administered for the entire month. 4. The Compliance Officer observed Trazodone 50 MG was not available in R1’s medication organizer. 5. Review of the facility’s policy and procedures revealed a policy titled, “C. Medication Administration record (MAR)” stated, “4. Ensure that medication is administered to a resident only as prescribed.” 6. In an interview, E3 acknowledged Trazodone 50 MG was not available and acknowledged medication was not administered in compliance with a medication order. 7. This is a repeat deficiency from the inspection conducted on December 27, 2024.

Based on record review, documentation review, and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record for three of four residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1’s, R2’s, and R3’s service plans revealed R1, R2, and R3 received medication administration. 2. Review of R1’s June 2025 medication administration record (MAR) revealed the following medications were administered: Donepezil 5 MG Levothyroxine Sodium 100 MCG Oxcarbazepine 300 MG Risperidone .5 MG However, documentation was not available showing that these medications were administered from June 28th to the present. 3. Review of R2’s June 2025 MAR revealed the following medications were administered: Gabapentin 600 MG Levothyroxine 75 MCG Oxybutynin ER 10 MG Tamsulosin .4 MG However, documentation was not available showing that these medications were administered from June 28th to the present. 4. Review of R3’s June 2025 MAR revealed the following medications were administered: Furosemide 20 MG Levothyroxine Sodium 50 MCG Sertraline HCL 100 MG However, documentation was not available showing that these medications were administered from June 28th to the present. 5. Review of the facility policies and procedures revealed a policy titled, “C. Medication Administration Record (MAR)” which stated, “8. A medication administered to a resident/ e. Is documented in the resident’s MAR.” 6. In an interview, E3 acknowledged documentation was not available showing R1's, R2's, and R3's medications were administered June 28th to the present. 7. This is a repeat deficiency from the inspection conducted on December 4, 2023.

Based on observation, documentation 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 in an unlocked kitchen cabinet the following: Two bottles of Omeprazole 40 MG Tolerodine tart ER 4 MG Atrovastatin 40 MG Hydroxyz Pam Cap 25 MG 2. The Compliance Officer observed in an unlocked refrigerator the following: Lorazepam 2 mg per mL Lispro INS 100 unit Lantus Solostar 100 unit Latanoprost .005% eye drops One Insulin Lispro Kiwikpen injection 3. Review of the facility policies and procedures revealed a policy titled, “C. Medication Administration Record (MAR)” which stated, “A resident’s medication is stored in the facility’s secured cabinet.” 4. In an interview, E3 acknowledged medication was stored unlocked.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed the following chemicals in an unlocked kitchen cabinet: A spray canister of Lysol Disinfectant spray; A spray bottle of Lysol All-Purpose Cleaner; and A spray canister of Raid. 2. The Compliance Officer observed the following chemicals in an unlocked common bathroom cabinet: (The cabinet had a latch, but was not locked.) A Spray bottle of Lysol All-Purpose Cleaner; and A bottle of Lysol Power Clinging Gel 3. The Compliance Officer observed a door with a key inserted into the lock. When the Compliance Officer opened the door it revealed the room was the facility’s pantry. Inside the pantry was a container of Clorox disinfectant wipes. 4. Review of the facility's policy and procedures revealed a policy titled, “ XI Security and Safety C. Environmental Safety,” which revealed, “7. Poisonous or toxic materials stored by the facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and inaccessible to residents.” 5. In an interview, E3 acknowledged toxic materials were not maintained in a locked area and inaccessible to residents

Based on observation, documentation review, and interview, the manager failed to ensure a pet was licensed consistent with local ordinances, for one of one pet records reviewed. The deficient practice posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1. The Compliance Officer observed O2 at the facility. 2. A review of the O2's records revealed no documentation of a license with Maricopa County. 3. In an interview, E3 acknowledged O2 did not have documentation of a Maricopa County license.

Based on documentation review, observation, and interview, the manager failed to ensure a pest control program that complied with A.A.C. R3-8-201(C)(4) was implemented and effective. The deficient practice posed a potential risk to residents. Findings include: 1. R3-8-201.C.4. stated "C. Applicator licensure. 4. An individual may not provide pest management services at a school, child care facility, health care institution, or food-handling establishment unless the individual is a certified applicator in the certification category for which services are being provided." 2. Review of the facility's policy and procedures revealed a policy titled, “ XI Security and Safety C. environmental Safety,” which revealed, “9. A pest control program is implemented and documented.” 3. A review of the facility’s pest control records revealed that pest control was last out to the facility on April 23, 2025. 4. The Compliance Officer observed a spray canister of Raid ant and roach killer under an unlocked kitchen cabinet sink. 5. In an interview, E3 acknowledged that E3 sprayed for bugs using the Raid spray canister under the kitchen sink. E3 acknowledged E3 was not a licensed applicator. 5. In an interview, E3 acknowledged the facility did not utilize a pest control program complaint with A.A.C. R3-8-201(C)(4).

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a health risk to the resident. Findings include: 1. Review of R1's medical record revealed a current written service plan dated August 5, 2024, This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a hospital discharge order dated December 18, 2024. This discharge order included a signed medication order that stated "Digoxin 125 MCG 1 tablet oral Daily" and included the next scheduled dose was "12/19/24 9 am." 3. Review of R1's medical record revealed a December 2024 medication administration record (MAR). This MAR showed Digoxin was not administered until December 23, 2024 at 8pm. 4. In an interview, E1 reported the medication was not administered until December 23rd because they were waiting on the pharmacy to pick up the medication. 5. A review of R1's medications revealed a bottle of Digoxin 125 MCG. The label on this bottle revealed the medication was dispensed on December 18, 2024. 6. In an interview, E1 acknowledged the medication was not administered in compliance with the medication order.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the facility quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Quality Management Programs" reviewed and signed by E4 March 29, 2023. This policy stated "A documented report is submitted quarterly by the manager or manager's designee..." 2. Review of the quality management program documentation revealed the last quality management report was completed April 2023 - June 2023. 3. In an interview, E1 acknowledged the quality management report was not submitted per the frequency established in the quality management program.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated November 25, 2023. This service plan stated the following services were needed: "Eating - Requires total care - 3x daily" "Oral Care - Requires Assistance - 2x daily and as needed" "Nail Care - Requires total care - daily and trim as needed" "Hair Care/Shaving - Requires Assistance - Comb hair daily and as needed" "Dressing - Requires Assistance - 2x daily and as needed" "Bathing - Requires total care - shower 2x every week by CNA and facility staff as needed" "Toileting - Requires total care - brief change in bed daily as needed" "Transferring - Requires total care - daily and as needed" However, documentation was not available indicating these services were provided December 1st - present. 2. Review of R2's medical record revealed a current written service plan for personal care services dated June 5, 2023. This service plan stated the following services were needed: "Eating - Requires total care - 3x daily feeding tube jevity for nutrition" "Oral Care - Requires Assistance - 2x daily and as needed" "Nail Care - Requires total care - daily and trim as needed" "Hair Care/Shaving - Requires Assistance - Comb hair daily and as needed" "Dressing - Requires Assistance - 2x daily and as needed" "Bathing - Requires total care - shower 2x every week staff as needed" "Toileting - Requires total care - brief change in bed daily as needed" However, documentation was not available indicating these services were provided December 1st - present. 3. In an interview, E1 acknowledged R1's and R2's medical records did not include documentation of the above listed services and reported the services were provided as indicated in the service plans.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. Review of R1's medical record revealed no documentation that showed the pneumonia vaccination was offered or received. Based on R1's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R1's medical record did not include current documentation that showed the pneumonia vaccination was offered or received.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed a current written service plan dated June 5, 2023. This service plan stated "Bed Bound". 2. Review of R2's medical record revealed a written determination from R2's medical practitioner signed and dated May 25, 2023. However, documentation was not available that stated R2's needs could be met by the facility and R2's needs were within the facility's scope of services, at least once every six months. 3. In an interview, E1 reported R2 was unable to ambulate even with assistance since acceptance and acknowledged R2's medical practitioner did not provide a written determination at least once every six months.

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 two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated November 25, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated February 27, 2023. These medication orders stated the following: "Atorvastatin 40mg oral tablet take 1 tablet QD" "Risperidone 0.25mg take 1 tablet Q 12 H" "Rivaroxaban 15mg oral tablet take 1 tablet QD" "Trazodone 100mg oral tablet take 1 tablet HS" 3. Review of R1's medical record revealed a December 2023 medication administration record (MAR). This MAR did not include documentation Atorvastatin, Risperidone, Rivaroxaban, and Trazodone were administered December 1st - present. 4. During an observation of R1's medications, Atorvastatin, Risperidone, Rivaroxaban, and Trazodone were observed. 5. Review of R2's medical record revealed a current written service plan dated June 5, 2023. This service plan indicated R2 received medication administration. 6. Review of R2's medical record revealed signed medication orders dated November 2, 2023. These medication orders stated the following: "Amitriptyline 150mg tablet take 1 tablet every day" "Eliquis 5mg tablet take 1 tablet by mouth twice daily" "Famotidine 40mg tablet take 1 tablet twice a day" "Metoprolol Tartrate 25mg tablet take 1/2 tablet by mouth twice daily" "Omeprazole 40mg capsule take 1 capsule twice a day" "Hydroxychloroquine 200mg tablet take 1 tablet every day" "Zolpidem 5mg tablet take 1 tablet every day" In addition, R2's medical record revealed a signed medication order dated November 27, 2023. This medication order stated the following: "Levothyroxine 112mcg tablet take 1 tablet every day" 7. Review of R2's medical record revealed a December 2023 MAR. This MAR did not include documentation Amitriptyline, Eliquis, Famotidine, Metoprolol, Omeprazole, Hydroxychloroquine, Zolpidem, and Levothyroxine were administered December 1st - present. 8. During an observation of R2's medications, Amitriptyline, Eliquis, Famotidine, Metoprolol, Omeprazole, Hydroxychloroquine, Zolpidem, and Levothyroxine were observed. 9. In an interview, E1 reported the medications were administered per the medication orders and acknowledged R1's and R2's medical records did not include documentation the medications were administered.

Based on interview and record review, the manager failed to ensure a therapeutic diet was provided to a resident according to a written order from the resident's primary care provider or a medical practitioner. Findings include: 1. In an interview, R2 reported R2 received G-tube feedings of Jevity 1.5 one can bolus at lunch and at dinner. 2. Review of R2's medical record revealed no written orders for Jevity 1.5 two times a day. 3. In an interview, E1 acknowledged R2 received G-tube feedings and a therapeutic diet order was not available.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "Disaster Drill and Relocation Plan." A document titled "Disaster Plan Review" revealed the disaster plan was last reviewed October 7, 2022. 2. In an interview, E1 acknowledged the facility's disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. Review of the December 2023 personnel schedule revealed two shifts; 7am -7pm (day shift) and 7pm - 7am (night shift). 2. Review of the facility's employee disaster drills revealed the most current disaster drill conducted April 9, 2023 on the day and night shift. No other employee disaster drills were available after April 9, 2023. 3. In an interview, E1 acknowledged documentation was not available that showed the employee disaster drills were conducted on each shift at least once every three months.

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. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. Review of the facility's employee and resident evacuation drills revealed the most current drill conducted April 9, 2023. No other employee and resident evacuation drills were available after April 9, 2023. 2. In an interview, E1 acknowledged the employee and resident evacuation drills were not conducted at least once every six months.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours of acceptance, for two of two residents reviewed. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency. Findings include: 1. Review of R1's medical record revealed documentation of orientation to the facility's evacuation plan. However, the orientation was not completed within 24 hours of acceptance. Based on R1's date of acceptance, this documentation was required. 2. Review of R2's medical record revealed documentation of orientation to the facility's evacuation plan. However, the orientation was not completed within 24 hours of acceptance. Based on R2's date of acceptance, this documentation was required. 3. In an interview, E1 acknowledged R1 and R2 were not oriented to the facility's evacuation plan within 24 hours of acceptance.