Arizona Sun Assisted Living 2, LLC

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for one of three personnel sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1’s personnel record revealed a chest X-ray. However, documentation was not available indicating E1 had a previous positive TB skin test or blood test and without such documentation, a chest x-ray is not acceptable as documentation of freedom from TB. In addition, there was no documentation of a risk assessment of prior exposure to infectious TB or a determination if E1 had signs or symptoms of TB. Based on E1's date of hire, this documentation was required. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident, for four of four residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a current written service plan dated June 6, 2025, which indicated R2 received personal care services. This service plan indicated R2 received caregiver assistance with bathing and dressing. 2. A review of R2's October 2025 “Activities of Daily Living Flowsheet” revealed R2 did not receive any assistance with bathing in October. 3. In an interview, E4 reported that R2 was independent with bathing; however, the staff would stand by for safety. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. § 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. The Compliance Officers (CO) observed a large cabinet in the living room. E4 opened the cabinet without unlocking the cabinet. The CO observed several ambulatory residents in the facility. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility with E3, the Compliance Officer (CO) observed two sets of kitchen cabinets with individual latch locks. However, the latches were open, and the padlock was hanging on the latch. The CO was able to open the cabinets. The cabinets contained medications for all the residents. 2. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food or medication contained a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. The deficient practice posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. During an environmental inspection of the facility with E3, the Compliance Officer did not observe a thermometer in the refrigerator in the kitchen. 2. In an exit interview, the findings were reviewed with E4, and no additional information was provided. 3. This is a repeat deficiency from the compliance inspection conducted on January 23, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure that a smoke detector was tested once a month. The deficient practice posed a health and safety risk to the residents. Findings include: 1. During the environmental inspection, the Compliance Officer (CO) did not observe a fire alarm system or a sprinkler system. The CO did observe smoke detectors. 2. A review of the facility's documentation revealed a “Maintenance Log.” The “Maintenance Log” indicated that the smoke detectors were last tested in August of 2025. 3. In an interview, E4 acknowledged that the smoke detectors have not been tested since August 2025. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication that was administered, for one of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R2's medical record revealed a current written service plan dated November 9, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed no documentation of a signed medication order or verbal medication order for Trazodone 50mg. 3. Review of R2's medical record revealed a January 2024 medication administration record (MAR). This MAR stated "Trazodone 50mg Tablet take 1 tablet by mouth at bedtime" and indicated one tab was administered at 8pm January 3rd - present. 4. During an observation of R2's medications, Trazodone 50mg was observed and one tab was observed prefilled in the "Bed" slot of R2's medication organizer. 5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R2's medical record did not contain a medication order from a medical practitioner for a medication that was administered.

Based on record review and interview, the manager failed to ensure a service plan included strategies to ensure a resident's personal safety, for one of one resident reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the caregivers did not know how to ensure the residents safety. Findings include: 1. Review of R1's medical record revealed a document titled "Health Care Visit Form" dated August 29, 2023. This document stated "...Pt's mattress being placed on floor at night to prevent falls..." Review of R1's written service plan for directed care services dated November 14, 2023 did not include that R1's mattress was placed on the floor at night. 2. In an interview, R6 and E3 reported R1's mattress was placed on the floor at night. 3. In an interview, E1 acknowledged R1's service plan did not include strategies to ensure R1's personal safety.

Based on record review, observation, and interview, the manager failed to ensure a written order verifying the verbal order was obtained from the medical practitioner within 14 calendar days after receipt of the verbal order, for one of two residents reviewed. The deficient practice posed a health risk to the resident. Findings include: 1. Review of R2's medical record revealed a current written service plan dated November 9, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a verbal medication order dated December 27, 2023. This order stated "Senna S 8.6-50mg 1 tab, twice a day as scheduled". However, documentation was not available that showed a written order was obtained from the medical practitioner within 14 days. 3. Review of R2's medical record revealed a January 2024 medication administration record (MAR). This MAR stated "Docusate/Senna leaf 50mg, 8.6mg take 1 tablet, film coated (total of 50mg, 8.6mg) BID" and indicated one tab was administered at 8am and 5pm January 1st - present. 4. During an observation of R2's medications, Senna S was observed and one tab was prefilled in R2's medication organizer in the "Morn" and "Eve" slot. 5. In an interview, E1 reported the medication was administered per the verbal medication order and acknowledged R2's medical record did not include a written order from the medical practitioner within 14 days.

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 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 a current written service plan dated November 9, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed no documentation of a signed medication order or verbal medication order for Trazodone 50mg. 3. Review of R2's medical record revealed a January 2024 medication administration record (MAR). This MAR stated "Trazodone 50mg Tablet take 1 tablet by mouth at bedtime" and indicated one tab was administered at 8pm January 3rd - present. 4. During an observation of R2's medications, Trazodone 50mg was observed and one tab was observed prefilled in the "Bed" slot of R2's medication organizer. 5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R2's medication was not administered in compliance with an available medication order. This is a repeat deficiency from the compliance inspection conducted on May 18, 2022.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed an opened bottle of Kikkoman Soy Sauce and two whole eggs stored in the kitchen pantry. The bottle stated "Refrigerate after opening". 2. In an interview, E1 and E2 acknowledged the foods were stored in the pantry and required refrigeration. 3. Technical assistance was provided on this Rule during the compliance inspection conducted May 18, 2022.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer. The deficient practice posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed that there was no thermometer in the refrigerator in the garage. This refrigerator contained food used for the residents. 2. In an interview, E2 reported the refrigerator was used to store food for the residents and E1 and E2 acknowledged the refrigerator did not contain a thermometer. 3. Technical assistance was provided on this Rule during the compliance inspection conducted May 18, 2022.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for two of three residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R4's medical record revealed a document titled "Progress Notes" dated May 8, 2023. This document stated "...blood pressure was elevated per home health nurse and suggested to send to the ER..." However, documentation was not available that showed R1's emergency contact and primary care provider were notified of this incident. 2. Review of R5's medical record revealed a document titled "Incident Report" dated November 15, 2023. This document stated "...Call 911...found resident on the floor, don't want to be assessed/touched, insisted to call 911..." However, documentation was not available that showed R1's emergency contact and primary care provider were notified of this incident. 3. In an interview, E1 acknowledged R4's and R5's medical records did not include documentation that showed a caregiver immediately notified the resident's emergency contact and primary care provider.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented the time of the incident; the action taken by the caregiver; and the individuals notified by the caregiver, for two of three residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R4's medical record revealed a document titled "Progress Notes" dated May 8, 2023. This document stated "...blood pressure was elevated per home health nurse and suggested to send to the ER..." However, the documentation did not include the time of the incident, the action taken by the caregiver, and the individuals notified by the caregiver. 2. Review of R5's medical record revealed a document titled "Incident Report" dated November 15, 2023. This document stated "...Call 911...found resident on the floor, don't want to be assessed/touched, insisted to call 911..." However, the documentation did not include the time of the incident and the individuals notified by the caregiver. 3. In an interview, E1 acknowledged R4's and R5's medical records did not include the required documentation.

Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed the window in R3's bedroom. This window had plantation shutters that were locked using a keyed lock that prevented the window from being accessed and opened. 2. In an interview, E1 and E2 acknowledged R3's bedroom window had a lock that prevented access to the window and E1 acknowledged the premises was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed one large oxygen tank, two medium oxygen tanks, and two small oxygen tanks unsecured in the facility garage. 2. In an interview, E1 and E2 acknowledged oxygen tanks were not secured in an upright position.