Arizona Sunset Assisted Living

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedure manual revealed an update date of May 30, 2021. 2. In an interview, E2 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that when initially developed, was signed and dated by the resident or resident’s representative, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated April 16, 2025. However, the resident or resident's representative did not sign and date the service plan. 2. In an interview, E2 acknowledged R1's service plan was not signed and dated by the resident or resident's representative.

Based on observation, record review, and interview, the manager failed to ensure that a resident or resident's representative consented to photographs of the resident before the resident was photographed, for two of two residents sampled. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed cameras used in the facility to monitor residents' whereabouts. 2. A review of R1's and R2's medical records did not contain a photographic consent form signed by the resident or resident's representative. 3. In an interview, E2 acknowledged R1's and R2's medical records did not contain consent to photographs by the resident or resident's representative before R1 and R2 were photographed.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2), for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R2's service plan (dated January 23, 2025) revealed R2 received personal care services and was confined to a bed or chair. 3. A review of R2's medical record revealed a determination for continued residency dated November 20, 2020. However, no further documentation was available for Compliance Officer review. 4. In an interview, E2 acknowledged R2's medical record did not include the required determination per R9-10-814(B)(2) updated at least once every six months.

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1’s medical record revealed a medication order for Gabapentin 400 milligrams (mg), 1 tablet by mouth (po) twice a day (bid). 2. A review of R1’s medication administration record (MAR) for July 2025 revealed R1 was administered Gabapentin 400 mg, 1 tablet po daily, and indicated 1 tablet was given at 8:00 AM July 1, 2025 - present. 3. The Compliance Officer observed Gabapentin 400 mg prefilled in R1's medication organizer for administration bid. 4. In an interview, E2 reported R1 was administered Gabapentin 400 mg at 8:00 AM and 8:00 PM. However, E2 acknowledged medication administered to R1 was not accurately documented in R1’s medical record.

Based on documentation review and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers requested the facility's toxicology reference guide. However, a guide was not available for review. 2. In an interview, E2 acknowledged a current toxicology reference guide was not available for use by personnel members.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C), for two of three caregivers sampled. The deficient practice posed a risk if E3 and E4 were a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(C) Owners 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. 2. A review of E3's (hired in 2023) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 3. A review of E4's (hired in 2023) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review. 4. In an interview, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C)(1)(2) for E3 and E4 was not available for review. This is a repeat deficiency from the on-site compliance inspection conducted on January 5, 2022.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures, for two of three caregivers sampled. The deficient practice posed a risk if E3 and E4 were unable to meet a resident's needs. Findings include: 1. The Compliance Officer observed E3 and E4 on the premises and working upon arrival. 2. A review of the facility's policies and procedures revealed a policy titled "Staffing, Documentation, and Recordkeeping" (dated May 30, 2021). The policy stated "Verify employee's skill and knowledge per the job description..." 3. A review of E3's (hired in 2023) personnel record revealed E3 was hired as a caregiver. However, documentation of the verification of E3's skills and knowledge was not available for review. 4. A review of E4's (hired in 2023) personnel record revealed E4 was hired as a caregiver. However, documentation of the verification of E4's skills and knowledge was not available for review. 5. In an interview, E1 acknowledged E3's and E4's skills and knowledge were not verified and documented prior to E3 and E4 providing physical health services and according to the facility's policies and procedures.

Based on observation, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the requirements in R9-10-806(C)(1)(c)(i)(iii)(vi)(ix), for one of four employees and R9-10-806(C)(1)(a)(b)(c)(i-iii)(vi)(ix), for one of four employees sampled. The deficient practice posed a risk if E3 and E4 were unable to meet a resident's needs, and the required information could not be verified for E3. Findings include: 1. The Compliance Officer observed E3 and E4 on the premises and working upon arrival to the premises. 2. A review of E3's (hired in 2023) personnel record revealed the following: -Name, date of birth, and contact telephone number; -Starting date of employment; -Education; -Experience; -Caregiver certificate; -Cardiopulmonary resuscitation training (CPR); and -First aid. However, documentation of the requirements in R9-10-806(C)(1)(c)(i)(iii)(vi)(ix) was not available for review. 3. A review of E4's (hired in 2023) personnel record revealed the following: -Name; -Caregiver certificate; -CPR; and -First aid. However, documentation of the requirements in R9-10-806(C)(1)(a)(b)(c)(i-iii)(vi)(ix) was not available for review. 4. In an interview, E1 acknowledged E3's personnel record to include the requirements in R9-10-806(C)(1)(c)(i)(iii)(vi)(ix) was not available for review. 5. In an interview, E1 acknowledged E4's personnel record to include the requirements in R9-10-806(C)(1)(a)(b)(c)(i-iii)(vi)(ix) was not available for review.

Based on observation and interview, the manager failed to ensure a life preserver or shepherd's crook was available and accessible in the swimming pool area. Findings include: 1. The Compliance Officer observed a swimming pool on premises, in the back yard. The swimming pool contained water. However, a life preserver or shepherd's crook was not available or accessible in the swimming pool area. 2. In an interview, E1 reported residents and personnel do not use the pool. E1 acknowledged the facility did not have a life preserver or shepherd's crook available in the swimming pool area.

Based on observation and interview, the manager failed to ensure pool safety requirements were conspicuously posted in the swimming pool area. Findings include: 1. The Compliance Officer observed a swimming pool on premises, in the back yard. The swimming pool contained water. However, pool safety requirements were not conspicuously posted in the swimming pool area. 2. In an interview, E1 reported residents and personnel do not use the pool. E1 acknowledged the pool safety requirements were not conspicuously posted in the swimming pool area.