Serendipity in the Sun, LLC

Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Fall Prevention and Fall Recovery.” The policy stated, “Existing personnel must complete a fall prevention and fall recovery training on or before the anniversary of his/her hire date or as part of the annual in-service training requirements, whichever is earlier.” 2. A review of E1's personnel record revealed E1’s hire date of December 16, 2021. A review of E1’s personnel record revealed fall prevention and fall recovery training completed on May 7, 2024. 3. A review of E2's personnel record revealed E2’s hire date of September 1, 2024. A review of E2’s personnel record revealed fall prevention and fall recovery training completed on June 23, 2024. 4. A review of E3's personnel record revealed E3’s hire date of June 20, 2024. A review of E3’s personnel record revealed fall prevention and fall recovery training completed on June 18, 2024. 5. In an exit interview, the findings were reviewed with E1 and E5, and no additional information was provided.

Based on record review, documentation review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution and annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of the facility’s October 2025 personnel schedule revealed the following: E1 worked from September 28, 2025, to October 6, 2025. E2 worked September 29, 2025, October 1, 2025, and October 4, 2025. E3 worked September 20, 2025, October 1, 2025, to October 4, 2025, and October 6, 2025. 2. A review of E1's personnel record revealed E1’s hire date of December 16, 2021. The personnel record revealed E1's documentation of training and education related to recognizing the signs and symptoms of TB dated April 15, 2024. 3. A review of E2's personnel record revealed E2’s hire date of September 1, 2024. The personnel record revealed E2's documentation of training and education related to recognizing the signs and symptoms of TB dated September 5, 2024. 4. A review of E3's personnel record revealed E3’s hire date of June 20, 2024. The personnel record revealed E3's documentation of training and education related to recognizing the signs and symptoms of TB dated June 18, 2024. 5. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment. 6. In an interview, E1 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 7. In an exit interview, the findings were reviewed with E1 and E5, and no additional information was provided.

Based on documentation review and interview, the governing authority failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility’s documentation revealed “Quality Management Program Evaluation” signed and dated on January 28, 2021. 2. In an interview, E1 acknowledged that “Quality Management Program Evaluation” was not conducted. 3. In an interview, E5 acknowledged that “Quality Management Program Evaluation” was not conducted for 2022, 2023, 2024, and 2025. 4. In an exit interview, the findings were reviewed with E1 and E5, and no additional information was provided.

Based on documentation review, 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 the facility’s policies and procedures revealed a policy titled “Service Plan.” The policy stated “Service Plan includes the following [...] the amount, type, and frequency of assisted living services being provided to the resident….” 2. A review of R1's medical record revealed a current written service plan dated June 12, 2025. This service plan indicated R1 received full assistance with bathing and dressing. However, the service plan did not indicate the frequency of bathing and dressing. 3. A review of the facility’s documentation revealed the facility's shower schedule. The shower schedule indicated R1 received showers on Wednesday and Friday. 4. A review of R1’s record revealed a September 2025 “task administration record.” The record revealed the following: R1 received showers on Wednesday and Friday R1 received a sponge bath on Monday, Tuesday, Thursday, Saturday, and Sunday. R1 was assisted with dressing every morning and evening. 5. A review of R2's medical record revealed a current written service plan dated September 16, 2025. This service plan indicated R2 received full assistance with bathing and dressing. However, the service plan did not indicate the frequency of bathing and dressing. 6. A review of the facility’s documentation revealed the facility's shower schedule. The shower schedule indicated R2 received showers on Thursday and Sunday. 7. A review of R2’s record revealed a September 2025 “task administration record.” The record revealed the following: R2 received showers on Thursday and Sunday. R2 received a sponge bath on Monday, Tuesday, Wednesday, Friday, and Saturday. R2 was assisted with dressing every morning and evening. 8. A review of R3's medical record revealed a current written service plan dated September 16, 2025. This service plan indicated R3 received full assistance with bathing and dressing. However, the service plan did not indicate the frequency of bathing and dressing. 9. A review of the facility’s documentation revealed the facility's shower schedule. The shower schedule indicated R3 received showers on Tuesday and Thursday. 10. A review of R3’s record revealed a September 2025 “task administration record.” The record revealed the following: R3 received showers on Tuesday and Thursday. R3 received a sponge bath on Monday, Wednesday, Friday, Saturday, and Sunday. R3 was assisted with dressing every morning and evening. 11. A review of R4's medical record revealed a current written service plan dated October 10, 2025. This service plan indicated R4 received full assistance with bathing and dr

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one of one resident sampled who received directed care services. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services, dated March 1, 2023. However, a more recently reviewed and updated service plan was not available for review. 2. In an interview, E1 acknowledged R2's service plan was not reviewed and updated at least once every three months.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the signature and date from the resident or resident's representative, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services, dated March 1, 2023. However, the service plan did not include a signature and date from the resident or resident's representative. 2. In an interview, E1 reported the facility sent all updated service plans to R2's representative, but R2's representative never reviewed and signed them. E1 acknowledged R2's written service plans did not include a signature and date from the resident or resident's representative.

Based on documentation review, observation, record review, and interview, the manager retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, without meeting the requirements in Arizona Administrative Code (A.A.C.) R9-10-814(B)(2), for one of one resident sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. Findings include: 1. A.A.C. R9-10-814(B)(2)(b) states: "The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: The resident's primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition; ii. Reviews the assisted living facility's scope of services; and iii. Signs and dates a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility;" 2. During the environmental inspection of the facility, the Compliance Officer observed R2 lying in R2's bed. 3. A review of R2's medical record revealed a current service plan for directed care services, dated March 1, 2023. R2's service plan stated, "Transferring - Full Assistance...Provide full assistance with transferring to/from wheelchair, chair, bed, standing position, etc. Requires full assistance from staff for all transfers...Is the resident confined to a bed or chair? Yes, Confined to Bed/Chair...Physical Disabilities: Non ambulatory..." 4. Further review of R2's medical record revealed a document titled "Determination and Authorization for Continued Residency" which stated, "The Arizona Department of Health Services requires that the primary care provider or other medical practitioner written authorization to authorize the above named patient to reside or continue to reside in the Assisted living facility...Please examine the resident and give us, the Assisted Living Facility, your consent and authorization...This authorization is required at the onset of the above condition...and at least once every six months throughout the duration of the resident's condition, that the facility can meet the resident's needs within the scope of services of the facility...This authorization is valid for the next six months from the date signed." The document was signed by a nurse practitioner on September 2, 2021. However, R2's medical record revealed no further documentation which indicated a medical practitioner examined R2 at least once every six months throughout the duration of R2's condition. 5. In an interview, E2 reported R2 had been confined to a bed or chair for the duration of R2's residence at the facility. E2 acknowledged documentation to demonstrate the requirements in A.A.C. R9-10-