Sun City West, Assisted Living & Memory Care

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of three 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 R1’s medical record revealed a current written service plan dated February 27, 2025. This service plan indicated R1 received medication administration. 2. Review of R1’s medical record revealed a signed medication order dated April 9, 2024. This medication order stated, “Digoxin 125 MCG tablet. Take 1 TAB by mouth every day for heart: hold for HR< 50.” 3. Review of R1’s medical record revealed Medication Administration Records (MARs) that showed the following: -January 17, 2025, the Digoxin 125 MCG entry revealed no heart rate was recorded and the facility was “waiting on pharmacy” -March 26, 2025, the Digoxin 125 MCG entry revealed R1's heart rate was 53, indicating Digoxin should be administered. However, Digoxin 125 MCG was not administered. -April 3, 2025, the Digoxin 125 MCG entry revealed no heart rate was recorded and the “medication was not available” -April 10, 2025, the Digoxin 125 MCG entry revealed R1's heart rate was 51, indicating Digoxin should be administered. However, Digoxin 125 MCG was not administered and the MAR notes stated "BP low" 4. In an interview, E3 reported if the MAR notes said, "Medication not available” or “waiting on Pharmacy” the medication was not administered. 5. In an interview, E1 acknowledged R1's medication was not administered in compliance with the medication order. 6. This is a repeat deficiency from the inspections conducted on September 18, 2023, July 17, 2024, and September 20, 2024.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of three residents reviewed. The deficient practice posed a health and safety risk to the resident. Findings include: 1. Review of R1’s medical record revealed a current written service plan dated February 27, 2025. This service plan indicated R1 received medication administration. 2. Review of R1’s medical record revealed a signed medication order that stated, “Potassium Chloride 20 MEQ TAB Take 1 TAB by mouth 1 dose 2/1/2025.” 3. Review of R1’s medical record revealed a February 2025 medication administration record (MAR). This MAR revealed Potassium Chloride 20 MEQ was administered February 1-8 2025. However, according to the order, it was a one-time dose. 4. In an interview, E3 acknowledged the medication was a single dose and was documented incorrectly. 5. In an interview, E1 and E3 acknowledged R1's medication was not accurately documented. 6. This is a repeat deficiency from the inspection conducted on June 13, 2022.

Based on documentation review, record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of six residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan and the Department was provided false or misleading documentation. Findings include: R9-10-101.5. "Activities of daily living" (ADL) means ambulating, bathing, toileting, grooming, eating, and getting in or out of a bed or a chair. 1. A review of R1's medical record revealed R1 was sent to the hospital on September 6th, 2024 and returned to the facility on September 11th, 2024. 2. A review of R1's medical record revealed a service plan dated in July 2024. The service plan indicated R1 received assistance with ADL's. 3. A review of R1's September 2024 ADL sheet documented R1 received the following services September 6th - 11th, when R1 was documented to be at the hospital: - Assist to/ from bathroom, - Care Partner checks throughout the day and night; - Skin checks; - Fall interventions; - Escort to and from meals; - Daily event reminders to the resident; - Resident meal reminders; - Ensure resident is using mobility device; and - Staff to assist resident with dressing and grooming. 4. In an interview, E1 acknowledged R1 was in the hospital from September 6th to September 11th. E1 acknowledged the ADL sheet was filled out when R1 was away from the facility and the Department was provided false or misleading documentation.

Based on record review and interview, the manager failed to ensure a resident's medication was administered in compliance with a medication order for two of six 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. A review of R3's medical record revealed no documentation of a signed medication order or a verbal medication order for NalTrexone 50 mg. 2. A review of R3's medical record revealed the following: -A signed order dated January 2024 for Furosemide 40 mg one tablet a day for 30 days. -A signed order dated February 2024 for Aspirin 325 mg one tablet a day for 30 days. -A signed order dated May 2024 for Gabapentin 300 mg two capsules once a day for 30 days. No current orders were available at the time of the inspection to continue the medications. 3. A review of R3's medical record revealed a Medication Administration Record (MAR) dated for September 2024. This MAR indicated the following: -NalTrexone 50 mg one tablet was administered at 8 am September 1st - present. -Furosemide 40 mg one tablet a day was administered at 8 am September 1st - present. -Aspirin 325 mg one tablet a day was administered at 8 am September 1st - present. -Gabapentin 300 mg one capsule twice a day was administered at 8 am and 8 pm September 1st - present. 4. A review of R4's medical record revealed no documentation of a signed medication order or a verbal medication order for Trazodone 50 mg. 5. A review of R4's medical record revealed a MAR dated for September 2024. This MAR indicated the following: -Trazodone 50 mg one tablet at bed time was administered at 8 pm September 3rd and 4th. 6. In an interview, E1 acknowledged the aforementioned medications were not administered in compliance with an order from a medical practitioner. This is a repeat deficiency from the compliance inspection conducted on September 18, 2023 and the complaint investigation conducted July 17, 2024.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of four residents reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. A review of R3's medical record revealed an incident report dated May 2024 that indicated R3 sustained an injury and medical services were required. The documentation did not include any action taken to prevent the incident from occurring in the future. 2. In an interview, E1 acknowledged R3's medical record did not include documentation of any action taken to prevent the incident from occurring in the future. This is a repeat deficiency from the compliance inspection conducted on September 18, 2023.

Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed areas of what appears to be vinyl flooring in R3's and R5's rooms were bubbled and lifted off the ground. R3 and R5 were ambulatory. 2. In an interview, R3 stated R3 had tripped over the raised floor. 3. In an interview, E1 acknowledged the premises at the assisted living facility were 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 an assistant caregiver interacted with residents under the supervision of a manager or caregiver, for one of one assistant caregiver reviewed. The deficient practice posed a risk as the individual was not qualified to provide the required services unsupervised. Findings include: 1. Arizona Revised Statutes (A.R.S.) \'a7 36-401.A.42. states "Supervision" means "direct overseeing and inspection of the act of accomplishing a function or activity." 2. During the complaint investigation, the facility had a resident census of 61 residents; with 53 residents who resided in the facility's "Assisted Living section," and nine residents who resided in the secured "Memory Care unit." 3. In documentation review, the staffing schedule for August 20, and August 27, 2024, showed documentation E5 and E6 worked at the facility on the night shift. 4. In record review, the personnel records for E5 and E6 indicated E5 was hired as a caregiver on June 18, 2024, and E6 was hired as an assistant caregiver on April 8, 2024. E6's personnel record included a job description for an assistant caregiver, and did not include documentation E6 completed a caregiver traing program. 5. During an interview, E1 reported E5 worked the night shift on the Assisted Living section, and E6 worked the night shift on the Memory Care unit, without supervision. E5 reported E5 worked on the Assisted Living section. E1 acknowledged E6 was required interact with residents under the supervision of a manager or caregiver; however, had worked alone with residents on the night shift on the memory care unit.

Based on documentation review, record review, and interview, for one of four caregivers and assistant caregivers reviewed, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB), as required by R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure to residents and staff. 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. In record review, E6's personnel record (hired as an assistant caregiver on April 8, 2024), did not include documentation the caregiver provided evidence of freedom from infectious TB, including a screening and risk assessment, as required. 3. In documentation review, the staffing schedule for August 2024, indicated E6 worked shifts at the facility. 4. During an interview, E1 acknowledged the personnel record for E6 did not include documentation E6 provided evidence of freedom from TB, as required by R9-10-113.

Based on record review, documentation review, and interview, for two of four caregivers and assistant caregivers reviewed, the manager failed to ensure a caregiver provided documentation of first aid (FA) training. The deficient practice posed a health and safety risk to residents if caregivers did not have FA training. Findings include: 1. In record review, the personnel records for E5 (hired on June 18, 2024, as a caregiver) and E8 (hired February 13, 2024, as a caregiver) did not include documentation of current FA training, as required. 2. In documentation review, the staffing schedule indicated E5 and E8 worked shifts at the facility, in August 2024. 3. During an interview, E1 acknowledged E5 and E8 did not provide documentation of current FA training, as required.

Based on record review and interview, for one of two residents reviewed, who received personal care services, the manager failed to ensure a written service plan was updated, signed and dated, at least once every six months. The deficient practice posed a health and safety risk to residents if the service plans were not reviewed and updated to include services to be provided for the resident to address the resident's current condition. Findings include: 1. In record review, R1's medical record (received personal care services), included a service plan dated December 31, 2023. The record did not include documentation R1's service plan was reviewed and updated at least once every six months. 2. During an interview, the Compliance Officer reviewed the findings with E1. E1 provided a service plan for R1, dated April 9, 2024, which E1 reported was printed from the computer. The service plan was not signed as reviewed and updated. E1 acknowledged a resident who received personal care services was required to have a written service plan reviewed and updated at least once every six months.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for two of three personnel sampled. The deficient practice posed a risk to the health and safety of residents if caregivers did not have the skills and knowledge before providing services to residents. Findings include: 1. A review of E3's and E4's personnel records revealed no documentation of the verification of E3's and E4's skills and knowledge. 2. A review of the facility's policy and procedures revealed a policy titled "Arizona State Specific Training Requirements" stated, "The community ED and Designees will document that Community Associates are competent to provide personal care before assuming responsibilities and have received the following training," 3. In an interview, E1 acknowledged E3's and E4's skills and knowledge documentation was not in the personnel records to be viewed.

Based on documentation review and interview, the manager failed to establish and document a policy and procedure to protect the health and safety of a resident that covered assisting a resident in procuring medication. The deficient practice posed a risk of residents having an adverse reaction due to stopping a medication without an order. Findings include: 1. Review of the facility's policies and procedures showed no documented evidence of a policy and procedure that covered assisting a resident in procuring medication had been established and documented. 2. In an interview, E1 acknowledged the policy for procuring medication for a resident was not available to be viewed.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for two of four residents sampled. The deficient practice posed a risk if residents experienced a change in condition due to improper medication administration. Findings include: 1. A review of R3's service plan dated April 19, 2024 revealed R3 required supervision when taking the prescribed medication. 2. A review of R3's medication administration record (MAR) dated June 2024 revealed that on June 6th the medication for Chamosyn w/Aloe and Chamomile .45%- 20% ointment was not available. 3. A review of R4's service plan dated June 7, 2024 revealed R4 received medication assistance from the facility. 4. A review of R4's MAR dated July 2024 revealed that the facility was waiting on the pharmacy for the listed medications: - July 9, 2024 Aspirin EC 81 mg and Memantine HCL F/C 10 mg - July 10. 2024 Aspirin EC 81 mg and Memantine HCL F/C 10 mg - July 11, 2024 Memantine HCL F/C 10 mg 5. In an interview, E1 reported when the facility was waiting on the pharmacy for medication the resident did not receive the medication that day. 6. In an interview, E1 acknowledged R3's and R4's medications were not administered in compliance with the available medication orders. This is a repeat deficiency from the compliance inspection conducted on September 18, 2023.

Based on documentation review and interview, the governing authority failed to designate a certified manager, in writing, a manager who has either a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. A review of the Department records for the facility revealed that O1 was the current manager; no information was received from the governing authority to indicate that a new manager had been appointed. 2. The Compliance Officer observed an assisted living facility managers license was not conspicuously posted in the facility. 3. In a telephonic interview, E1 reported the previous manager O1 was terminated on April 15, 2024. In addition, E1 reported the facility did not have a manager with a certificate or a temporary certificate as an assisted living facility manager, as required. However, E1 was the temporary executive director of the facility but was not able to temporarily post E1's assisted living facility manager's certificate due to the NCIA Board regulation R4-33-411(B)(1). 4. R4-33-411(B)(1) states "Appointment as Manager of Multiple Assisted Living Facilities. B. A individual certified under R4-33-401 who is appointed to manage two assisted living facilities shall: 1. Ensure that the two assisted living facilities are no more than 25 miles apart." 5. In a telephonic interview, E1 acknowledged the facility did not designate in writing a manager who either had a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. 6. This is a repeat deficiency from the compliance and complaint inspection conducted September 18, 2023.

Based on observation, record review, documentation review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of five residents sampled. The deficient practice posed a risk as the service plan to direct services was not followed. Findings include: 1. During the environmental tour, the Compliance Officer observed R1 was in a wheelchair. However, R1 was able to ambulate with minimum assistance. 2. A review of R1's medical record revealed a current written service plan for personal care services. The service plan stated "Escort assistance - Need: Resident has difficulty ambulating and requires escorting and /or physical assistance..." The service plan also stated "Bathroom Assistance - Service: Resident's care needs will be met, either independently or with assistance." In addition, the service plan stated "Status Checks? - Resident requires status checks during the night. Care partners will observe resident periodically throughout the night to assist with needs or help ensure safety." 3. A review of Department documents revealed and incident that occurred early morning on March 30, 2024. This incident documented that R1 called for assistance for toileting, however E4 refused. 4. In an interview, R1 reported that E4 refused to provide bathroom assistance and suggested R1 urinate in R1's pants and E4 would change R1 in the bed. 5. In an interview, E1 and E2 acknowledged a caregiver did not provide R1 with the assisted living services indicated in the service plan.