Sun Groves Assisted Living LLC

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities, including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB. 2. In an interview, E4 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. The facility was licensed at the directed care level. 2. A.R.S. § 36-401.A.42. defines "Supervision" means directly overseeing and inspecting the act of accomplishing a function or activity. 3. Upon arrival at the facility, E1 was standing in front of the garage with R1. The Compliance Officers were greeted by E2 inside, while E1 assisted R1 back into the facility. 4. A review of E1’s personnel record revealed that E1 was an assistant caregiver. 5. During an interview, E4 reported that E1 was an assistant caregiver. E2 was the certified caregiver. 6. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that caregiver’s and assistant caregiver’s skills and knowledge were verified and documented before providing physical health services, according to policies and procedures, for two of three employees sampled. The deficient practice posed a health and safety risk. Findings include: 1. A review of E2’s personnel record revealed E2’s hire date was September 30, 2024. 2. A review of E2’s personnel record revealed the following: Documentation of skills and knowledge was conducted on September 30, 2024. This skills and knowledge documentation did not include basic patient care and medication management. A caregiver certification was issued to E2 on August 30, 2025. No documentation of skills and knowledge after the caregiver certification was issued. 3. A review of the September 2025 personnel schedule revealed E2 worked from September 1, 2025, to September 16, 2025. 4. A review of R1's medical record revealed a September 2025 medication administration record (MAR). E2 signed the MAR from September 6, 2025, to September 15, 2025. 5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation, documentation review, record review, and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible, for two of two residents sampled. The deficient practice posed a risk to the residents' health and safety if the documentation in the medical records was not accurate and legible. Findings include: 1. During an environmental inspection of the facility with E4, the Compliance Officers observed a plastic container with correction tape in it. 2. A review of R1's medical record revealed the following change with white corrective tape: -Medication Administration Record (MAR) for August 2025 -The HIPAA Release Form -MAR for September 2025 2. A review of R2's medical record revealed the following change with white corrective tape: - The Pre-Hospital Medical Care Directive -The Admission Agreement Disclosure -Medication Order dated May 8, 2025 -MAR for August 2025 3. A review of facility policies and procedures revealed no policy on documenting in medical records. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided. 5. Technical assistance was provided on this Rule during the inspection conducted on July 26, 2024.

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. During the environmental tour, the Compliance Officers observed residents’ medical records on clipboards sitting unsecured on top of a file cabinet. The file cabinet was located to the left when you enter through the front door. 3. A review of facility policies and procedures revealed no policy on storing medical records. 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 medical record contained a copy of a resident's health care power of attorney (POA), for one of two residents reviewed. The deficient practice posed a risk if the facility did not have the required legal documentation of a resident's responsible party. Findings include: 1. A review of R2's medical record revealed the current service plan date on July 10, 2025. The service plan indicated R2 received directed care services. The current service plan was signed by R2’s representative. The record did not include a copy of R2's health care POA. 2. During an interview, E4 reported that R2 had a POA. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a resident’s medical record included the name and signature of the individual administering medication for two of two residents sampled. The deficient practice posed a health and safety risk to residents if the facility did not properly document medication administration for a resident, and the Department was provided false or misleading information. Findings include: 1. Upon arrival at the facility at 9:29 am, E1 was standing in front of the garage with R1. The Compliance Officers were greeted by E2 inside. E2 stepped aside to give E4 a call. 2. During the inspection, the Compliance Officers observed E4 filling out the Medication Administration Record (MAR) and Activities of Daily Living (ADLs) for September 16, 2025, for R1 and R2. 3. A review of R1’s and R2's medical records revealed E2’s initials on the MAR and ADLs for the morning of September 16, 2025. E4 was signing E2’s initials. 4. A review of the facilities personnel schedule revealed E4 was not on the schedule for the morning of September 16, 2025. 5. A review of facility policies and procedures titled “Recording MAR and Maintenance.” The policy stated, “The facility shall maintain a daily medications administration (MAR) for each resident who receives assistance with self-administration of medications or medication administration. A MAR must include the name of the resident and any known allergies the resident may have; the name of the resident’s healthcare provider, the health care provider’s telephone number; the name, strength, and directions for use of each medication; and a chart for recording each medication is taken, any missed dosages, refusals to take medications as prescribed, or medication errors. The MAR must be immediately updated each time the medication is offered or administered.” 6. In an interview, E4 reported that E2 administered medication when E2 was scheduled. 7. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure the means of exiting the facility for residents who do not have a key, special knowledge for egress, or the ability to expend increased physical effort, monitored 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. Upon arrival at the facility, E1 was standing in front of the garage with R1. The Compliance Officers observed E1 enter the house through the side door of the garage. 2. During an environmental inspection, the Compliance Officers observed the following: The door in the laundry room leading to the garage was unlocked and not monitored or alerted. The side door in the garage was unlocked and not monitored or alerted. R1’s room had a sliding door. The sliding door was not monitored or alerted. The door was easily opened by unlocking the lock on the handle. 3. In an interview, E4 acknowledged that the side garage door and R1’s sliding door were not monitored or alerted. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

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; and included all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. The deficient practice posed a health and safety risk to residents and employees if the employee were unable to implement the evacuation plan. Findings include: 1. A review of the facility’s evacuation drill records revealed an evacuation drill conducted on January 5, 2025 and July 5, 2025. However, these drills did not include a physical evacuation of the residents and staff. 2. In an interview, E4 acknowledged that the residents were not evacuated. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that toxic materials were stored 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. During an environmental inspection of the facility, the Compliance Officers observed an unlocked closet in the hallway and near the kitchen. The closet contained Cutex Care nail polish remover. 2. During an environmental inspection of the facility, the Compliance Officers observed the garage door in the laundry room. The door was unlocked and not alarmed. In the garage, the Compliance Officers observed a spray can of WD-40 and a can of paint. 3. A review of the facility’s policies and procedures revealed a policy and procedure titled “Environmental Hazards & Safety.” The policy stated, “Poisonous or toxic materials, cleaning supplies and insecticides will be safely stored in labeled containers in a locked area separate from food preparation and storage, dining areas, and medication and should not be accessible to residents.” 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. In an on-site abbreviated compliance inspection, the Compliance Officer requested to review documentation of the caregivers and assistant caregivers working each day since the facility opened and had residents. 2. In an interview, E2 reported the documentation was not available for review. 3. In an interview, E2 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked by each.

Based on observation, record review, and interview, the manager failed to ensure a complete personnel record was available for two of three employees sampled. The deficient practice posed a risk as required information could not be verified for E1 and E3. Findings include: 1. Upon arrival, the Compliance Officer was greeted by E3 and observed E3 was the only caregiver on-site with two residents. E1 and E2 arrived approximately 30 minutes later. 2. The Compliance Officer requested all personnel records for review. The Compliance Officer received only E2's personnel record. 3. During the inspection, the Compliance Officer left the dining room (where the Compliance Officer was reviewing documents) and walked around the corner to the kitchen. The Compliance Officer observed E1 and E3 sitting at the kitchen island hastily completing E1's and E3's personnel records. 4. In an interview, E2 acknowledged there were no personnel records available for review for E1 and E3.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance for one of two residents reviewed. The deficient practice posed a risk as there was no service plan to direct the services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed no service plan was available for review. Based on R2's date of admission, this service plan was required. 2. In an interview, E2 acknowledged R2's service plan was not completed within 14 calendar days of acceptance.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of one resident sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan and the Department was given false and misleading information. Findings include: 1. A review of R1's medical record revealed a service plan dated February 5, 2024. The service plan indicated R1 required the following services: -Complete bath: two times weekly; -Shampoo: two times weekly; -Oral care: daily; -Nail care: clean daily and as needed; -Shave: as needed; -Comb/brush hair: daily; -Dressing: partial assist two times a day; -Toileting: Independent with partial caregiver assistance as needed; -Transfers: Independent with partial caregiver assistance as needed; -Ambulation: Independent with partial caregiver assistance as needed; and -Medication administration. 2. A review of R1's activities of daily living (ADL) documentation revealed services provided had not been documented as provided from July 21, 2024-present. 3. In an interview, the Compliance Officer discussed the incomplete ADL documentation with E2. E2 reported the documentation was complete and presented the Compliance Officer with R1's ADL documentation. The Compliance Officer observed the documentation was now complete and current and asked E2 if E2 recently filled in the documentation while the Compliance Officer was on-site. E2 denied altering the documentation. The Compliance Officer then presented a picture of the incomplete documentation taken earlier during the inspection. E2 did not provide any additional clarification.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk to the health and safety of residents if employees were unaware of a resident's egress from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During a tour of the facility, the Compliance Officer observed there was no alarm to alert employees of the egress of a resident out of the front door. The Compliance Officer observed an alert system was installed on the front door. However, the the alert system was not activated. 3. During a tour of the facility, the Compliance Officer observed when exiting from the patio door to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility. The Compliance Officer observed an alert system was installed on the patio door. However, the alert system was not activated. 4. During a tour of the facility, the Compliance Officer observed the aforementioned doors allowed residents to be at least 30 feet away from the facility. 5. In an interview, E2 acknowledged the aforementioned doors did not alert employees of the egress of a resident from the facility.