Sunrise Assisted Living Facility

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's personnel schedule revealed there were two shifts: Day and Night. 2. A review of the facility's disaster drills revealed documentation of a disaster drill conducted on the following dates and times: -May 27, 2024, at 11:15 AM -May 27, 2024, at 7:35 PM -August 29, 2024, at 2:50 PM -August 29, 2024 7:45 PM -April 15, 2025, at 11:10 AM -April 15, 2025, at 7:20 PM However, no documentation was provided to demonstrate that a drill was conducted between August 2024 and April 2025. 3. In an interview, E2 acknowledged that a disaster drill for employees was not conducted on each shift at least once every three months. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on May 6, 2022.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a residency agreement. However, this residency agreement did not include the signature of the manager and date signed. Based on R1's acceptance date, this document was required to be signed. 2. A review of R2's medical record revealed a residency agreement. However, this residency agreement did not include the signature of the manager and date signed. Based on R2's acceptance date, this document was required to be signed. 3. In an interview, E1 and E2 acknowledged that R1's and R2's residency agreements did not include the signature of the manager and date signed. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to annually assess the facility's risk of exposure to infectious tuberculosis. Findings include: 1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis per R9-10-113(A)(2)(d) was available for review. 2. In an interview, E2 acknowledged that the health care institution had no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis per R9-10-113(A)(2)(d) available for review. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for two of two resident sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record revealed R1 requested to receive the flu vaccinations on October 02, 2024. However, documentation was not available showing whether the pneumonia vaccination was received or refused. Based on R1's acceptance date, this documentation was required. 3. A review of R2's medical record revealed R2 requested to receive the flu vaccinations on October 02, 2024. However, documentation was not available showing whether the pneumonia vaccination was received or refused. Based on R2's acceptance date, this documentation was required. 4. In an interview, E1 and E2 acknowledged that R1's and R2's medical records did not include documentation showing that pneumonia vaccinations were received or refused. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.