Sunrise Assisted Living Home

Based on documentation review, interview, record review, and observation, the manager failed to ensure an individual authorized to administer opioids identified the resident's need for an opioid before administering the opioid and the effect of the opioid administered for one of two residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility's medication policy and procedures stated, “3. Facility personnel will provide opioid medication based on doctor’s orders for regular administration (on a regular basis) and will identify and document the level of pain and/ or need the caregiver will administer or assist with self administration of the opioid based on the physician PRN written order.” 2. In an interview, the Compliance Officers asked E1 who is taking opioids and not on hospice. E1 reported R2 was. 3. A review of R2’s current service plan dated September 2025 revealed R2 received medication administration. The service plan also did not have any indication R2 was receiving hospice services or receiving end of life care. 4. A review of R2’s medication orders revealed R2 was taking Oxycodone 10 mg. Which stated “Give 1 tablet by mouth every 8 hours needed for pain 1-10”. 5. A review of R2’s “PRN administration record” revealed R2 was taking “Oxycodone 15mg tab take 1 tab, by mouth 3 times daily as needed for pain” on January 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, and 10th of 2026. On this record it recorded the effectiveness however it did not record the pain level. 6. The Compliance Officers observed the Oxycodone 10 mg in a blister pack. A few of the Oxycodone 10 mg were administered from the blister pack. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411(C)(2) for one of two personnel reviewed. The deficient practice posed a risk as required information could not be verified for personnel to determine a person's fitness to work in the assisted living home. Findings include: 1. A.R.S. § 36-411(C)(2) states, "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card." 2. A review of the Arizona Department of Public Safety Fingerprint Clearance Status website revealed E1 and E2 currently had valid fingerprint clearance cards. However there was no verification of E2’s fingerprint verification within E2's record. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled residents. The deficient practice posed a potential TB exposure risk to residents and the department was provided false and misleading information. Findings include: 1. R9-10-113(A)(2)(a)(i-ii) 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…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 [and] ii. Determining if the individual has signs or symptoms of tuberculosis." 2. A review of R2’s resident record revealed a blank TB signs and symptoms risk assessment. R2’s resident record also revealed one TB skin test dated September 2025. However there was not an indication if R2 was negative or positive TB. Based on R2’s suspected date of admission this was required. 3. In an interview, the Compliance Officers reported the Compliance Officers found the blank TB signs and symptoms risk assessment. E1 took R2’s records back from the Compliance Officers which E1 reported E1 was going to try to find the missing document. E1 then returned the file at the time of the exit interview. E1 showed the Compliance Officers a filled TB signs and symptoms risk assessment, however it was missing the signature from the person who read the test. Also the blank TB signs and symptoms risk assessment was now missing from the file. The Compliance Officers reported the missing blank TB signs and symptoms risk assessment to E1. E1 reported that it was always there. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included terms of occupancy, including the date of occupancy or expected date of occupancy, for one of two sampled residents. Findings include: 1. A review of R2’s medical record revealed a residency agreement. However, the residency agreement did not include R2’s dates of occupancy or expected dates of occupancy. 2. In an interview, E1 referred to the date that was signed by the resident or resident’s representative was the date of occupancy. However on the residency agreement there was a part that was labeled “Admission date:” was left blank. E1 was going to write in the date of residency on the blank space in front of the Compliance Officers. However, the Compliance Officers told E1 not to edit the document. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for one of two residents sampled. The deficient practice posed a health and safety risk if the required individual did not acknowledge the services that were to be provided. Findings include: 1. A review of R2’s medical record revealed a service plan dated September 2025, for supervisory care services, including medication administration services. However, this service plan did not include a signature and date by the resident or the resident’s representative, facility manager, or a nurse or medical practitioner. The service plan that was given to the Compliance Officer showed that six of the seven pages were given. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview the manager failed to ensure that medication administered to a resident was documented in the resident’s medical record for one of two sampled residents. 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 service plan dated October 2025 revealed R1 received medication administration services. 2. A review of R1’s medication orders signed and dated on November 2025 revealed R1 was ordered to take the following medication: - Trazodone 100 mg 1 tablet at bedtime - Carvedillol 12.5 mg 1 tablet “2xdaily” - Atorvastatin Calcium 40 mg 1 tablet at bedtime - Nifedipine ER 30 mg “Tab” once daily - Seroquel 50 mg 1 tablet at bedtime - Amlodipine 10 mg 1 tablet at bedtime 3. A review of R1’s medication administration record for the month of January 2026 (MAR) revealed the following was not documented on the listed days: - Trazodone 100 mg January 12th and 13th at 8 pm - Carvedilol 12.5 mg 1 tablet January 12th at 8 pm and January 13th at 8 am and pm. - Atorvastatin Calcium 40 mg January 12th and 13th at 8 pm - Nifedipine ER 30 mg January 13th at 8 am - Seroquel 50 mg January 12th and 13th at 8 pm - Amlodipine 10 mg January 13th at 8 am 4. In an interview, E1 reported the medications were administered however not documented on the MAR. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and documentation review, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. During an environmental tour, the Compliance Officer observed a locked cabinet. After further observation, it was revealed that the cabinet lock was loosely attached and fell off. 11 bubble packs of resident medication was stored in the cabinet. 2. A review of the facility’s policies and procedures revealed a policy titled “Medications Including Opioids and Narcotics”. The policy stated, “Medication stored by the facility will be locked in the medication storage area.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled "Disaster plan, Relocation, Records, Medication, Food and Water”. The policy stated, “The disaster plan is reviewed and the review is documented at least once every 12 months and includes the date and time of the disaster plan review, the name of each employee or volunteer participating in the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement.” 2. A review of the facility’s disaster plan review revealed an August 2024 completed disaster plan review. After further review, the disaster plan for 2025 could not be located. An incomplete document that only contained the manager’s name and title on the document was located. 3. In an interview, E1 acknowledged the 2025 disaster plan review sheet was not completed. 4. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and documentation review, the manager failed to ensure hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour, the Compliance Officer observed steam from a faucet in a common bathroom. After further observation, the Compliance Officer observed a hot water temperature of 150º F in a common bathroom. 2. A review of the facility’s policies and procedures revealed a policy titled "Environmental and Physical Plant Safety”. The policy stated, “Hot water temperature will be maintained between 95º F and 120º F at all times. Water temperatures outside the prescribed range will be reported to the Manager for correction immediately.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour, the Compliance Officer observed an unlocked garage door. Upon further observation the Compliance Officer observed a bottle of Bleach, Weed and Grass Killer, Comet, and multiple open boxes of surface cleaners and air fresheners. 2. A review of the facility’s policies and procedures revealed a policy titled "Environmental and Physical Plant Safety”. The policy stated, “Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dining areas, and medications and are inaccessible to residents." 3. In an interview, E1 reported the garage normally was locked and restricted for residents. 4. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour, the Compliance Officer observed an unlocked garage door. Upon further observation the Compliance Officer observed a canister of gasoline. 2. During an environmental tour, the Compliance Officer observed charcoal and lighter fluid in the backyard near the grill. 3. A review of the facility’s policies and procedures revealed a policy titled "Environmental and Physical Plant Safety”. The policy stated, “Combustible, flammable and other hazardous materials will be stored in safety approved containers or original container in a storage area that is locked and inaccessible to the residents." 4. In an interview, E1 reported the gasoline in the garage was for the lawn mower, but the garage normally was locked and restricted for residents. 5. In an interview, E1 acknowledged the lighter fluid and charcoal could be a fire hazard and would be locked away. 6. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that at least one manager or caregiver was present at the assisted living facility when a resident was on the premises. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. Upon entry at approximately 2:24 PM, the Compliance Officer observed E2 was the only staff in the facility with one resident. 2. E2 made a phone call and reported E1 went out to the mailbox and will return shortly. At approximately 2:50 PM E1 arrived at the facility. 3. A review of E2's personnel record revealed E2 was an assistant caregiver and a housekeeper. 4. In an interview, E1 acknowledged E2 was not a certified caregiver. 5. In an interview, E1 acknowledged a manager or caregiver was not present at the assisted living facility when a resident was on the premises.