Sunrise Oasis Assisted Living

Based on record review and interview, the manager failed to ensure that, before providing assisted living services to a resident, a caregiver provided current cardiopulmonary resuscitation (CPR) training specific to adults, for one of four personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E4's personnel record revealed a certificate of completion for CPR and Automated External Defibrillator (AED) from the NationalCPRFoundation with an expiration date of April 1, 2027. 2. A review of the facility’s personnel schedule for November 2025 revealed E4 worked November 2, 2025, to November 6, 2025; November 9, 2025, to November 12, 2025; November 15, 2025, to November 18, 2025; November 21, 2025, to November 24, 2025; and November 27, 2025, to November 30, 2025. 3. A review of the facility’s personnel schedule for December 2025 revealed that E4 worked December 1, 2025; and December 4, 2025 to December 9, 2025. 4. A review of the facility’s policies and procedures revealed a policy titled “CPR and First Aid.” The policy stated, “CPR and First Aid shall not be obtained from online courses.” 5. A review of the National CPR Foundation website, https://nationalcprfoundation.com/, revealed the following: The website stated, “National CPR Foundation is known for providing Life-Skill Techniques for longer more lasting lives. Harness the Power of Our Online Training and Earn Your Certification Today - The Smarter Way.” In the FAQ’s section, stated “Do you offer hands-on training? No, we do not offer hands-on training.” 6. In an exit interview, the findings were reviewed with E5 and O1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that 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 R9-10-113, for two of three residents sampled. The deficient practice posed a TB exposure risk to residents and false or misleading information was provided to the Department.  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. During the inspection, the Compliance Officers were sitting at the black desk in the kitchen. The Compliance Officer got up to ask a question. O1 and E5 were standing at the stove with residents' files. The Compliance Officer observed O1 filling out documentation of “Walker Services Service Plans, TB Skin Tests, Flu, Pneumonia & B12 shots” for R1. The Compliance Officer watched O1 fill in the “Mfr” and “Lot#” with black ink. The Compliance Officer asked O1 to stop and not fill out any additional documentation. 3. A review of R1’s medical record revealed the following: Two photo copies titled “Walker Services Service Plans, TB Skin Tests, Flu, Pneumonia & B12 shots” on one page that were signed and dated March 11, 2025. The “Mantoux Tb Skin Test” was checked off, but “Mfr,” “Lot#,” “Exp,” and “Dose” were not filled out. The top copy had the black ink from where O1 began to fill in the “Mfr” and “Lot#.” No other evidence of freedom from TB. 4. A review of R3’s medical record revealed no documentation of TB risk assessment. 5. In an exit interview, the findings were reviewed with E5 and O1, 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 documented the level of service the resident was expected to receive for one of two applicable residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1’s medical record revealed the following: A current service plan dated December 1, 2025, which indicated that R1 received supervisory care services. The service plan indicated the next renewal date would be March 1, 2027. The service plan indicated that R1 receives medication administration. 2. In an interview, E5 reported that R1 received directed care services. 3. In an interview, O1 reported that the top corner of the service plan indicated directed care services, which O1 believed was acceptable for the service plan. 4. In an exit interview, the findings were reviewed with O1, and no additional information was provided.

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. The Compliance Officers arrived at the facility at 9:47 am. The Compliance Officers arrived at the facility at 9:47 am. While waiting for E5 to arrive, the Compliance Officers observed R4 in the backyard carrying a medication bubble pack. 3. During the environmental inspection with E5, the Compliance Officers observed the trash and recycling bins overflowing and a separate pile of additional recycling materials. 4. In an interview, R4 reported that R4 walked over to the recycling pile to pick up a cardboard piece to pick up the dog waste in the backyard. R4 reported that when R4 was done picking up dog waste R4 took the cardboard covered in dog waste and threw it in the trash can. 5. During the environmental inspection with E5, the Compliance Officers opened the trash can and observed the medication bubble pack with a full prescription label was stuffed into an empty tissue box with the label in full view. 6. In an exit interview, the findings were reviewed with E5 and O1, 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 with E5, the Compliance Officers observed a plastic shelf with a blue basket on top in R1’s room. The Compliance Officers observed a bottle of “Equate Nail Polish Remover.” 2. During an environmental inspection of the facility with E5, the Compliance Officers observed a dresser with a green basket on top in R2’s room. The Compliance Officers observed a box of “Polident 3-minute daily Cleanser Antibacterial Dental Applicance Cleanser.” 3. A review of the facility’s policies and procedures revealed a policy titled “Facility Grounds and Free of Hazards.” The policy stated “The facility manager and/or that owner and staff will ensure that all poisonous or toxic materials (this is to include all cleaning supplies) will be stored in labeled containers in a locked area separate from food preparation and storage, dining areas and medications.” 5. In an interview, E5 acknowledged that the “Equate Nail Polish Remover” and the box of “Polident 3-minute daily Cleanser Antibacterial Dental Applicance Cleanser” were not locked up as required. 6. In an exit interview, the findings were reviewed with E5 and O1, and no additional information was provided.