Sunshine Village

Based on record review, documentation review, and interview, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of eight residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R5's medical record revealed a service plan. The service plan indicated R5 received directed care services and medication administration. 2. A review of R5's medical record revealed the resident did not have an end of life condition or an active malignancy. 3. A review of R5's medical record revealed a medication order signed by a physician and dated December 26, 2024 that prescribed Tramadol HCL 50 MG Tablet, 1 Tablet by mouth every 12 hours for pain. 4. A review of R5's medication administration record revealed the medication was administered as ordered every day from October 1, 2025, and October 15, 2025, at 8am and 8pm. The medication was also administered as ordered every day from October 16, 2025, and October 31, 2025, at 8am and 4pm. However, documentation of the monitoring of the effect of the opioid was not available for review. 5. When asked for documentation for the need of the administration of the medication to the resident, E1 stated, "the need is already included in the prescription instructions" [which states that it is for pain.] No other forms of documentation for the need was available for review. 6. In an exit interview, the findings were reviewed with E1 and no additional information was provided. E1 stated, "we don't have it."

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available and accessible in a bedroom or residential unit. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed there was no bell, intercom, or other mechanical means to alert employees to a resident’s needs available for any of the several houses where residents stayed, besides one single bell seen in house four. 2. In an interview, E1 acknowledged that there was no bell, intercom, or other mechanical means to alert employees to a resident’s needs besides verbally asking for assistance. 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 medication administered to a resident was administered in compliance with a medication order for two of eight 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 R2's medical record revealed a medication order signed by a physician and dated June 21, 2025 that prescribed "Metoprolol Tart, 25 mg, 1/2 tablet by mouth twice daily with food, hold if systolic blood pressure (sbp) is lower than 105". 2. On October 11, 2025, R2's sbp was measured at 90, however, R2's medication administration record (MAR) revealed R2 was still administered Metoprolol at 4pm. 3. A review of R2's medical record revealed a medication order signed by a physician and dated June 21, 2025 that prescribed "Lisinopril, 40 mg, 1 tablet by mouth twice daily, hold if systolic blood pressure (sbp) is lower than 105". 4. On October 12, 2025, R2's sbp was measured at 100, however, R2's MAR revealed R2 was still administered Lisinopril at 8am. 5. A review of R4's medical record revealed a medication order signed by a physician and dated June 21, 2025 that prescribed "Losartan Potassium, 25 mg, 1 tablet by mouth once daily for hypertension, hold if systolic blood pressure (sbp) is lower than 105". 6. On October 30, 2025, R4's sbp was measured at 100, however, R4's MAR revealed R4 was still administered Losartan Potassium at 8am. 7. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of four sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication error report dated October 8, 2024. The report indicated that on October 8, 2024, "R1 medication was administered twice." 3. A review of R1's medical record revealed an incident report dated October 8, 2024. The report stated that "R1 had an early morning appointment on October 8, 2024 with a pick-up time at 7am. Night Shift MedTech instructed by Urology to give early breakfast and all morning medication including 8 am medication before the resident leave for appointment. Resident returned about 9:30 am same day, and the morning MedTech gave resident 8 am medications." 4. A review of R2's medical record revealed R2 received medication administration. 5. A review of R2's medical record revealed an incident report dated September 16, 2024. The report indicated that on September 16, 2024 R2 was given another resident's medication. 6. In an interview, E1 acknowledged medication for R1 and R2 was not administered in compliance with a medication order.

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. Findings include: 1. A review of the facility's policies and procedures revealed no documentation of a policy covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented. 2. In an interview, E1 acknowledged a policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented was not available for review at the time of the inspection.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after acceptance, for nine of nine residents sampled. Findings include: 1. A review of R1's medical record revealed an orientation form signed on January 11, 2024. However, the date was not within 24 hours after the resident's acceptance into the facility. 2. A review of R2's medical record revealed an orientation form signed on November 16, 2020. However, the date was not within 24 hours after the resident's acceptance into the facility. 3. A review of R3's medical record revealed an orientation form signed on April 26, 2024. However, the date was not within 24 hours after the resident's acceptance into the facility. 4. A review of R4's medical record revealed an orientation form signed on February 21, 2023. However, the date was not within 24 hours after the resident's acceptance into the facility. 5. A review of R5's medical record revealed an orientation form signed on July 15, 2022. However, the date was not within 24 hours after the resident's acceptance into the facility. 6. A review of R6's medical record revealed an orientation form signed on February 25, 2021. However, the date was not within 24 hours after the resident's acceptance into the facility. 7. A review of R7's medical record revealed an orientation form signed on May 17, 2023. However, the date was not within 24 hours after the resident's acceptance into the facility. 8. A review of R8's medical record revealed an orientation form signed on July 31, 2024. However, the date was not within 24 hours after the resident's acceptance into the facility. 9. A review of R9's medical record revealed an orientation form signed on June 27, 2024. However, the date was not within 24 hours after the resident's acceptance into the facility. 10. In an interview, E1 acknowledged the residents' orientation was not completed within 24 hours after the resident's acceptance into the facility.

Based on observation and interview, the manager failed to ensure the premises was 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 residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a gated fence which allowed an individual to leave the facility property. The gate had a padlock. However, the padlock was unlocked, and the Compliance Officers were able to remove the padlock and open the gate allowing access to an area outside the facility grounds. 2. In an interview, E1 reported E1 informed staff the gate should always be locked and was unsure why it wasn't locked. E1 acknowledged the unlocked gate posed a risk to the safety of the residents.

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 and accurately documented in the resident's medical record, for two of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. In an interview, E1 reported all residents received medication administration services. 2. A review of R1's medical record revealed a document titled "Notes." On April 21, 2024, the document stated "Spoke to...about resident medications that [pharmacy] did not refill...Atorvastatin 20 MG (milligrams), Tamotidine 20 MG tab, Lisinopril 10 MG tab..." 3. In an interview, E1 reported R1 had not received "Atorvastatin" between April 19-21, 2024 due to the medication not being delivered, as well as April 24-25, 2024 due to an error from the pharmacy cancelling the medication. E1 reported "Lisinopril" and "Famotidine" were also unavailable between April 19-21, 2024. 4. A review of R3's medical record revealed a discontinue order for "Lorazepam" dated December 1, 2023. However, R3's medical record contained a medication error report submitted by the facility to the Arizona Health Care Cost Containment System (AHCCCS) reporting the medication was incorrectly administered on December 20 and 21, 2023. 5. In an interview, E1 acknowledged R1's and R3's medication was not administered in compliance with a medication order.