Sunshine Tucson Ach, LLC.

“Based on record review and interview, the Governing Authority failed to ensure compliance with A.R.S. § 36-411 by failing to verify the current status of a volunteer’s fingerprint clearance card, or verifying a volunteer was not on the adult protective services registry for one of two volunteers sampled. The deficient practice posed a risk if O1 was a danger to a vulnerable population.       Findings include:       1. A review of O1’s personnel record revealed O1 was retained as a caregiver on May 5, 2025. Further review revealed a document titled “Non-IVP Fingerprint Clearance Card Application Receipt,” dated May 12, 2025. However, evidence of documentation of the current status of O1’s fingerprint clearance card was unavailable for review. In addition, review of O1’s personnel record revealed evidence of documentation indicating O1 was not on the adult protective services registry was unavailable for review.      2. In an interview, R1 advised O1 was often observed in the facility, organizing recreational activities at the facility, and performing general cleaning duties in resident rooms.       3. In an interview, E1 advised O1 worked numerous shifts after March 12, 2025. E1 reported O1 regularly volunteered at the facility, arranging activities for residents, and performing other duties such as cleaning resident rooms, without direct supervision. E1 acknowledged they did not verify the validity of O1’s fingerprint clearance card, or verify O1 was not on the adult protective service registry, as required in A.R.S. § 36-411.       4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review, documentation review, and interview, the manager failed to ensure a volunteer provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at or on behalf of the facility, for one of two volunteers sampled who were expected to have more than eight hours per week of direct interaction with residents. The deficient practice posed a potential TB exposure risk to residents.       Findings include:       1. A review of O2’s personnel record revealed an application for volunteer services which indicated O2 was available to work at least eight hours per week. O2’s personnel record also contained evidence of documentation of one negative skin test for infectious tuberculosis (TB), dated within twelve months of O2’s start date as a volunteer. However, evidence of documentation of a second negative skin test, a negative blood test, or baseline screening for signs and symptoms, and risk assessment was unavailable for review.        3. In an interview, R1 advised O2 worked numerous days per week, and provided cleaning services, and coordinated and participated in activities at the facility.        4. A review of facility policy and procedures, last reviewed June 18, 2024, revealed a policy titled “Volunteer Job Descriptions, Duties, and Qualifications.” The policy read, in part, “All volunteers are expected or scheduled to have more than 8 hours of direct interaction per week with the residents, and are also required to provide evidence of freedom from infectious tuberculosis…”       5. In an interview, E1 advised O2 performed various, non-caregiver duties at the facility weekly, at least 8 hours per week.       6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the assisted living facility failed to provide the required documentation to an emergency responder for four of four sampled residents for whom an emergency responder had been contacted, and the resident was transported to a hospital.       Findings include:       1. A review of facility documentation revealed two incident reports between August 1, 2024, and February 28, 2025, in which emergency medical services were called and residents were transported to the hospital. The Compliance Officer requested to review the standardized form and documentation provided to emergency medical services prior to each resident's transportation. However, evidence of such documentation was unavailable for review.       2. In an interview, E1 reported being aware of the implementation of A.R.S. 36-420.04. E1 advised all of the information required per A.R.S. 36-420.04 had been provided to emergency responders. However, E1 advised the facility did not have a standardized form used for each resident as required. E1 stated a copy of the documentation of what was given to the emergency responders for each resident was not available for review.”

“Based on documentation review and interview, the manager failed to ensure a documented report was submitted to the governing authority and a copy of the report was maintained for at least twelve months after the date the report was submitted.     Findings include:     1. A review of facility policy and procedures, last reviewed June 18, 2024, revealed a policy titled “Quality Management.” The policy indicated a “…report will be submitted to the governing authority at least every six (6) months…”     2. A request was made to review any reports submitted to the governing authority in the past twelve months. However, evidence of documentation of any such reports was unavailable for review.     3. In an interview, E1 acknowledged reports had not been documented and submitted to the governing authority, as required per policy and R9-10-804(2).”

“Based on observation and record review, for one of two caregivers sampled, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.     Findings include:     1. During a tour of the facility, the Compliance Officer observed E3 providing assisted living services.     2. A review of E3's personnel record revealed E3 was hired on October 12, 2023, as a caregiver. E3’s record included evidence of documentation of first aid and CPR training. However, the documentation of CPR training was from an organization that did not provide an in-person verification of an individual’s ability to perform CPR.     3. In an interview, E3 reported they did not obtain CPR training which included a demonstration of E3’s ability to perform CPR.     4. In an interview, E1 advised they had instructed E3 to obtain CPR certification, which included an in-person demonstration of skills and knowledge on how to perform CPR. E1 agreed E3 did not obtain CPR training specific to adults, which included a demonstration of E3’s ability to perform CPR.”

“Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During a tour of the facility, the Compliance Officer observed several cabinets in the kitchen that were equipped with hasps meant to be secured with locks; however, the hasps were not secured. The Compliance Officer was able to open the cabinets with little effort. Inside the cabinets, the Compliance Officer observed numerous plastic bins filled with prescription medication bottles and bubble packs of prescription medications, as well as medication organizers that were filled with various medications. 2. In an interview, E1 indicated the cabinets were only used for medication storage. E1 acknowledged that medications in the cabinet were not secured. This is a repeat citation from a compliance inspection conducted on December 05, 2022, and November 7, 2023.”

“Based on observation and interview, the manager failed to ensure the premises and equipment used at the facility was free from a condition or situation which may cause a resident or other individual to suffer physical injury. Findings include: 1. During a facility tour, the Compliance Officer observed a family room with ceramic tile flooring, which transitioned to wood laminate flooring in a hallway. At the transition point, there was a metal threshold, the edge of which had pulled away from the flooring and was raised approximately two inches, and presented a tripping hazard. 2. In an interview, the manager acknowledged the threshold had pulled away from the flooring and presented a hazard.”

“Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order.   Findings include:   1. During a facility tour, the Compliance Officer observed a family room with ceramic tile flooring, which transitioned to wood laminate flooring into a hallway. At the transition point, there was a metal threshold which had pulled away from the flooring and presented a tripping hazard. The Compliance Officer entered a shared resident bathroom and observed a sink cabinet which had pulled away from the wall approximately two inches.   2. In an interview, E1 acknowledged the equipment used at the assisted living facility had not been maintained in working order.”

“Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of two employees sampled. The deficient practice posed a risk if E2 was a danger or immediate threat to vulnerable populations. Findings include: 1. The Compliance Officer observed E2 working as a caregiver in the facility on November 07, 2023. 2. A review of E2's (hire date October 10, 2023) personnel record revealed no documentation of a valid fingerprint clearance card. The record included a copy of a completed fingerprint card application for E2, however evidence indicating the application for fingerprint clearance card had been submitted was unavailable for review. 3. In an interview, E1 acknowledged E2's personnel record did not contain evidence of a valid fingerprint clearance card or an application for fingerprint clearance card.”

“Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for one of two residents sampled who received personal care services. Findings include: 1. A review of R2's medical record revealed a service plan dated April 20, 2023, for personal care services. However, a current service plan dated on or before October 20, 2023, was not available for review. 2. In an interview, E1 acknowledged R2's service plan had not been reviewed and updated at least once every six months as required.”

“Based on documentation review, record review, and interview, the manager failed to ensure entries in the medical record were not changed to make the initial entry illegible for one of two resident records sampled. Findings include: 1. A review of R2's medical record revealed a medication order signed by a medical provider and dated July 31, 2023. At the top of the medication order was the word, "Name:," however, R2's name had been hand written over white correction fluid which had been applied to the order. The Compliance Officer could see illegible writing underneath the correction fluid. 2. In an interview, E1 acknowledged the entry in R2's medical record had been changed to make the initial entry illegible.”

“Based on record review and interview, the manager failed to ensure medication administered to a resident is administered in compliance with a medication order for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan which indicated R1 received personal care services and medication administration. The medical record contained a doctor's order, dated in August 2023, directing R1 take "Glimepiride 1mg PO daily" and "Hydroxyurea 500 mg cap 2 PO S, M, W, F, Sat, 1 PO T & Th." 2. A review of R1's Medication Administration Record (MAR) for August 2023 revealed R1 was being administered medications as ordered. However, R1's MAR for September and October did not include evidence R1 was administered "Glimepiride 1 mg" daily as ordered. R1's MAR for August and September documented administration of "Hydroxyurea 500 mg" as ordered. However, the MAR for October documented R1 received "Hydroxyurea 500 mg" one capsule daily for the month instead of two capsules per day on "S, M, W, F and Sat" as ordered. 3. In an interview E1 acknowledged R1 did not receive their medications as ordered.”

“Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During a tour of the facility, the Compliance Officer observed a refrigerator in the kitchen area, which was unlocked. Inside the refrigerator door, the Compliance Officer observed the prescription medications "Robafen 200 MG/10 ML Syru" and including Lorazepam, stored in the door of the refrigerator; and "Guaifenesin Oral Solution, USP." The Compliance Officer observed several cabinets in the kitchen which were equipped with hasps and combination locks, however the combination locks were not secured. The Compliance Officer observed E1 and E2 step outside the kitchen area, leaving the unlocked cabinets unsupervised. Inside the cabinets, the Compliance officer observed numerous plastic bins filled with prescription medication bottles and bubble packs of prescription medications. 2. In an interview, E1 acknowledged that medications in the refrigerator and unlocked cabinet not stored in a self-contained unit or locked cabinet used only for medication. This is a repeat citation from a compliance inspection conducted on December 05, 2022.”

“Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. The Compliance Officer observed the hot water temperature measured at 138.3 \'b0F in a shared bathroom. 2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95 \'b0F and 120 \'b0F. This is a repeat citation from a compliance inspection conducted on December 05, 2022.”