THE WOODMARK AT SUN CITY

INSP-0161841

Enforcement

Date: 10/17/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-10-31

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00147958, 00147934, and 00145069 conducted on October 17, 2025:

Deficiencies Found: 8

INSP-0092210

Complete

Date: 5/21/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-07-02

Summary:

An on-site investigation of complaint AZ00210284 was conducted on May 21, 2024, and the following deficiency was cited :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

C. A manager shall ensure that policies and procedures are:
1. Established, documented, and implemented to protect the health and safety of a resident that:
m. Cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide;

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. The deficient practice prevented the facility's staff from ensuring the health and safety of the resident.

Findings include:

1. In documentation review, a review of Department documentation revealed AL11305 was authorized to provide directed care services. E1 reported there is a personal care services building and a directed care services building.

2. A review of R1's medical record contained a service plan dated January 2024 for personal care services and documented residence at the personal care services building.

3. In documentation review, the facility submitted documentation, dated April and May 2024, which documented the following:

- April 19, 2024: R1 "lost and no where to be found then found in another resident's bedroom".
- April 29, 2024: R1 "went out of the building, please keep an eye on R1 as goes out the door when people open it".
- April 30, 2024: POA called to report R1 is more forgetful and has been wandering and not knowing surroundings, said it would be time to move to memory care.
- May 7, 2024: "Informed POA that R1 had to be re-directed several times...attempting to wander outside alone and confused...".

4. A review of the facility policies and procedures dated January 2023 contained a General Whereabouts of a Resident and a Missing Resident Policy that identified procedural steps until a resident is found. However, a system was not in place to ensure the general or specific whereabouts of a resident.

5. During an interview, E1 reported R1 had not signed out of the facility on April 29, 2024 and May 7, 2024 for the above listed incidents.

INSP-0092209

Complete

Date: 4/9/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-04-29

Summary:

An on-site investigation of complaints AZ00207048, AZ00207304, and AZ00208414 were conducted on April 9, 2023, and no deficiencies were cited.

✓ No deficiencies cited during this inspection.

INSP-0092207

Complete

Date: 3/19/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-04-02

Summary:

An on-site investigation of complaint AZ00207514 and AZ00207553 was conducted on March 19, 2024, and the following deficiency was cited :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f):
a. No later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident reviewed who experienced a change of condition. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed.

Findings include:

1. Review of R1's medical record revealed written service plan dated November 2023. The service plan stated R1 required standby assist for bathing and toileting. However, the narrative charting notes dated December 2023 revealed Hospice services were started and R1 now requires full assist with bathing and toileting.

2. Review of R1's medical record revealed R1's service plan was not updated to show these changes.

3. In an interview, E1 reported R1 required the increased need for services and acknowledged R1's service plan was not updated.

INSP-0092208

Complete

Date: 2/20/2024 - 4/1/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-05-21

Summary:

An on-site investigation of complaint AZ00204896, AZ00205711, AZ00206000, and AZ00206289 was conducted on February 20, 2024, and an off-site record review was conducted on April 1, 2024, and the following deficiency was cited:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Based on record review and interview, the manager of an assisted living center who contacted an emergency responder on behalf of a resident failed to provide to the emergency responder a written document that included all required documentation, for two of four residents sampled.

Findings include:

1. A review of R3's medical record revealed an incident report dated January 30, 2024. The incident report revealed R3 had an accident, emergency, or injury, the facility contacted an emergency responder, and R3 was taken to the hospital. However, the documented information provided to the emergency responder did not include the following:
-The reason or reasons the emergency responder was requested on behalf of R3;
-The name, address and telephone number of the resident's current pharmacy;
-The point-of-contact information for the assisted living center, including the cell phone number and email address; and
-A copy of R3's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R3's discharge.

2. A review of R4's medical record revealed an incident report dated February 10, 2024. The incident report revealed R4 had an accident, emergency, or injury, the facility contacted an emergency responder, and R4 was taken to the hospital. However, the documented information provided to the emergency responder did not include the following:
-The reason or reasons the emergency responder was requested on behalf of R4;
-The name, address and telephone number of the resident's current pharmacy;
-The point-of-contact information for the assisted living center, including the cell phone number and email address; and
-A copy of R4's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R4's discharge.

3. In an interview, E1 reported E1 had not yet updated the facility documentation to include the required information.

INSP-0092214

Complete

Date: 12/1/2023 - 4/22/2024

Type: Complaint

Worksheet: Assisted Living Center

Evidence/Findings:

Based on record review and interview, the manager failed to provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of eight employees reviewed. The deficient practice posed a TB exposure risk to residents.

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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used."

3. Review of E7 and E8's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E7 and E8's hire date, this documentation was required.

4. In an interview, E1 acknowledged E7 and E8 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

Deficiency #4

Rule/Regulation Violated:

C. A manager shall ensure that:
1. A caregiver or an assistant caregiver:
g. Documents the services provided in the resident's medical record; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of five residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. Review of R1's medical record revealed a current written service plan for personal care services dated February 2023. This service plan stated the following services were needed:
"Bathing twice a week"
"Requires stand-by assist with dressing".

However, documentation was not available indicating these services were provided in May, June, July 2023.

2. In an interview, E2 acknowledged R1's medical record did not include documentation of the above listed services and reported the Activities of Daily Living Sheet were given to APS and copies were not made for the file. E2 reported the services were provided as indicated in the service plan.

This is a repeat deficiency from the complaint investigation conducted on August 17, 2020, the compliance inspection conducted on August 25, 2021, the complaint investigation conducted on August 29, 2022, and the complaint investigation and compliance inspection conducted on August 9, 2023.

INSP-0092205

Complete

Date: 8/9/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-08-23

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00193417, AZ00196191, and AZ00198786 conducted on August 9, 2023:

Deficiencies Found: 9

Deficiency #1

Rule/Regulation Violated:

J. If a manager has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall:
5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2):
a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition;
c. The names of witnesses to the suspected abuse, neglect, or exploitation; and
d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure an investigation of suspected abuse, neglect, or exploitation on the premises documented a description of any injury to the resident related to the suspected abuse, neglect, or exploitation and any change to the resident's physical, cognitive, functional, or emotional condition; the names of witnesses to the suspected abuse, neglect, or exploitation; and actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future.

Findings include:

1. A review of facility documentation revealed a report was made to Adult Protective Services for an incident occurring in January 2023. The report stated "[R11] is being financially exploited from an outside source who is sending [R1] taxis to go to [R1's] bank multiple times a week and send funds by money order. There is often an escort to the bank. This person is usually driving the car or taxi. [R1] is receiving multiple calls from out of state and possibly out of country. Family has been notified." The report included documentation of the dates, times, and description of the suspected abuse, neglect, or exploitation. However, a description of any injury to the resident related to the suspected abuse, neglect, or exploitation and any change to the resident's physical, cognitive, functional, or emotional condition; the names of witnesses to the suspected abuse, neglect, or exploitation; and actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future were not documented.

2. In an interview, E1 acknowledged a description of any injury to the resident related to the suspected abuse, neglect, or exploitation and any change to the resident's physical, cognitive, functional, or emotional condition; the names of witnesses to the suspected abuse, neglect, or exploitation; and actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future were not documented.

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Based on documentation review, observation, and interview, the manager failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. \'a7 11-593, within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for the other residents residing in the assisted living facility.

Findings include:

Arizona Revised Statutes (A.R.S.) \'a7 11-593(B) Reporting is required in the following circumstances:
1. Death when not under the current care of a health care provider as defined pursuant to section 36-301.
2. Death resulting from violence.
3. Unexpected or unexplained death.
4. Death of a person in a custodial agency as defined in section 13-4401.
5. Unexpected or unexplained death of an infant or child.
6. Death occurring in a suspicious, unusual or nonnatural manner, including death from an accident believed to be related to the deceased person's occupation or employment.
7. Death occurring as a result of anesthetic or surgical procedures.
8. Death suspected to be caused by a previously unreported or undiagnosed disease that constitutes a threat to public safety.
9. Death involving unidentifiable bodies.

1. A review of documentation revealed a complaint was received by the Department on August 2, 2023. The complaint alleged a suspected heat-related death of a resident (later identified as R10). The complaint alleged the resident passed away on May 27, 2023.

2. A review of documentation, received by the Department on August 9, 2023, revealed a document titled "Preliminary Investigative Report" (dated May 27, 2023). The document stated "Jurisdictional Criterion Suspicious, unusual or non-natural manner ... Preliminary Sub Manner of Death Environment - Heat associated" and "It was reported that the decedent had apparently left the facility of [R10's] own accord and went out the front entrance, and circled around the building, and tried to use the back entrance. The back entrance is locked at all times and is for emergency personnel only. The pavement of the entrance shows tire tracks suspected to be from the electronic scooter, which shows the scooter going to the entrance, turning around, and getting stuck in the rocks. The decedent had apparently not been seen for several hours during the day. [R10's] medical alert pendant supposedly went off around 12:30 hours but [R10] could not be located by facility staff. [R10] was later discovered in [R10's] scooter outside of the emergency exit, unresponsive. [R10's] death was pronounced on scene without resuscitative effort."

3. In an interview, E2 reported R10 liked privacy and did not go out very often.

4. In an interview, E2 reported E2 saw R10 in the dining room at around 11:15PM for lunch and at around 12:30PM to check mail. E2 reported all residents are checked on every two hours. E2 reported E2 did not check for R10 because E2 just saw R10 check the mail.

5. In an interview, E2 reported R10's pendant was alerted. E2 reported E2 went looking for R10 but R10 was not in R10's residential unit or in the dining room. E2 reported E2 asked the front desk about R10's whereabouts and the front desk reported to E2 that R10 went out. E2 reported E2 believed this meant R10 went out with family so E2 and a colleague stopped looking for R10.

6. In an interview, E2 reported residents are expected to sign in and out when leaving the facility.

7. In an interview, E2 reported an employee from the kitchen discovered R10 at approximately 2:00PM. E2 reported the location where R10 was discovered was difficult to see from the parking lot of the facility.

8. A review of facility documentation revealed a document titled "Resident Sign Out and In." However, documentation to demonstrate R10 signed out on May 27, 2023 was not available for review.

9. In an interview, E1 reported residents sometimes do not sign out if they are still on the premises.

10. The Compliance Officer observed the back entrance where R10 was discovered. The Compliance Officer observed multiple vehicles in the parking lot may be within view of the back entrance.

11. The Compliance Officer requested to review the facility's written notification to the Department of R10's death. However, the facility's written notification to the Department of R10's death was not provided for review.

12. A review of Department documentation revealed documentation to demonstrate AL11305 provided written notification to the Department of R10's death was not available for review.

13. In an interview, E1 reported written notification to the Department of R10's death was not provided.

14. In an interview, E1 reported E1 did not know R10's death had to be reported. E1 reported E1 did not believe R10's death was unexpected or unexplained, or suspicious, unusual or nonnatural.

15. In an interview, E1 acknowledged written notification to the Department of R10's death was not provided to the Department.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A caregiver:
b. Provides documentation of:
i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of one individual sampled who was hired a caregiver. The deficient posed a risk if E6 was not trained to provide the required services.

Findings include:

1. A review of facility documentation revealed a staffing schedule for July 2023. The schedule revealed E6 was scheduled to work from 6:00AM to 2:00PM on the following dates:
-July 1, 2023;
-July 4-8, 2023;
-July 11-15, 2023;
-July 18-22, 2023; and
-July 25-28, 2023.

2. A review of E6's (hired in 2020) personnel record revealed E6 was hired as a caregiver/medication technician. E6's personnel record revealed documentation of completion of a caregiver training program (issued September 5, 2012). The document stated "Coordinated by Assisted Living Trainers Assisted Living Trainers Curriculum AITP #0050" and was signed by "Christine T.D Ellis RN." The documentation did not include a name of the program.

3. A review of the NCIA Board website for caregiver training programs (https://nciaboard.az.gov/news/caregiver-certificate-verification) revealed SDL Enterprises Assisted Living Trainers, ALTP# 50 was in operation from April 29, 2003 to April 30, 2013.

4. A review of Department documentation, provided by the NCIA Board, revealed ALTP# 50 had different contracted training programs operating under ALTP# 50. "Christine T.D Ellis RN" operated Cedar Sanctuary, LLC Training Program from August 19, 2000 to July 31, 2011.

5. A review of https://az.tmuniverse.com revealed E6 had not completed a caregiver training program.

6. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

This is a repeat deficiency from the on-site complaint investigation conducted on August 29, 2022.

Deficiency #4

Rule/Regulation Violated:

Summary:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

INSP-0159506

Summary:

INSP-0129807

Summary:

INSP-0092215

Summary:

Deficiencies Found: 15

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #10

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #11

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #12

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #13

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #14

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #15