SUNRISE OF CHANDLER

INSP-0160284

Complete

Date: 9/23/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-10-01

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on September 23, 2025:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

R9-10-113.A.1-2. Tuberculosis Screening A. 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: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 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); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities, including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. A review of the facility’s documentation revealed an incomplete annual assessment of the facility's TB risk assessment for 2024, with no signatures. No other current documentation of an annual assessment was available. 2. In an interview, E9 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 3. In an exit interview, the findings were reviewed with E8 and E9, and no additional information was provided.

Temporary Solution:

We have updated the annual TB assessment forum per state regulation. Attached is the signed forum

Permanent Solution:

The Resident Care Director will conduct monthly audits to verify that all infection control documentation, including TB risk assessments, are completed, signed, and filed appropriately. The community has implemented a standardized protocol to ensure that the annual TB risk assessment is completed by December 31st of each calendar year. This includes:
Use of the correct TB risk assessment form.
Review and signature by the Resident Care Director.
Filing in the infection control binder and electronic health record system. All department heads have been re-educated on TB infection control requirements, including the importance of timely and complete documentation.

Person Responsible:

Logan Watts, Executive Director

Deficiency #2

Rule/Regulation Violated:

R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident’s date of occupancy, and 2. As specified in R9-10-113

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for eight of eight residents sampled. The deficient practice posed a high potential health and safety risk to residents and staff of TB exposure. 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. A review of R1's, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed no documentation of an assessment of the residents' risk of exposure to infectious TB. Based on the acceptance dates, this documentation was required. 3. A review of the facility's policies and procedures revealed a policy titled “TB Screening.” The policy stated, “ For states/provinces requiring TB screening/testing, requirements may include: Risk evaluation, symptom screening, and IGRA blood test.” 4. In an interview, E9 acknowledged that an assessment of the resident’s risk of exposure to infectious TB was not conducted. 5. In an exit interview, the findings were reviewed with E8 and E9, and no additional information was provided.

Temporary Solution:

We have updated R1 through R8 with the correct forum per state regulation.

Permanent Solution:

The community has transitioned to using the correct and approved TB screening form, which includes all required components: risk assessment, symptom screening, and documentation of freedom from infectious TB. The Resident Care Director has completed updated TB screenings for all current residents using the correct form. Effective immediately, the Resident Care Director will complete the TB screening form in full for each resident at the time of admission. This ensures compliance with R9-10-113 from the outset of residency. The correct TB screening form has been embedded into the community’s admission packet and electronic health record system to prevent use of outdated or incorrect forms. All care staff and admissions personnel have been re-educated on TB screening requirements and the proper use of the approved form.

Person Responsible:

Logan Watts, Executive Director

Deficiency #3

Rule/Regulation Violated:

R9-10-817.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order for one of eight residents reviewed. 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 R3's medical record revealed a current written service plan dated September 3, 2025. This service plan indicated R3 received medication administration. 2. A review of R3's medical record revealed signed medication orders dated June 9, 2025. The medication order stated “Propranolol HCl Oral Tablet 20 mg. Give 1 tablet by mouth two times a day related to Essential Hypertension. Hold for SBP less than 100 or HR less than 60.” 3. A review of R3's medical record revealed a September 2025 medication administration record (MAR). This MAR stated “Propranolol HCl Oral Tablet 20 mg. Give 1 tablet by mouth two times a day related to Essential Hypertension. Hold for SBP less than 100 or HR less than 60.” “Propranolol” was administered on the following dates: <ul><li>September 2, 2025, between 1900-2100 with R3’s heart rate (HR) at 56 </li><li>September 15, 2025 between 0700 - 0900 with R3’s HR at 58</li><li>September 21, 2025 between 0700 - 0900 with R3’s HR at 57</li><li>September 22, 2025 between 0700 - 0900 with R3’s HR at 47</li></ul> 4. In an interview, E8 acknowledged that “Propranolol” was supposed to be held on those dates. 5. In an exit interview, the findings were reviewed with E8 and E9, and no additional information was provided.

Permanent Solution:

The community has reviewed the medication administration records for all residents and identified any medications with hold parameters. The Resident Care Director has audited each resident’s medication list and consulted with their primary care physicians to determine whether parameters should be maintained or removed based on current clinical stability. Updated orders have been obtained and documented accordingly. The Resident Care Director will audit each resident’s medication list upon admission and quarterly thereafter to ensure all medications with parameters are clearly documented and followed. For any medication with hold parameters, the Resident Care Director will consult with the resident’s primary care physician to confirm the appropriateness of the parameters and obtain updated orders if necessary. All medication administration staff have been re-educated on the importance of adhering to medication parameters and verifying vital signs prior to administration. The MAR (Medication Administration Record) will be reviewed weekly to ensure that hold parameters are clearly visible and being followed.

Person Responsible:

Logan Watts, Executive Director

INSP-0088669

Complete

Date: 4/5/2023 - 4/10/2023

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2023-04-14

Summary:

An on-site investigation of complaint AZ00191891 was conducted on April 5, 2023. An off-site documentation review was conducted on April 10, 2023. T he following deficiencies were cited:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

B. A manager:
3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is:
a. At least 21 years of age, and
b. Present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises.

Evidence/Findings:

Based on observation, record review, and interview, the manager failed to designate, in writing, a caregiver who was present on the facility's premises and accountable for the facility when the manager was not present, as the manager's designee.

Findings include:

1. When the compliance officer arrived at the facility, the manager was not present.

2. The compliance officer observed a manager's certificate conspicuously posted, however, there was no documentation available for review who was the manager's designee at the facility when the manager was not present at the facility.

3. In an interview, the compliance officer requested from E1 and E2 written documentation of who was the manager's designee when the manager was not on the premises. E1 acknowledge that there was no written documentation by the manager that E1 or any other qualified personnel to be a manager's designee when the manager was not present at the facility.

Deficiency #2

Rule/Regulation Violated:

D. A manager shall ensure that the following are conspicuously posted:
1. A list of resident rights;
2. The assisted living facility ' s license;
3. Current phone numbers of:
a. The unit in the Department responsible for licensing and monitoring the assisted living facility,
b. Adult Protective Services in the Department of Economic Security,
c. The State Long-Term Care Ombudsman, and
d. The Arizona Center for Disability Law; and
4. The location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed.

Evidence/Findings:

Based on observation and interview, the manager failed to conspicuously post the required documents: a list of resident rights; the assisted living facility's license; current phone numbers of: the unit in the Department responsible for licensing and monitoring the assisted living facility, Adult Protective Services in the Department of Economic Security, the State Long-Term Care Ombudsman, and the Arizona Center for Disability Law; and the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed, in an area visible and accessible where the public enters the premises of a health care institution.

R9-10-101. Definitions
In addition to the definitions in A.R.S. \'a7\'a7 36-401(A) and 36-439, the following definitions apply in this Chapter unless otherwise specified:
54. "Conspicuously posted" means placed:
a. At a location that is visible and accessible; and
b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution.

Findings include:

1. During a complaint investigation, E1, E2, and the compliance officer observed the required documents were not conspicuously posted.

2. In an interview, after searching different areas of the facility, E1 and E2 acknowledged there was no conspicuously posted list of resident rights; the assisted living facility's license; current agencies phone numbers; and the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed.

Facility Information

Inspection History

INSP-0160284

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0088671

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

INSP-0088669

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings: