Inspection Reports for
Woodmark At Sun City

R9-10-811 — The manager failed to ensure residents' medical records contained complete documentation of medication administration, including date, time, and dosage. Errors included a medication marked as administered when unavailable and missing dosage information for insulin administration.

R9-10-808 — The manager failed to ensure a resident's service plan included the frequency of assisted living services provided, posing a risk to proper care.

R9-10-808 — The manager failed to ensure a resident's service plan was signed and dated by all required parties when initially developed and updated, risking health and safety.

R9-10-808 — The manager failed to ensure caregivers documented services provided in residents' medical records, resulting in inaccurate or missing assistance records.

R9-10-811 — The manager failed to ensure medication administration records included dosage documentation, leading to false or misleading information for two residents.

R9-10-814 — The manager failed to ensure a functioning bell, intercom, or mechanical alert was available and accessible in a resident's bedroom receiving personal care services.

R9-10-815 — The manager failed to ensure a mechanical alert or alternative means was available in bedrooms of residents receiving directed care services, risking timely response to emergencies.

R9-10-817 — The manager failed to ensure medications were administered in compliance with medication orders, including incorrect dosages and missing signed orders.

R9-10-820 — The manager failed to ensure garbage and refuse were stored in covered containers, posing a health and safety risk due to uncovered waste.

R9-10-803 — The governing authority failed to notify the Department immediately of a change in the manager, leaving the Department unaware if the facility maintained a qualified manager.

R9-10-803 — The manager failed to ensure the health, safety, or welfare of a resident was protected when facility personnel were unaware of the whereabouts of a resident who eloped from the facility.

R9-10-803 — The manager failed to ensure policies and procedures were established and implemented to track the whereabouts of residents based on their level of care, resulting in staff being unaware of a resident's location after elopement.

R9-10-806 — The manager failed to maintain documentation for at least 12 months of caregivers and assistant caregivers working each day, including hours worked, resulting in incomplete staff records.

R9-10-817 — The manager failed to ensure medication was administered in compliance with medication orders, as evidenced by incomplete or inaccurate medication administration records.

R9-10-817 — The manager failed to ensure medication administration was properly documented in residents' medical records, including instances of false or misleading information on medication administration records.

R9-10-113 — The facility failed to provide tuberculosis infection control training and education related to recognizing signs and symptoms of tuberculosis to four of five employees reviewed.

R9-10-803 — The manager failed to immediately report suspected abuse of a resident and did not document witnesses or preventive actions, delaying the report by several days.

R9-10-806 — The manager failed to ensure a caregiver received orientation specific to their duties before providing assisted living services for one of five caregivers sampled.

R9-10-808 — The manager failed to ensure caregivers documented services provided in residents' medical records, as documentation was prefilled and misleading for two residents.

R9-10-811 — The manager failed to ensure residents' medical records contained documentation of orientation to facility exits for six residents reviewed.

R9-10-814 — The manager failed to include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections in service plans for three residents receiving personal care services.

R9-10-815 — The manager failed to include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections in service plans for three residents receiving directed care services.

R9-10-819 — The manager failed to ensure disaster drills were conducted on each shift at least once every three months and properly documented.

36-420.01 — No evidence text provided for the requirement that health care institutions develop and administer a fall prevention and fall recovery training program for all staff.

36-420.04 — No evidence text provided for the requirement that emergency responders be provided with a written document containing specific resident information when contacted on behalf of a resident.

A manager shall ensure that a caregiver's or assistant caregiver's skills and knowledge are verified and documented before providing physical or behavioral health services and according to policies and procedures; no evidence was provided.

R9-10-113 — No evidence text provided for the requirement that staff and volunteers with more than eight hours per week of direct resident interaction provide evidence of freedom from infectious tuberculosis before starting work.

A manager shall ensure that current documentation of first aid and adult CPR training certification is provided before assisted living services begin; no evidence was provided.

R9-10-808 — No evidence text provided for the requirement that residents provide evidence of freedom from infectious tuberculosis before or within seven days of occupancy.

A manager shall ensure that a resident has a written service plan signed and dated by the resident or representative, manager, and required medical reviewers; no evidence was provided.

A manager shall ensure that caregivers document services provided in the resident's medical record; no evidence was provided.

A manager shall ensure medication service policies include procedures for assisting residents in procuring medication; no evidence was provided.

A manager shall ensure medications administered to residents comply with medication orders; no evidence was provided.

A manager shall ensure medications administered to residents are documented in the resident's medical record; no evidence was provided.

A manager shall ensure a disaster plan is developed, documented, maintained, and implemented as necessary, including resident relocation and medication availability during disasters; no evidence was provided.

A manager shall ensure evacuation drill documentation is created and maintained for at least 12 months, including drill details and recommendations for improvement; no evidence was provided.

A manager shall ensure caregivers immediately notify a resident's emergency contact and primary care provider after an accident or emergency requiring medical services; no evidence was provided.

R9-10-113 — No evidence text provided for tuberculosis screening requirements including baseline screening and documentation of freedom from infectious tuberculosis for staff and residents.

36-420.01 — The governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, with some staff not receiving timely training.

36-420.04 — The manager failed to provide a written document with all required information to emergency responders contacted on behalf of residents, omitting critical health and contact details.

Caregiver skills verification — The manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services.

R9-10-113 — The manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services.

The manager failed to ensure a caregiver provided current documentation of first aid and adult CPR training certification before providing assisted living services.

R9-10-808 — The manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis within the required timeframe.

The manager failed to ensure a resident's written service plan was signed by the resident or representative, the manager, and the nurse who reviewed the plan.

The manager failed to ensure caregivers documented services provided in residents' medical records, with missing documentation for multiple residents.

The manager failed to ensure medication service policies included procedures for assisting residents in procuring medications, resulting in unavailable medications for several residents.

The manager failed to ensure medications were administered in compliance with medication orders for multiple residents.

The manager failed to ensure medication administration was documented in residents' medical records, risking lack of accurate health data in emergencies.

The manager failed to ensure the facility had a developed and documented disaster plan accessible to caregivers and assistant caregivers.

The manager failed to ensure evacuation drill documentation included required details such as time, evacuation duration, and identification of residents needing assistance or not evacuated.

The manager failed to ensure immediate notification of a resident's primary care provider following an accident or injury requiring medical services.

R9-10-113 — The healthcare institution failed to implement tuberculosis infection control activities, including baseline screening and documentation for residents.

The manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident by covering methods to be aware of the resident's general or specific whereabouts based on the level of services provided. This failure prevented staff from ensuring the resident's safety, as documented incidents showed the resident wandering and being found in unauthorized locations without proper tracking.

The manager failed to timely document suspected abuse or neglect, any actions taken, and the required report, resulting in inadequate investigation and documentation of alleged abuse incidents.

The manager failed to provide written notification to the Department of a resident's death within one working day as required by A.R.S. § 11-593.

R9-10-113 — The manager failed to provide evidence of freedom from infectious tuberculosis for two employees as required, posing a TB exposure risk to residents.

The manager failed to ensure a caregiver documented services provided in a resident's medical record, preventing verification of services against the service plan.

36-420.04 — The manager failed to provide emergency responders with a written document including all required information for two residents, missing details such as the reason for the emergency response, pharmacy contact information, point-of-contact details, and HIPAA release authorization.

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, posing a health and safety risk. The service plan did not reflect the increased care needs after Hospice services began.

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 — The manager failed to ensure an investigation documented a description of any injury to the resident, names of witnesses, and actions taken to prevent future abuse, neglect, or exploitation.

Notification failure — The manager failed to provide written notification to the Department of a resident's death within one working day as required, preventing the Department from assessing immediate health and safety concerns for other residents.

Caregiver training documentation — 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.

First aid and CPR certification — The manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Fingerprint clearance card — The manager failed to ensure a personnel record included documentation of a valid fingerprint clearance card as required by A.R.S. § 36-411(A).

Service plan timeliness — The manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance.

Service plan content — The manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, risking unclear service expectations.

Service plan details — The manager failed to ensure a resident's written service plan included the amount and frequency of assisted living services being provided.

Service documentation — The manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, risking unverifiable service delivery and misleading information.