Sheridan Garden Assisted Living Home

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of two personnel sampled. 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 the Centers for Disease Control and Prevention website revealed a web page titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read. 3. A review of E3's personnel record revealed one negative chest X-ray from January 6, 2022, a screening and risk assessment document. 4. In an interview, E2 acknowledged E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure a resident had a written service plan. Findings include: 1. A review of R2's medical record revealed that R2 did not have a service plan. Based on the resident's date of acceptance, this documentation was required 2. In an interview, E2 acknowledged R2 had no written service plan.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. The Compliance Officer observed one ambulatory resident on the premises. 2. The Compliance Officer observed the following medications, unlocked, in a kitchen drawer: -one bottle of "Omeprazol C\'e1psulas 20mg;" -one small medication organizer containing various pills of size and color; and -one unit-dose package of white pills. 3. In an interview, E2 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. 4. In an interview, E2 reported the medications belonged to E3. 5. In a joint interview, E1, E2, and E5 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

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 two of two individuals sampled who were hired as caregivers. The deficient posed a risk if E3 and E4 were not trained to provide the required services, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. The Compliance Officer observed E3 working on the premises. 2. A review of facility documentation revealed a staffing schedule for May 2023 and June 2023. The schedule revealed E3 was scheduled to work (24 hours) on the following dates: -May 7-31, 2023; -June 1-12, 2023; and -June 23-30, 2023. 3. A review of E3's (hired in 2022) personnel record revealed E3 was hired as a caregiver. E3's personnel record revealed documentation of completion of a caregiver training program from Adult Caregiver Training Institute, ALTP-0136 (issued May 10, 2010). However, the documentation was a photocopy and contained marks and various different fonts. The documentation contained uneven wording and missing parts of text. The documentation contained what appeared to be markings to indicate correction tape was used where the date was located. 4. A review of E3's personnel record revealed documentation of experience. The documentation revealed E3 worked as a private caregiver since 2016. 5. In an interview, E3 reported E3 could not remember when E3 first came to Arizona. E3 reported E3 could not remember the name of the caregiver training program E3 completed. 6. A review of facility documentation revealed a staffing schedule for May 2023 and June 2023. The schedule revealed E4 was scheduled to work (24 hours) on the following dates: -May 1-4, 2023; and -June 17-21, 2023. 7. A review of E4's (hired in 2020) personnel record revealed E4 was hired as a caregiver. E4's personnel record revealed documentation of completion of a caregiver training program from Adult Caregiver Training Institute, ALTP-0136 (issued August 20, 2011). However, the documentation was a photocopy and contained marks and various different fonts. The documentation contained uneven wording and missing parts of text. The documentation contained what appeared to be markings to indicate correction tape was used where E4's name was located. 8. A review of E4's personnel record revealed documentation of experience. The documentation revealed E4 worked as a caregiver since 2013. 9. In a joint interview, the findings were reviewed with E1 and E5 and no additional comments or statements were provided regarding the findings.