Sheridan Garden Assisted Living

Based on record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of E1's personnel record revealed there was no documentation of fall prevention and fall recovery training. 2. In an interview, E2 reviewed and acknowledged that E1's personnel record did not include documentation of fall prevention and fall recovery training. This is a repeat deficiency from the compliance inspection conducted on June 2, 2022.

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis infection control activities that included annually assessing its risk of exposure to infectious tuberculosis. Findings include: 1. A review of the facility’s documentation revealed there was no documentation of an assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. In an interview, E2 acknowledged that the health care institution failed to implement tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents who received medication administration services. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical records revealed a service plan, which reflected that R2 received medication administration services. 2. A review of R2's medical record revealed a medication order dated May 21, 2025 for Humalog (Lispro) INS 100 unit/ml pen inject as per sliding scale according to blood sugar: if below 150 administer zero units: 150 through 199 administer one unit; 200 through 249 administer two units; 250 through 299 administer four units; 300 through 349 administer six units; 350 through 399 administer eight units and blood sugar above 400 call primary physician. 3. A review of R2's medical record revealed a medication administration record dated October 2025, which reflected R2 was administered Humalog along with the following documented blood sugar: - 8 am on October 9, 2025, R2’s blood sugar was 153, and was administered two units; - 8 am on October 10, 2025, R2’s blood sugar was 156, and was administered two units; - 8 am on October 11, 2025, R2’s blood sugar was 150, and was administered two units; - 5 pm on October 12, 2025, R2’s blood sugar was 154, and was administered two units; - 5 pm on October 13, 2025, R2’s blood sugar was 181, and was administered two units; - 8 pm on October 13, 2025, R2’s blood sugar was 239, and was administered two units; - 8 pm on October 17, 2025, R2’s blood sugar was 263, and was administered two units; - 8 pm on October 18, 2025, R2’s blood sugar was 253, and was administered two units.  4. In an interview, E2 acknowledged R2’s Humalog was not administered to R2 in compliance with a medication order. This is a repeat deficiency from the compliance inspection conducted on June 2, 2022.

Based on observation, record review, and interview, the manager failed to ensure care instructions provided by a home health agency or hospice service agency were documented on a resident's service plan, for one of two sampled residents receiving services from hospice. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a foley catheter bag next to R1's bed. 2. In an interview, E1 reported R1 was on hospice and had a foley catheter. E1 reported the caregivers were responsible for emptying the foley catheter bag. 3. A review of R1's medical record revealed a service plan dated July 4, 2023. R1's service plan did not reflect R1 had a foley catheter, hospice instructions for care of R1's foley catheter, or the amount, type, or frequency of services to be provided by the caregiver. 4. In an interview, E1 reviewed and acknowledged R1's service plan did not reflect R1 had a foley catheter, hospice instructions for care of R1's foley catheter, or the amount, type, or frequency of services to be provided regarding R1's catheter.

Based on record review and interview, the manager failed to ensure the requirements in Arizona Administrative Code (A.A.C.) R9-10-814(B)(2) were met for a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, for one of two sampled non-ambulatory residents. Findings include: 1. A review of R1's medical record revealed a service plan dated December 13, 2022 for personal care services. The service plan reflected R1 was bed-bound. 2. A review of R1's medical record revealed a document titled "Bed or Chair Bound Consent For Treatment" dated November 3, 2019. However, there was no recent authorization for continued residency available for review. 3. In an interview, E1 acknowledged there was no current documentation to authorize contained residency for R1.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer measured the hot water temperature in a shared resident bathroom of the facility using a Department-issued thermometer. The thermometer indicated the water temperature was 125.5 \'b0F. 2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95 \'b0F and 120 \'b0F.