Sheridan Garden Assisted Living

Based on record review and interview, the manager failed to ensure that the emergency responder face sheet contained the name, address and telephone number of the resident's current pharmacy as required under Arizona Revised Statute (A.R.S.) 36-420.04. A.3. Findings include: 1. A record review of the facility's prefilled Emergency Medical Services (EMS) Face Sheet for R1 and R2, revealed that the form was missing the name, address, and phone number of the resident's current pharmacy. 2. In an interview, E1 acknowledged that the EMS face sheets did not contain the name, address, and phone number of the resident's current pharmacy as required.

Based on observation and interview, the manager failed to ensure that a manager or caregiver who was able to read, write, understand, and communicate in English was on the assisted living facility’s premises. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for the residents residing in the assisted living facility. Findings include: 1. Upon arrival at the facility, the Compliance Officer and Compliance Officer Supervisor were greeted by E3 and E4. 2. The Compliance Officer attempted to speak with both employees in English but were told, "No Habla English" by E3. 3. The Compliance Officer was able to use "Google Translate" in order to communicate with the employees in Spanish. The Compliance Officer asked E3 to contact the facility manager. 4. E3 called E1, who spoke the Compliance Officer. E1 came to the facility in order to complete the inspection. 5. In an interview, E1 acknowledged that a manager or caregiver who was able to read, write, understand, and communicate in English was not on the assisted living facility’s premises.

Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. Upon arrival at the facility, the Compliance Officer and Compliance Officer Supervisor were greeted by E3 and E4. 2. E3 called E1, who spoke the Compliance Officer. E1 revealed that E2 was designated as the manager. However, neither E1 nor E2 were present at the facility at time of inspection . 3. Review of the manager designation form listed E2 as authorized to be designated manager in the absence of E1. 6. In an interview, E1 acknowledged that no manager or designee was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises.

Based on record review, documentation review, and interviews, the manager failed to ensure that a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults for two of four personnel reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the personnel file for E1 revealed that the employee’s Cardiopulmonary resuscitation (CPR) and First Aid (FA) certification expired March 15, 2023. 2.A review of the personnel file for E2 revealed that the employee’s Cardiopulmonary resuscitation (CPR) and First Aid (FA) certification expired July 7, 2025. 3. A documentation review of the facility's Policies and Procedures revealed a policy titled, "Cardiopulmonary Resuscitation" [and] 'First Aid" which stated " The manager shall verify that applicable personnel have valid cardiopulmonary resuscitation/first aid training upon hiring that include demonstration and that the time-frames for renewal has not expired." 4. E1 acknowledged that E1 and E2 did not provide current documentation of first aid training and cardiopulmonary resuscitation (CPR) training.

Based on record review, documentation review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for E4. Findings include: 1. A review of E2's personnel record revealed that the employee completed the TB screening form but did not provide verification of freedom from TB as required. 2. A documentation review of the facility's Policies and Procedures Manual revealed a policy titled, "Tuberculosis Infectious Control", which stated, "1. The facility manager shall ensure that all staff have a negative TB test, such as Mantoux skin test, or other tuberculosis screening tests as recommended by the CDC at the time of employment and every twelve months thereafter. The TB test should not be more than three months old. A risk assessment should be conducted at the time of a at the time of hiring." 3. In an interview, E1 acknowledged that the manager failed to ensure that an employee provided documentation of freedom from infectious Tuberculosis (TB).

Based on record review, documentation review and interview, the manager failed to ensure that a resident provides evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy, for R2. Findings include: 1. A review of R2's medical record revealed that the resident did not provide a TB screening form nor verification of freedom from TB as required. 2. A documentation review of the facility's Policies and Procedures Manual revealed a policy titled, "Tuberculosis Infectious Control", which stated, "2. The facility manager shall ensure that potential residents provide a negative TB test, such as Mantoux skin test, or other tuberculosis screening tests as recommended by the CDC and every twelve months thereafter. The TB test should not be more than three months old. A risk assessment should be conducted at the time of a at the time of acceptance." 3. In an interview, E1 acknowledged that the manager failed to ensure that a resident provides evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that, when initially developed and when updated, was signed and dated by the resident or resident’s representative. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1’s service plan, revealed that it was signed by the facility manager and RN on May 15, 2025. It was not signed by the resident nor the resident’s representative. R1's previous service plan dated, November 30, 2024, was not signed by the resident nor resident representative. 2. A review of the facility’s Polices and Procedures revealed a policy titled, “Resident's Rights” which stated, “The resident has the following rights: To participate or have the resident's representative participate in the development of, or decisions concerning the resident's service plan." 3. In an interview, E1 acknowledged that R1 did not have a service plan that was signed and dated by the resident or resident’s representative.

Based on observation and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice violated a resident's rights. Findings include: 1. During the environmental inspection, the Compliance Officer and Compliance Officer Supervisor, observed a large number of adult briefs, in various sizes and various brands, located in the closet of a bedroom that was occupied by a resident. 2. During the environmental inspection, the Compliance Officer and Compliance Officer Supervisor, observed a Hoyer Lift being stored in a resident’s bedroom. 3. In an interview, E1 revealed that the briefs did not belong to the resident and that the closet was being used as a storage area. E1 also revealed that the Hoyer Lift did not belong to the resident and was being stored in a resident's bedroom. 4. E1 acknowledged that resident bedrooms were being used for storage and residents were not treated with dignity, respect, and consideration;.

Based on record review, documentation review and interview, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for one of two residents sampled who were confined to a bed or chair because of an inability to ambulate even with assistance. The deficient practice posed a risk if the facility was unable to meet a resident's needs. 1. A review of R1's service plan revealed that the resident was confined to a wheelchair. 2. A review of the "Continued Residency Statement" form, revealed that it was last signed by R1's physician on February 18, 2022. 3. A review of the facility's Policies and Procedures titled “Doctor Authorization for Continuance of Care” read, "The doctor (PCP) shall testify that Sheridan Gardens Assisted Living has the services/ability to continue providing care to a resident. This ability shall be evaluated every six (6) months." 4. In an interview, E1 acknowledged that the facility retained a resident who was confined to a chair without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition.

Based on observations, documentation review, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection, the Compliance Officer observed that when the patio door was opened, no alarm sounded to alert employees that a person was entering or exiting the facility. 3. A review of the facility's Policies and Procedures revealed a policy titled, “Safety of Wandering Residents” which stated, “The facility will set up alarms on the facility exit doors to alert in the event of an unauthorized departure.” 4. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation and interview the manager failed to ensure that food was obtained, prepared, served, and stored with potentially hazardous food being refrigerated at a temperature maintained at 41° F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During the environmental inspection, the Compliance Officer and Compliance Officer Supervisor observed a bottle of Grape Jelly and a bottle of Ketchup unrefrigerated laying at the top of a kitchen cabinet shelf. Both items read, "refrigerate after opening." 2. In an interview, E1 acknowledged that foods requiring refrigeration were not maintained at 41° F or below.

Based on observation, documentation review and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection, the Compliance Officer and Compliance Officer Supervisor, observed a step that led from the kitchen to the refrigerator area. The step was not marked with a caution sign nor was there a wheelchair ramp that led down from the step. As a result, the Compliance Officer tripped over the step and suffered minor injury. 2. During the environmental inspection, the Compliance Officer and Compliance Officer Supervisor, observed that the wheelchair ramp on the outside of the patio door, was cracked in the middle as the Compliance Officer Supervisor stepped on it. The ramp was not secured to the base of the door. 3. A review of the facility's Policies and Procedures revealed a policy titled, "Environmental" which stated, "A Manager shall ensure that the premises and equipment, used at the assisted living facility are maintained and free from a condition or situation that may cause a resident or other individuals to suffer injury or illness as outlined in the procedures below: Facility premises and equipment used there in are in working order, used and cleaned according to the manufactures recommendations and, if applicable disinfected as needed to prevent, minimize, and control illness or infection.” 4. In an interview, E1 acknowledged that the premises and equipment used at the assisted living facility were no free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's written service plan, when initially developed and when updated, was signed and dated by the resident or resident's representative, the manager, and if a review was required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plans, for one of three residents sampled. Findings include: 1. Arizona Adminsitrative Code (A.A.C.) R9-10-808(A)(3)(d) states: "A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: d. For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner;". 2.A review of R1's medical record revealed a service plan dated January 7, 2023. R1's service plan reflected R1 recieved medication administration. The service plan was not signed by R1 or R1's representative, the manager, or a nurse or medical practitioner. 3. In an interview, E1 reviewed and acknowledged R1's service plan was not signed and dated by R1 or R1's representative, the manager, and a nurse or medical practitioner.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident, including the time of administration, for one of three sampled residents. Findings include: 1. A review of R2's medical record revealed a medication order for "Midodrine 10 mg (milligrams) take one tablet by mouth three times daily" dated April 24, 2023. 2. A review of R2's medical record revealed a medication administration record (MAR) dated June 2023. The MAR reflected R2 was administered "Midodrine 10 mg" from June 1, 2023 to June 5, 2023 at 8:00 AM, 12:00 PM, and 5:00 PM. R2's medical record also contain a document titled "Vitial Signs" which reflected R2 was administered "Midodrine 10 mg" at 8:00 AM, 12:00 PM, and 8:00 PM from June 1, 2023 to June 5, 2023. 3. In an interview, E1 reported R2's "Midodrine" was administered three times daily at 8:00 AM, 12:00 PM, and 5:00 PM, and was not administered at 8:00 PM. E1 reported the "Vital Signs" document was incorrect.