Sherwood Heights Adult Living

Based on documentation review, record review, and interview, the manager failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for the other residents residing in the assisted living facility. Findings include: 1. A.R.S. § 11-593.B. states, "Reporting is required in the following circumstances: 1. Death when not under the current care of a health care provider as defined pursuant to section 36-301. 2. Death resulting from violence. 3. Unexpected or unexplained death. 4. Death of a person in a custodial agency as defined in section 13-4401. 5. Unexpected or unexplained death of an infant or child. 6. Death occurring in a suspicious, unusual or nonnatural manner, including death from an accident believed to be related to the deceased person's occupation or employment. 7. Death occurring as a result of anesthetic or surgical procedures. 8. Death suspected to be caused by a previously unreported or undiagnosed disease that constitutes a threat to public safety. 9. Death involving unidentifiable bodies." 2. Review of Department documentation revealed no evidence that E1 or the facility had reported R1's death to the Department. 3. Review of Department documentation revealed R1 was taken to the hospital and according to the document, R1 “suffered the following: bruising, left arm broken at shoulder, L 1 vertebrae was broken, right leg was broken above the ankle.” The document also stated, “[R1] fell into a coma at the hospital and passed away from [R1’s] injuries…” 4. Review of R1’s medical record revealed a document titled, “Incident Report” dated May 5, 2025 which stated, “When changing resident on [R1’s] side, I reached for a wipe with the other hand and resident fell forward heading/falling towards the ground. A chair was in the way and [R1’s] head touched the chair. [R1] fell face up.” The “Incident Report” indicated R1 was admitted to the hospital. 5. Review of R1's medical record revealed no documentation showing R1 was terminated from the facility. 6. Review of facility documentation revealed a letter, dated May 12, 2025, from the Maricopa County Office of the Medical Examiner that stated the date of death was May 10, 2025. 7. In an interview, E3 reported the facility sought legal advice and understood it was not required to report the death.

Based on record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training, for two of three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E1's personnel record did not include documentation of Fall Prevention and Fall Recovery training. Given E1's date of hire, this documentation was required. 2. A review of E3's personnel record did not include documentation of Fall Prevention and Fall Recovery training. Given E3's date of hire, this documentation was required. 3. In an interview, E1 acknowledged documentation of E1's and E3's Fall Prevention and Fall Recovery trainings were not available for review.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of three personnel sampled. The deficient practice posed a risk if E1 and E3 were a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(C)(2) states, "Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person ' s fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person ' s fingerprint clearance card." 2. A review of E1's personnel record did not include documentation of the following items: - the facility's good faith effort to contact E1's previous employers; and - verification of E1's fingerprint clearance card (FPCC) verification. 3. A review of E3's personnel record did not include documentation of the following items: - the facility's good faith effort to contact E3's previous employers; and - verification of E3's FPCC verification. 4. In an interview, E1 acknowledged that E1's and E3's personnel records did not include compliance with A.R.S. \'a7 36-411.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a review was conducted on March 1, 2021. However, documentation of an additional review was not available for review. 2. In an interview, E1 acknowledged that the facility's policies and procedures were not reviewed at least once every three years and updated as needed.

Based on documentation review and interview, the manager failed to ensure that documentation was maintained for at least 12 months after the date on the documentation of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. A review of the facility's personnel schedule for January 2025 revealed documentation of the caregivers working each day. However, the schedule did not include the hours worked by each caregiver. 2. In an interview, E1 acknowledged the facility's personnel schedule did not include documentation of the hours worked by each caregiver. Technical assistance was provided regarding this rule during the compliance inspection conducted on May 18, 2022.

Based on record review and interview, the manager failed to ensure that a personnel record for each employee or volunteer included documentation of the individual's education and experience applicable to the individual's job duties. Findings include: 1. A review of E3's personnel record did not include documentation of E3's education and experience applicable to E3's job duties. 2. In an interview, E5 reported the documentation was stored in a separate location and was not available for review. E1 acknowledged that E3's personnel record did not include documentation of E3's education and experience applicable to E3's job duties.

Based on documentation review, record review, and interview, the manager failed to ensure that a personnel record for each employee or volunteer included documentation of cardiopulmonary resuscitation (CPR) and first aid (FA) training, if required for the individual in the facility's policies and procedures, for one of three personnel sampled. 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 facility's policies and procedures revealed a policy titled, "Cardiopulmonary Resuscitation and First Aid Requirements." The policy stated, "1. Each manager, caregiver, and other applicable employees shall: a. Obtain CPR training specific to adults... b. Obtain first aid training specific to adults." 2. A review of the facility's policies and procedures revealed a policy that stated, "4. To work as Volunteer and/or Support Staff you must have a file that contains... 5. All of the above staff must have: a. A file that is maintained on the premises for each employee or volunteer containing the following: 3) Current training in adult CPR and adult first aid that meets the requirements of this assisted living facility's policy and procedures." 3. A review of R3's personnel record did not include documentation of completed CPR/FA training. 4. In an interview, E1 acknowledged E3's personnel record did not include documentation of CPR/FA training as required in the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure that a caregiver documented the services provided in the resident's medical record, for two of four residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan, dated October 12, 2024, that indicated R1 required the following services: - Skin checks, daily (qd); - Comb hair, qd; - Assistance with dressing, qd; - Provided hydration, qd; - Lotion applied, qd; - Meals provided, three times a day (tid); - Oral care, qd; - Cognitive stimulation, qd; - Orient every two hours, qd; - Partial shower, qd; - Shaving, qd; - Snacks provided, twice a day (bid); and - Toileting, qd. 2. A review of R1's activities of daily living (ADL) documentation, for January 2025, did not include documentation of all aforementioned services provided to R1 on January 29, 2025. 3. A review of R2's personnel record revealed a service plan, dated November 15, 2024, that indicated R2 required the following services: - Skin checks, qd; - Comb hair, qd; - Assistance with dressing, qd; - Lotion applied, qd; - Meals provided, tid; - Oral care, qd; - Cognitive stimulation, qd; - Orient every two hours, qd; - Partial shower, qd; - Shaving, qd; - Snacks provided, bid; - Incontinent checks, qd; and - Toileting, qd. 4. A review of R2's ADL documentation, for January 2025, did not include documentation of all aforementioned services provided to R2 on January 29, 2025. 5. In an interview, E5 reported R1 and R2 received all services required per R1's and R2's service plans on January 29, 2025. E1 acknowledged that a caregiver did not document the services provided in the resident's medical record.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2)(b)(iii), for one of four residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2)(b)(iii) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R2's service plan (dated November 15, 2024) revealed R2 received directed care services, and was confined to a bed or chair. 3. A review of R2's medical record revealed documentation of the determination required dated May 20, 2023. However, additional documentation signed by R2's primary care provider was not available for review. 4. In an interview, E1 acknowledged R2's medical record did not include the required determination per R9-10-814(B)(2)(b)(iii).

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record, for two of four residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication list, dated January 8, 2025, that included the following medications: - Acetaminophen 500 milligrams (mg), 2 tablets by mouth (po) three times a day (tid); - Amlodipine 5 mg, 1 tablet po at bedtime (qhs); - Gabapentin 100 mg, 2 capsules po tid; - Gabapentin 400 mg, 1 capsule po qhs; - Metformin 500 mg, 2 tablet po twice a day (bid); - Tramadol HCL 50 mg, 1 tablet po tid; and - Trazodone HCL 100 mg, 2 tablets po qhs. 3. A review of R1's medication administration record (MAR) for January 2025 revealed missing documentation of the following medications, on the following dates: - Acetaminophen 500 mg, at 8:00 PM on January 11, 2025, January 24, 2025, and January 25, 2025; - Amlodipine 5 mg, at 8:00 PM on January 24, 2025 and January 25, 2025; - Gabapentin 100 mg, at 2:00 PM on January 29, 2025; - Gabapentin 400 mg, at 8:00 PM on January 11, 2025, January 24, 2025, and January 25, 2025; - Metformin 500 mg, at 8:00 PM on January 24, 2025 and January 25, 2025; - Tramadol HCL 50 mg, at 8:00 PM on January 24, 2025 and January 25, 2025; and - Trazodone HCL 100 mg, at 8:00 PM on January 11, 2025, January 24, 2025, and January 25, 2025. 4. A review of R2's medical record revealed R2 received medication administration. 5. A review of R2's medical record revealed a medication list, dated January 15, 2025, that included the following medications: - Advair Diskus 250 - 50 micrograms (MCG), 1 inhale every 12 hours (q12h); - Atorvastatin Calcium 40 mg, 1 tablet po qhs; - Carbidopa-Levodopa 25-250 mg, 1 tablet po tid; - Quetiapine Fumarate 25 mg, 1 tablet po at 1:00 PM, 6:00pm, and qhs; - Rivastigmine Tartrate 4.5 mg, 1 capsule po bid; and - Senna 8.6 mg, 1 tablet po qd. 6. A review of R2's MAR for January 2025, revealed missing documentation of the following medications, on the following dates: - Advair Diskus 250 - 50 mcg, at 8:00 PM on January 11, 2025, January 24, 2025, and January 25, 2025; - Atorvastatin Calcium 40 mg, at 8:00 PM on January 11, 2025; - Carbidopa-Levodopa 25-250 mg, at 12:00 PM on January 29, 2025; - Quetiapine Fumarate 25 mg, at 8:00 PM on January 11, 2025, January 24, 2025, and January 25, 2025; - Quetiapine Fumarate 25 mg, at 1:00 PM on January 29, 2025; and - Rivastigmine Tartrate 4.5 mg, at 8:00 PM on January 11, 2025, January 24, 2025, and January 25, 2025. 7. In an interview, E1 reported R1 and R2 received all aforementioned medications at the required times; however, documentation of the administration was not available for review. E1 acknowledged R1's and R2's medical recor

Based on documentation review and interview, the manager failed to ensure that documentation of the test required in (F)(4)(a)(iv) was maintained for at least 12 months after the date of the test. Findings include: 1. R9-10-818.F.4.a.iv states, "a. A smoke detector is: iv. Tested at least once a month." 2. A review of facility maintenance documentation revealed a documented smoke detector test documented in the month of February 2024. However, documentation of additional testing was not available for review. 3. In an interview, E1 reported the facility conducted monthly smoke detector tests; however, the documentation of the tests was not available. E1 acknowledged documentation of monthly smoke detector tests was not maintained for at least 12 months after the date of the test.