Sherwood Village Assisted Living and Memory Care

Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for one of ten resident records reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R5's medical record revealed R5 received personal care services and medication administration. 2. Further review of R5’s medical record revealed a signed medication order dated November 28, 2025, for "Lantus Subcutaneous Suspension… Inject 30 unit subcutaneously in the evening for diabetes before evening meals. Hold if blood sugar is 100 or below.” 3. A review of R5’s Medication Administration Record (MAR) dated January 2026 revealed Lantus was administered on January 10, 2026. A progress note revealed R2’s blood sugar measured 99. 4. On January 1, 3, 5, 8, 12, 16, 22, 24, 26, and 28, 2026, R5’s Lantus was held. However, no documentation was provided to indicate R5’s blood sugar was measured on these dates. On January 2, 4, 9, 11, 13, 15, 20, 21, 23, 27, and 29, R5 was administered Lantus. However, no documentation was provided to indicate R5's blood sugar was measured prior to administration on these dates. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat citation from the on-site compliance inspection and investigation of complaints AZ00199574, AZ00195353, AZ00195354, and AZ00190529, conducted on July 25, 2024.

Based on record review and interview, 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 for three of ten resident records reviewed. The deficient practice posed a risk as there was no completed service plan to direct services to be provided to a resident. Findings include: 1. A review of R6's medical record revealed an initial service plan with the following information: - Facility nurse signed and dated the document on April 18, 2025; - Facility manager signed and dated April 18, 2025; and - Resident/Resident’s Representative, unsigned and undated. Based on R6's date of acceptance, the service plan was not completed within 14 calendar days of R6's date of acceptance. 2. A review of R7's medical record revealed an initial service plan with the following information: - Facility nurse signed and dated the document on February 28, 2025; - Facility manager signed and dated February 28, 2025; and - Resident/Resident’s Representative, signed and dated document on March 18, 2025. Based on R7's date of acceptance, the service plan was not completed within 14 calendar days of R7's date of acceptance. 3. A review of R8's medical record revealed an initial service plan with the following information: - Facility nurse signed and dated the document on May 19, 2025; - Facility manager signed and dated May 19, 2025; and - Resident/Resident’s Representative, unsigned and undated. Based on R8's date of acceptance, the service plan was not completed within 14 calendar days of R8's date of acceptance. 4. In an interview, E1 acknowledged the service plans were not completed within 14 calendar days of the residents' date of acceptance.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for one of ten personnel records reviewed. The deficient practice posed a risk if E6 was unable to meet the needs of residents. Findings include: 1. A review of E6's personnel record revealed E6 was employed as a caregiver. 2. A review of E6's personnel record revealed no evidence of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. Further review of the personnel record revealed a certificate of completion for a caregiver continuing education class. The Compliance Officer observed the signature line, participant name, and date appeared altered. E1 reported the facility was unable to verify the document. 3. An online search for caregiver certification revealed E6 did not obtain caregiver certification after August 2013. 4. The Compliance officer was advised E6 was on site, and would be sent home until the issue was resolved. 5. A review of the facility work schedule, for May 2024, revealed E6 was scheduled to work as a caregiver 5 days per week. 6. In an interview, E4 acknowledged E6 was working as a caregiver for the facility and E6's personnel record did not include documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of ten resident records reviewed. Findings include: 1. A review of R6's medical record revealed a signed list of medications dated May 15, 2024. The medication list included: - "Carvedilol Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet by mouth two times a day for blood pressure hold for SBP <100 or pulse <60". 2. A review of R6's medical record revealed a Medication Administration Record (MAR) dated July 2024. The MAR revealed Carvedilol 3.125MG was administered to R6 twice per day from July 1, 2024 through July 24, 2024. 3. A review of R6's medical record revealed no evidence R6's blood pressure or pulse were checked prior to administering the Carvedilol. 4. In an interview, E4 acknowledged the medication had not been administered to R6 in compliance with the medication order.

Based on observation, record review, and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. Findings include: 1. During an tour of the facility, the Compliance Officer observed a bottle of "ZADITOR ANTIHISTAMINE EYE DROPS", on R11's night stand, in R11's bedroom. 2. A review of resident records revealed R11 received personal care services including medication administration. 3. E4 removed the medication from R11's room. 4. During an interview, E4 acknowledged the Compliance Officer found a medication stored in an unlocked area.