SHERWOOD VILLAGE ASSISTED LIVING AND MEMORY CARE

INSP-0107977

Complete

Date: 8/6/2025 - 8/7/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-09-18

Summary:

The following deficiency was found during the on-site compliance inspection and investigation of complaints 00121630, 00108578, 00108718, 00104150, 00105214, 00105640, and 00134727 conducted on August 6, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-808.A.1. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 1. Is completed no later than 14 calendar days after the resident’s date of acceptance;

Evidence/Findings:

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.

Temporary Solution:

R6, 7 and 9 all signed their Initial SP. R6 did sign initial SP on 04/22/25, which is in compliance. Wellness Coordinator had it in her email but failed to print it out and update the Wellness chart. R7 was signed by POA, but was signed 7 days late. SP on R8 who originally refused to sign finally signed SP on 8/7/25. Audit of all charts was completed on 08/15/2025, and all initial SP are signed by resident/resident representative. Did In Service with Department Heads on 08/08/2025 regarding needing a wet signature on Initial SP within 14 days of admission. In Service included "Documented Attempts" not qualifying as signature.

Permanent Solution:

Wet signature requirement added to chart check list.

Person Responsible:

Russell Sylvester, Executive Director

INSP-0087039

Complete

Date: 7/25/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-08-15

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00199574, AZ00195353, AZ00195354, and AZ00190529, conducted on July 25, 2024:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A caregiver:
b. Provides documentation of:
i. 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;

Evidence/Findings:

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.

Deficiency #2

Rule/Regulation Violated:

B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
b. Is administered in compliance with a medication order, and

Evidence/Findings:

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

Deficiency #3

Rule/Regulation Violated:

F. When medication is stored by an assisted living facility, a manager shall ensure that:
1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Evidence/Findings:

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.

SHERWOOD VILLAGE ASSISTED LIVING AND MEMORY CARE

Facility Information

Inspection History

INSP-0107977

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0087039

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings: