Inspection Reports for
Sherwood Heights Adult Living

No evidence was provided to show that the facility developed and administered a training program for all staff regarding fall prevention and fall recovery.

The governing authority failed to ensure compliance with A.R.S. § 36-411.

Policies and procedures were not reviewed at least once every three years and updated as needed.

Documentation was not maintained for at least 12 months after the last date on the documentation of caregivers and assistant caregivers working each day, including hours worked by each.

Personnel records for employees or volunteers did not include documentation of the individual's education and experience applicable to their job duties.

Personnel records did not include documentation of required cardiopulmonary resuscitation and first aid training, if applicable.

Caregivers or assistant caregivers failed to document the services provided in the resident's medical record.

R9-10-814 — The facility accepted or retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, contrary to the rule.

Medication administration was not documented in the resident's medical record as required.

Documentation of required tests was not maintained for at least 12 months after the date of the test as required.

R9-10-803 — The manager failed to provide written notification to the Department of a resident's death within one working day as required, preventing the Department from assessing immediate health and safety concerns for other residents.

36-420.01 — The manager failed to ensure the facility administered a fall prevention and fall recovery training program including initial and continued competency training for two of three personnel sampled.

The governing authority failed to ensure compliance with A.R.S. § 36-411 by not documenting good faith efforts to contact previous employers and verify fingerprint clearance cards for two of three personnel sampled.

The manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed, with no documentation of a review after March 1, 2021.

The manager failed to maintain documentation for at least 12 months of caregivers working each day including hours worked, as the personnel schedule lacked hours worked by each caregiver.

The manager failed to ensure personnel records included documentation of education and experience applicable to job duties for one employee.

The manager failed to ensure personnel records included documentation of required CPR and first aid training for one employee as per facility policies.

The manager failed to ensure caregivers documented services provided in residents' medical records for two of four residents sampled, risking verification of services against service plans.

R9-10-814 — The manager retained a resident confined to a bed or chair without required documentation from the primary care provider confirming the resident's needs could be met by the facility.

The manager failed to ensure medication administration was documented in residents' medical records for two of four residents sampled, with multiple missing entries on medication administration records.

The manager failed to maintain documentation of monthly smoke detector tests for at least 12 months, with only one test documented in February 2024.