SKY VISTA

<p style="text-align: justify;"><br></p><p><span style="font-size: 12pt;"> </span>Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for seven of seven personnel sampled. The deficient practice posed a potential illness risk to residents. </p><p> </p><p>Findings include: </p><p> </p><p>1.   A review of E1's, E2's, E3's, E4's, E5's, E6's, and E7's personnel records revealed documentation of initial training and education related to recognizing the signs and symptoms of TB. However, documentation of annual training and education related to recognizing the signs and symptoms of TB, which is required at least once every 12 months, was not available for review for 2023 and 2024. </p><p> </p><p>1.   In an interview, E1 acknowledged that E1's, E2’s, E3’s, E4’s, E5’s, E6’s, and E7's documentation of annual training and education related to recognizing the signs and symptoms of TB at least once every 12 months was not available for review for 2023 and 2024.</p><p style="text-align: justify;"><br></p><p><br></p>

<p>Based on the record review and interview, the manager failed to ensure that a resident medical record contained documentation showing the pneumonia vaccination was offered every 12 months to three of the three residents reviewed. The deficient practice posed a potential illness risk to residents.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A review of R2's and R4's records revealed no documentation showing that the pneumonia vaccination was offered or received.</p><p><br></p><p>2. In an interview, E1 acknowledged that R2's and R4's records did not include current documentation showing that the pneumonia vaccination was offered or received.  </p>

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. Review of facility documentation revealed a policy and procedure titled "Fall Reduction Program". This policy listed annual training on "Falls overview; Back Safety; Assistive Devices; Transfer and Ambulation; Competency Checklist". However, this document did not list training in fall recovery.

2. Review of E1's, E2's, E3's, E4's, and E5's personnel records revealed no documentation showing completion of fall recovery training.

3. In an interview, E5 reported that not all staff received training on fall recovery, and that some get it during orientation. E5 acknowledged E1's, E2's, E3's, E4's, and E5's personnel records did not contain documentation that showed the health care institution had administered a training program for all staff regarding fall recovery.

4. This is a repeat deficiency from the complaint investigation conducted June 22, 2023.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. A review of facility documentation revealed an undated policy and procedure titled "Fall Reduction Program." The policy and procedure stated " ...Staff Training ...All staff receive fall training during their initial orientation ...All staff will receive fall training annually ..."

2. A review of E3's (hired in 2023) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

3. A review of E4's (hired in 2021) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

4. A review of E5's (hired in 2022) personnel record revealed initial training in fall prevention and fall recoverywas not available for review.

5. In an interview, E1 acknowledged the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery.

6. A review of Department documentation revealed A.R.S. \'a7 36-420.01. went into effect on October 1, 2021.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for one of one former caregiver sampled. The deficient practice posed a risk if E5 was unable to meet a resident's needs.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "GP 37 - Care and Medication Training (dated May 9, 2022). The policy and procedure stated "5. Each new Caregiver's skills and knowledge must be verified and documented before the Caregiver provides any services to any resident ..."

2. In an interview, E6 stated caregiver's skills and knowledge are verified during "on-boarding."

3. A review of E5's (hired in 2022) personnel record revealed E5 was initially hired as a housekeeper and completed on-boarding training for a housekeeping position.

4. A further review of E5's medical record revealed E5 completed a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers in July 2022 and was promoted to a caregiver. However, documentation E5's skills and knowledge were verified was not available for review.

5. In an interview, the findings were discussed with E1 and E1 reported to be unsure if E5's skills and knowledge were verified before providing physical health services and according to the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure a service plan included coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan, for two of two discharged residents sampled who received directed care services and one of one current resident sampled who received directed care services. The deficient practice posed a risk if the resident's representative and other individuals identified were unable to participate in decisions concerning the assisted living services the resident was to receive.

Findings include:

A.R.S. 36-401(A)(16) "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

1. A review of R1's (discharged in 2023) medical record revealed a service plan dated in January 2023. However, the service plan did not include coordination of communications with family members, and, if applicable, other individuals identified in the resident's service plan.

2. A review of R2's (discharged in 2023) medical record revealed a service plan dated in December 2022. However, the service plan did not include coordination of communications with family members, and, if applicable, other individuals identified in the resident's service plan.

3. A review of R3's (admitted in 2023) medical record revealed a service plan dated in April 2023. However, the service plan did not include coordination of communications with family members, and, if applicable, other individuals identified in the resident's service plan.

4. In an interview, E1 acknowledged R1's, R2's, and R3's service plans did not include coordination of communication with the resident's representative, family members, and other individuals identified in the resident's service plan.

This is a repeat deficiency from the onsite compliance inspection completed on January 23, 2023.

Based on documentation review and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident. The deficient practice posed a risk as there were no policies and procedures to reinforce and clarify the health care institution's standards, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures (dated in December 2022) revealed no evidence the following policies and procedures were established and documented:
-Covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers;
-Covering orientation and in-service education for employees and volunteers;
-Covering cardiopulmonary resuscitation training for applicable employees and volunteers including; including:
i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation;
ii. The qualifications for an individual to provide cardiopulmonary resuscitation training;
iii. The time-frame for renewal of cardiopulmonary resuscitation training; and
iv. The documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training.

2. In a joint interview, E1 and E10 reported to be unaware of the requirements.

3. A review of Department documentation revealed the license for AL11993 was effective November 12, 2021.

Based on documentation review, record review, and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the following documentation was not provided for review: the facility's policies and procedures required in R9-10-803.C.1.a-b.e.; E7's 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; E4's and E7's cardiopulmonary resuscitation (CPR) training, to include demonstration; E2's, E5's, E7's, and E8's documentation of compliance with A.R.S. \'a7 36-411(C)(2); R1's and R3's documentation required in R9-10-807.B.1.a-b.; R1's documentation required in R9-10-807.C.1.c.; R1's and R2's documentation required in R9-10-815.C.3. and R9-10-815.C.7.; the facility's policies and procedures for medication administration reviewed and approved by a medical practitioner, registered nurse, or pharmacist; and the facility's disaster plan review required in R9-10-818.A.3.a-d.

Findings include:

1. A review of the facility's policies and procedures (dated in December 2022) revealed no evidence the following policies and procedures were established and documented:
-Covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers;
-Covering orientation and in-service education for employees and volunteers;
-Covering cardiopulmonary resuscitation training for applicable employees and volunteers including; including:
i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation;
ii. The qualifications for an individual to provide cardiopulmonary resuscitation training;
iii. The time-frame for renewal of cardiopulmonary resuscitation training; and
iv. The documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training.

2. A review of E7's personnel record revealed a document indicating E7 completed a "National Caregiver Certification As A Home Health Aide" through "American Caregiver Association" dated July 17, 2013. However, a review of https://nciaboard.az.gov/news/fraudulent-caregiver-certificates revealed E1 did not have a caregiver certificate after August 3, 2013.

3. A review of E4's personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued December 1, 2021 and valid for two years.

4. A review of E7's personnel record revealed documentation of CPR and first aid training from "American Life & Health Foundation ...online course presented by www.CPRandFirstAid.net," issued October 22, 2022.

5. A review of E2's personnel record revealed a valid fingerprint clearance card. However, documentation to indicate E2's fingerprint clearance card was verified was not available for review.

6. A review of E5's personnel record revealed a valid fingerprint clearance card. However, documentation to indicate E5's fingerprint clearance card was verified was not available for review.

7. A review of E7's personnel record revealed a valid fingerprint clearance card. However, documentation to indicate E7's fingerprint clearance card was verified was not available for review.

8. A review of E8's personnel record revealed a valid fingerprint clearance card. However, documentation to indicate E8's fingerprint clearance card was verified was not available for review.

9. A review of R1's medical record revealed a document titled, "Physician's Report (Arizona)," signed and dated by a medical practitioner in November 2022. However, the document stated R1 had a diagnosis of dementia, needed to be escorted by staff due to "cognitive impairment," and expected to require "Supervisory Care Services."

10. A review of R3's medical record revealed a document titled, "Physician's Report" signed and dated by a medical practitioner stated R3 did not require "intermittent nursing services." However, the document did not indicate the level of care R3 was expected to receive and whether R3 required continuous medical services, continuous nursing services, or restraints.

11. A review of R1's medical record revealed a document titled, "Physician's Report (Arizona)," signed and dated by a medical practitioner in November 2022. The document stated, "In addition to supervisory, personal, or directed care services, please indicate of this resident is requesting or is expected to receive continuous behavioral health services, other than behavioral care:." The medical practitioner marked "Yes, resident is requesting or is expected to require continuous behavioral services" for the aforementioned question.

12. A review of R1's medical record revealed a service plan dated in November 2022 for directed care services. However, the service plan did not include cognitive stimulation and activities to maximize functioning.

13. A review of R2's medical record revealed a service plan dated in July 2022 for directed care services. However, the service plan did not include cognitive stimulation and activities to maximize functioning.

14. A review of R1's medical record revealed a service plan dated in November 2022. However, the service plan did not include coordination of communications with family members, and, if applicable, other individuals identified in the resident's service plan.

15. A review of R2's medical record revealed a service plan dated in July 2022. However, the service plan did not include coordination of communications with family members, and, if applicable, other individuals identified in the resident's service plan.

16. A review of facility documentation revealed a policy and procedure titled "Med 02-Medication Services" (dated in December 2022). However, the policy and procedure was not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

17. A review of facility documentation revealed a disaster plan review dated January 5, 2022. However, the disaster plan review did not include documentation of the time of the disaster plan review, the name of each employee or volunteer participating in the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement.

18. In an interview, E1 acknowledged the aforementioned documentation was not provided for review within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a caregiver provided 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, for one of one individual hired as a caregiver. The deficient practice posed a risk if E7 was not qualified to provide the required services, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of E7's (hired in 2022) personnel record revealed E7 was hired as a caregiver.

2. A review of E7's personnel record revealed a document indicating E7 completed a "National Caregiver Certification As A Home Health Aide" through "American Caregiver Association" dated July 17, 2013. However, a review of https://nciaboard.az.gov/news/fraudulent-caregiver-certificates revealed E1 did not have a caregiver certificate after August 3, 2013.

3. In a joint interview, E2 and E10 reported to be unaware E7 had not completed 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 a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training, to include demonstration, for two of five caregivers sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of E4's (hired in 2021) personnel record revealed documentation of CPR and first aid training from NationalCPRFoundation, issued December 1, 2021 and valid for two years.

2. A review of E7's (hired in 2022) personnel record revealed documentation of CPR and first aid training from "American Life & Health Foundation ...online course presented by www.CPRandFirstAid.net," issued October 22, 2022.

3. In an interview, E1 acknowledged E4's and E7's CPR training cards were each from an online program and documentation of current CPR training, with demonstration, was not available for review.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C), for four of eight employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

A.R.S. \'a7 36-411(C) states "Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card."

1. A review of E2's (hired in 2022) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate E2's fingerprint clearance card was verified was not available for review.

2. A review of E5's (hired in 2022) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate E5's fingerprint clearance card was verified was not available for review.

3. A review of E7's (hired in 2022) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate E7's fingerprint clearance card was verified was not available for review.

4. A review of E8's (hired in 2022) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate E8's fingerprint clearance card was verified was not available for review.

5. In an interview, E1 acknowledged E2's, E5's, E7's, and E8's fingerprint clearance cards were not verified.

Based on observation, record review, and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to include if an individual was requesting or expected to receive supervisory care services, personal care services, or directed care services; and whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of four current residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. The Compliance Officer observed R1's residential unit was located in the secured memory care unit of the facility.

2. A review of R1's (accepted in 2022) medical record revealed a document titled, "Physician's Report (Arizona)," signed and dated by a medical practitioner in November 2022. However, the document stated R1 had a diagnosis of dementia, needed to be escorted by staff due to "cognitive impairment," and was expected to require "Supervisory Care Services."

3. A review of R1's service plan dated in November 2022 stated "AZ Care Level: Directed."

4. In a joint interview, E2 and E9 reported the documentation may have been filled out incorrectly by R1's medical practitioner.

5. A review of R3's (accepted in 2022) medical record revealed a document titled, "Physician's Report (Arizona)" signed and dated by a medical practitioner in June 2022 stated R3 did not require "intermittent nursing services." However, the document did not indicate the level of care R3 was expected to receive and whether R3 required continuous medical services, continuous nursing services, or restraints.

6. In an interview, E1 acknowledged R3's documentation did not indicate the level of care R3 was expected to receive and whether R3 required continuous medical services, continuous nursing services, or restraints.

Based on documentation review, record review, and interview, the manager accepted and retained an individual who required continuous behavioral health services, for one of four current residents sampled. The deficient practice posed a risk as the health care institution was not authorized to provide behavioral health services, the Department was unable to determine substantial compliance as documentation to indicate R1 did not require continuous behavioral health services or documentation explaining why R1 was admitted when the documentation was in contradiction to what the facility was authorized to provide was not in the medical record during the inspection, and documentation to indicate R1 did not require continuous behavioral health services or documentation explaining why R1 was admitted when the documentation was in contradiction to what the facility was authorized to provide was not provided at the exit interview.

Findings include:

Arizona Revised Statutes (A.R.S.) \'a7 36-401.11. "Behavioral health services" means "services that pertain to mental health and substance use disorders and that are either: (a) Performed by or under the supervision of a professional who is licensed pursuant to title 32 and whose scope of practice allows for the provision of these services. (b) Performed on behalf of patients by behavioral health staff as prescribed by rule."

A.R.S. \'a7 36-401.13. "Continuous" means "available at all times without cessation, break or interruption."

1. A review of Department documentation revealed the facility was not authorized to provide behavioral health services.

2. A review of R1's (admitted in 2022) medical record revealed a document titled, "Physician's Report (Arizona)," signed and dated by a medical practitioner in November 2022. The document stated, "In addition to supervisory, personal, or directed care services, please indicate of this resident is requesting or is expected to receive continuous behavioral health services, other than behavioral care:." The medical practitioner marked "Yes, resident is requesting or is expected to require continuous behavioral services" for the aforementioned question.

3. In a joint interview, E2 and E9 reported the documentation may have been filled out incorrectly by R1's medical practitioner. E2 reported the facility did not provide behavioral health services to any residents.

4. In an interview, E1 acknowledged E1 accepted and retained an individual who required continuous behavioral health services. E1 did not provide documentation to indicate R1 did not require continuous behavioral health services or documentation explaining why R1 was admitted when the documentation was in contradiction to what the facility was authorized to provide.

Based on record review and interview, the manager failed to ensure a service plan included cognitive stimulation and activities to maximize functioning, for two of two residents who received directed care services. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a service plan dated in November 2022 for directed care services. However, the service plan did not include cognitive stimulation and activities to maximize functioning.

2. A review of R2's medical record revealed a service plan dated in January 2023 for directed care services. However, the service plan did not include cognitive stimulation and activities to maximize functioning.

3. In an interview, E1 acknowledged R1's and R2's service plans did not include cognitive stimulation and activities to maximize functioning.

Based on record review and interview, the manager failed to ensure a service plan included coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan, for two of two residents sampled who received directed care services. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

A.R.S. 36-401(A)(16) "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

1. A review of R1's medical record revealed a service plan dated in November 2022. However, the service plan did not include coordination of communications with family members, and, if applicable, other individuals identified in the resident's service plan.

2. A review of R2's medical record revealed a service plan dated in January 2023. However, the service plan did not include coordination of communications with family members, and, if applicable, other individuals identified in the resident's service plan.

3. In an interview, E1 acknowledged R1's and R2's service plans did not include coordination of communication with the resident's representative, family members, and other individuals identified in the resident's service plan.

Based on documentation review and interview, the manager failed to ensure the facility's policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Med 02-Medication Services" (dated in December 2022). However, the policy and procedure was not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

2. In an interview, E1 acknowledged the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Based on documentation review and interview, the manager failed to ensure a disaster plan review required in (A)(2) was documented to include: the time of the disaster plan review; the name of each employee or volunteer participating in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of facility documentation revealed a disaster plan review dated January 5, 2022. However, the disaster plan review did not include documentation of the time of the disaster plan review, the name of each employee or volunteer participating in the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement.

2. In an interview, E1 acknowledged the disaster plan review did not include the above mentioned requirements.