SKY RIDGE

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. 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 the facility's fall training program titled, "Falls: Responding Appropriately" did not include fall recovery and fall prevention.

2. A review of facility personnel records for E3 and E4, revealed E3 and E4 had training in "Falls: Responding Appropriately," in 2024. However, documentation was not available that showed E3 and E4 completed fall prevention and fall recovery training.

3. In an interview, E1 and E2 acknowledged a training program for all staff was not available that included fall prevention and fall recovery.

Based on documentation review, observation, 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. \'a7 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. Arizona Revised Statutes (A.R.S.) \'a7 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. A review of Department documentation revealed the Department was notified of R1's death on July 15, 2024 at 12:06pm. The notification stated, "On 7/11/2024 at 540pm Medical Emergency Upon entering resident apt attempting to admin medication. Noted resident was not in (R1's) apt or common area. checked resident patio right outside of (R1's) apt noted resident was laying on the floor face down with no shoes on (R1's) feet, slippers were found near the body. Called resident name and (R1) was non responsive attempted to obtain HR no reading. No oxygen saturation noted. Called 911. DNR on file. Last time (R1) was seen was in (R1's) apartment at approximately 130-200pm. (R1) was sleeping on (R1's) couch. (R1) talked to the caregiver about (R1's) cat and that (R1) had changed the cat litter. Medical examiner came to the scene and collected the body."

3. During a telephone call to the facility on July 15, 2024, E2 reported it appeared R1 tripped on the patio by the report provided by staff.

4. In an interview, E1 and E2 acknowledged that a written notification to the Department was not provided within one working day after a resident death.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for six of six employees sampled.

A.R.S. \'a7 36-411 states, "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work.

B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section.

C. Owners 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.

D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service.

E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked.

F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.

G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety.

H. For the purposes of this section:

1. "Direct supportive services":

(a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including:

(i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair.

(ii) Assistance with self-administration of medication.

Findings include:

1. A review of E4's personnel record revealed E4 had been hired as a caregiver in April of 2023. E4's personnel record included a valid fingerprint clearance card and a list of previous employers. However, E4's personnel record did not include documentation of good faith efforts to contact more than one previous employer to obtain information or recommendations that may have been relevant to E4's fitness to work in a residential care institution, and did not include documentation of verification of the status of E4's fingerprint clearance card. Additionally, E4's employment history indicated E4 was not employed between November of 2021 and August of 2022, a gap of more than six months, however, E4's fingerprint clearance card had been issued in September of 2021, before the gap in employment, and documentation that E4 had submitted a new set of fingerprints to the Department of Public Safety was not available for review.

2. A review of E5's personnel record revealed E5 had been hired as a caregiver in July of 2023. E5's personnel record included a valid fingerprint clearance card and a list of previous employers. However, E5's personnel record did not include documentation of good faith efforts to contact more than one previous employer to obtain information or recommendations that may have been relevant to E5's fitness to work in a residential care institution, and did not include documentation of verification of the status of E5's fingerprint clearance card.

3. A review of E6's personnel record revealed E6 had been hired as a caregiver in March of 2024. E6's personnel record included a valid fingerprint clearance card and a list of previous employers. However, E6's personnel record did not include documentation of good faith efforts to contact more than one previous employer to obtain information or recommendations that may have been relevant to E6's fitness to work in a residential care institution, and did not include documentation of verification of the status of E6's fingerprint clearance card. Additionally, E6's employment history indicated E6 was not employed prior to April of 2021, however, E6's fingerprint clearance card had been issued in May of 2020, more than six months prior, and documentation that E6 had submitted a new set of fingerprints to the Department of Public Safety was not available for review.

4. A review of E7's personnel record revealed E7 had been hired as a caregiver in December of 2023. E7's personnel record included a valid fingerprint clearance card and a previous employer. However, E7's personnel record did not include documentation of good faith efforts to contact the previous employer to obtain information or recommendations that may have been relevant to E7's fitness to work in a residential care institution, and did not include documentation of verification of the status of E7's fingerprint clearance card.

5. A review of E8's personnel record revealed E8 had been hired as a cook in October of 2023. E8's personnel record included a valid fingerprint clearance card and a list of previous employers. However, E8's personnel record did not include documentation of verification of the status of E8's fingerprint clearance card.

6. A review of E9's personnel record revealed E9 had been hired as a housekeeper in November of 2021. E9's personnel record included a valid fingerprint clearance card and a list of previous employers. However, E9's personnel record did no

Based on documentation review and interview, the manager failed to ensure all required policies and procedures were established, documented and implemented.

Findings include:

1. A review of the facility's policy and procedure manual revealed several required policies were not contained in the provided policy and procedure manual, to include:
- a policy to cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers;
- a policy to cover orientation and in-service education for employees and volunteers;
- a policy to cover the requirements in A.R.S. Title 36, Chapter 4, Article 11;
- a policy to cover cardiopulmonary resuscitation training for applicable employees and volunteers, including, the method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation; the qualifications for an individual to provide cardiopulmonary resuscitation training; the time-frame for renewal of cardiopulmonary resuscitation training; and the documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training;
- a policy to cover first aid training;
- a policy to cover cover contracted services; and
- a policy to cover cover equipment inspection and maintenance.

2. A review of E4's personnel record revealed Job Descriptions, signed by E4 on the date of hire, for "Caregiver - Connections for Living" and for "Medication Technician."

3. A review of E4's personnel record revealed E4 did not have caregiver certification or cardiopulmonary resuscitation training at the time of hire.

4. In an interview, E1 reported E4 was hired as an assistant caregiver, and became a certified caregiver after some time.

5. In an interview, E3 reported there is no job description available for assistant caregivers, so the caregiver job description was used instead.

6. In an interview, E1 acknowledged the policy manual provided to the Compliance Officer for review had not included all required policies.

Based on documentation review, record review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for two of four caregivers sampled. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents.

Findings include:

1. A review of the facility's policies and procedures revealed job descriptions for each sampled personnel member which included a list of required skills and knowledge. However, a policy covering how a caregiver's or assistant caregiver's skills and knowledge would be verified and documented was not available for review.

2. A review of department records revealed a plan of correction (POC) for the on-site compliance inspection conducted on May 11, 2023. The POC had a correction date of July 18, 2023 and stated, "Manager will ensure caregiver skills will be verified and
documented before providing health services. A skills checklist will be completed prior to providing health services."

3. A review of E6's personnel record revealed E6 had been hired at a caregiver in March of 2024, after the correction date of the previous citation. However documentation to indicate E6's skills and knowledge were verified, using a skills checklist, before E6 provided physical health services at the facility was not available for review.

4. A review of E7's personnel record revealed E7 had been hired at a caregiver in December of 2023, after the correction date of the previous citation. However documentation to indicate E7's skills and knowledge were verified, using a skills checklist, before E7 provided physical health services at the facility was not available for review.

5. In an interview, E1 acknowledged E6 and E7 had been hired after the previous correction was completed, however, their personnel records did not contain documented verification of verification of each caregiver's skills and knowledge in a facility determined format.

This is a repeat deficiency from the on-site compliance inspection conducted on July 18, 2023.

Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of six employees sampled.

Findings include:

1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."

2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read."

3. A review of E6's personnel record revealed E6 had been hired as a caregiver in March of 2024. E3's personnel record included a single TST and a complete baseline screening to include an assessment of risks of prior exposure to infectious tuberculosis, a determination if E6 has signs or symptoms of tuberculosis, and a second-step TST, as recommended by the CDC, was not available for review.

4. In an interview, E1 acknowledged E6 had not provided documentation of evidence of freedom from infectious TB upon hire as required by R9-10-113.

Based on record review, and interview, the manager failed to ensure a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with Arizona Administrative Code (A.A.C.) R9-10-807(G), for seven of seven residents reviewed.

Findings include:

1. A review of R1's, R2's, R3's, R4's, R5's, R6's, and R7's medical records revealed each record contained a residency agreement titled, "Sky Ridge MBK Senior Living Assisted Living Residence and Services Agreement." The residency agreements included the facility's termination policy and procedure as required. However, the termination policy was not in compliance with the requirements in R9-10-807(G), including the following provisions:
- "b. Termination by Manager. Manager may terminate this agreement: i. Immediately, without any notice, if:....2. Upon a decision that Resident may be permanently transferred to another facility because of the inability of the community to meet the needs of Resident consistent with its authority granted by license; 3. Resident has developed a dangerous or contagious disease; or 4. Resident's urgent medical or health needs require immediate transfer to another health care institution."

2. In an interview, E1 acknowledged the termination policy found in each resident's residency agreement did not comply with the requirements in R9-10-807(G).

Based on record review and interview, the manager failed to ensure a resident had a written service plan, reviewed and updated at least once every six months, for one of two residents sampled who received personal care services; and at least once every three months for one of five residents sampled who received directed care services.

Findings include:

1. A review of R6's medical record revealed a written service plan for directed care services dated November 28, 2023. However, an updated service plan, dated no later than February 28, 2024 was not provided for review.

2. A review of R7's medical record revealed a written service plan for personal care services dated September 26, 2023. However, an updated service plan, dated no later than March 26, 2023, was not provided for review.

3. In an interview, E1 acknowledged the provided service plans had not been updated as required.

Based on record review, observation, and interview, the manager failed to ensure a resident was provided a diet that met the resident's nutritional needs as specified in the resident's service plan, for one of seven sampled residents.

Findings include:

1. A review of R3's medical record revealed a form titled, "Dietary Physicians Orders." The form had been signed by a physician on September 1, 2022 and stated, "Food Allergies: Soy, Soy products."

2. A review of R3's medical record revealed a face sheet which documented the following allergies, "Sulfa, Gluten."

3. A review of R3's medical record revealed a form titled, "Physician's Report (Arizona)," signed and dated November 11, 2023, which stated, "Primary Diagnosis: CAD, CVA, HTN, Celiac Disease, Dementia, Low back w/ Sciatica...Allergies: Gluten, Sulfa...Special Diet: Yes, Gluten Free, Celiac Disease"

4. A review of R3's medical record revealed a form titled, "Admission Orders (Arizona)," signed and dated November 11, 2023, which stated, "Does the resident require a special diet?.. Yes...Gluten Free."

5. A review of R3's service plan, updated April 3, 2024, revealed R3 would receive, "Diet: Regular, and stated, "Allergies:...Gluten, Diagnoses...Celiac disease...Meals/Nutrition Assistance: Total Assist, responsible party: Care Staff."

6. During an environmental tour of the facility's commercial kitchen, the Compliance Officer observed a binder in the kitchen office included dietary orders for residents, including both regular diet or a special diet for each resident. However, a dietary order for R3 was not present in the binder.

7. During an environmental tour of the facility, the Compliance officer observed R3 was eating pancakes, eggs, and bacon.

8. In an interview, the dietary staff in the memory care section of the facility reported R3 did not have a special diet, and the caregiver in the area would notify them if a special diet was required.

9. In an interview, E10, a caregiver in the memory care unit, reported special diets are posted inside a cabinet in the serving area. E10 showed the Compliance Officer the posting. E10 reported R3 did not require a special diet per R3's responsible party.

10. The Compliance Officer observed a posting of special diets for resident in the memory care area did not indicated R3 would receive a gluten free diet, or had a gluten allergy or celiac disease.

11. In an interview, E1 reported R3's responsible party indicated R3 was aware of the gluten allergy but had always ignored it and requested a regular diet. E1 acknowledged R3 was not being provided a diet that met the resident's nutritional needs as specified in the resident's service plan, as R3 was being provided with foods R3 was allergic to and the facility had been ordered not to provide.

Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of one residents sampled who was administered an opioid.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "MP29 - Pain Management and Opioid Medications," which stated, "...g. Document on the MAR the resident's need, monitoring, and response to the medication. This documentation shall include: i. The name of the staff member responsible for administering/assisting the resident with the opioid medication. ii. The resident's level of pain prior to administering the medication. iii. How the resident's level of pain was assessed. iv. How the resident's response was monitored including the time and person(s) responsible for monitoring, and v. The resulting effect of the medication on the resident."

2. A review of R7's medical record revealed a service plan, dated September 26, 2023, for personal care services including medication administration. The service plan indicated R2 did not receive hospice services.

3. A review of R7's medical record revealed an order, dated February 9, 2024, for, "Hydrocodone - Acetaminophen 5/325 mg tab, admin one tab PO Q 8 hours PRN."

4. A review of R7's medical record revealed a Medication Administration Record (MAR) dated March 2024. The MAR indicated R7 had been administered Hydrocodone on March 17, 20, 21, 22, 24, 26, and March 26, 2024. The PRN comment section of the MAR included the following information: The date and time of administration, the reason given, "Pain," the initials of the person who administered the opioid and monitored the resident, and the results, "Effective."

5. A review of R7's medical record revealed documentation of R7's level of pain prior to administration, how the level of pain was assessed, how the resident's response was monitored, and the time of the monitoring were not available for review.

6. In an interview, E1 acknowledged the caregivers administering opioids to R7 had not documented the identification of R7's need for the opioid before every administered dose and had not documented monitoring of the effectiveness of the opioid in the manner prescribed by the facility's policies and procedures.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed.

Findings include:

1. A review of facility documentation revealed documents labeled "MBK Senior Living Clinical Policy and Procedure Manual Arizona." However, there was no documentation to indicate the policies and procedures were reviewed at least once every three years and updated as needed.

3. In a joint interview, E1 and E2 acknowledged the policies and procedures were completed by "MBK" and there was no documentation to indicate the policies and procedures were reviewed at least once every three years.

Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, for three of three caregivers reviewed.

Findings include:

1. A review of E4's personnel record revealed no documentation to indicate E4's skills and knowledge were verified before E4 provided physical health services at the facility.

2. A review of E5's personnel record revealed no documentation to indicate E5's skills and knowledge were verified before E5 provided physical health services at the facility.

3. A review of E6's personnel record revealed no documentation to indicate E6's skills and knowledge were verified before E6 provided physical health services at the facility.

4. In a joint interview, E1 and E2 acknowledged E4's, E5's, and E6's personnel records did not contain documented verification of E4's, E5's, and E6's skills and knowledge.

Based on documentation review and interview, the manager failed to ensure 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 an undated clinical policy and procedure manual. The manual included a section labeled "Medication Policies", including medication administration. However, there was no documentation to indicate the policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

2. In an interview, E1 and E2 acknowledged the policy and procedure for medication administration was not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours of acceptance, for six of six residents sampled. The deficient practice posed a health and safety risk if the residents were unable to safely exit the facility in an emergency.

Findings include:

1. A review of R1's medical record revealed no documentation to indicate R1 received orientation to the exits from the facility and the route to be used when evacuating. Based on R1's date of acceptance, this documentation was required.

2. A review of R2's medical record revealed no documentation to indicate R2 received orientation to the exits from the facility and the route to be used when evacuating. Based on R2's date of acceptance, this documentation was required.

3. A review of R3's medical record revealed no documentation to indicate R3 received orientation to the exits from the facility and the route to be used when evacuating. Based on R3's date of acceptance, this documentation was required.

4. A review of R4's medical record revealed no documentation to indicate R4 received orientation to the exits from the facility and the route to be used when evacuating. Based on R4's date of acceptance, this documentation was required.

5. A review of R5's medical record revealed no documentation to indicate R5 received orientation to the exits from the facility and the route to be used when evacuating. Based on R5's date of acceptance, this documentation was required.

6. A review of R6's medical record revealed no documentation to indicate R6 received orientation to the exits from the facility and the route to be used when evacuating. Based on R6's date of acceptance, this documentation was required.

7. In a joint interview, E1 and E2 acknowledged there was no documentation indicating R1, R2, R3, R4, R5 and R6 received orientation to the exits from the facility and the route to be used when evacuating. E1 and E2 acknowledged the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours of acceptance.

Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistant caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future, for two of six residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services.

Findings include:

1. A review of facility documentation revealed an incident report for R1 dated in November 2022. The document stated, "...[R1's spouse] pressed [R1's] pendant stating [R1] was in alot of pain on [R1's] right side and requested for 911 to be called. [R1] was taken to...hospital by ambulance..." However, the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future.

2. A review of facility documentation revealed an incident report for R4 dated in March 2023. The document stated, "...Care staff was answering call and upon entering the room heard [R4] yelling for help. [R4] was found laying on the floor by sink in the dark. [R4] was taken to...Hospital by EMS..." However, the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future.

3. In a joint interview, E1 and E2 acknowledged the incident reports for R1 and R4 did not contain any actions taken to prevent the accident, emergency, or injury from occurring in the future.