Blue Sky Manor, INC

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years. Findings include: 1. A review of facility documentation revealed the policies and procedures required in Article 8 were dated December 4, 2015. However, documentation to indicate the policies and procedures had been reviewed and updated at least once every three years was not available for review. 2. In a joint interview, E1 and E4 acknowledged the policies and procedures had not been reviewed at least once every three years.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed an undated "Disaster Relocation Plan Policy and Procedure." 2. The Compliance Officer requested at 9:45 AM to review the facility's disaster plan annual review. However, the requested documentation was not provided for review. 3. In an interview, E1 reported E1 was unable to locate the requested documentation.

Based on observation and interview, the manager failed to ensure documentation required by Article 8 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. Findings include: 1. The Compliance Officer requested at 9:45 AM to review documentation per R9-10-806.A.7., maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. However, the requested documentation was not provided for review. 2. The Compliance Officer requested at 9:45 AM to review the facility's disaster plan annual review. However, the requested documentation was not provided for review. 3. In a joint interview at 1:30 pm, E1 and E4 acknowledged documentation required by Article 8 was not provided to the Department within two hours after a Department request.

Based on observation and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregiver working each day, including the hours worked. Findings include: 1. The Compliance Officer observed E2 and E3 on the premises and working upon arrival at 8:45 AM. 2. The Compliance Officer requested at 9:45 AM to review staff schedules maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. However, the requested documentation was not provided for review. 3. In an interview, E1 reported E1 was unable to locate the requested documentation. 4. In a joint interview, E1 and E4 acknowledged documentation was not maintained for at least 12 months of the caregivers and assistant caregiver working each day, including the hours worked by each.

Based on observation, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for two of two caregivers sampled. The deficient practice posed a risk if E2 and E3 were unable to meet a resident's needs. Findings include: 1. The Compliance Officer observed E2 and E3 one the premises and working upon arrival at 8:45 AM. 2. A review of E2's (hired in 2015) personnel record revealed documentation of the verification of E2's skills and knowledge were not available for review. 3. A review of E3's (hired in 2008) personnel record revealed documentation of the verification of E3's skills and knowledge were not available for review. 4. In an interview, E1 reported to be unaware of the requirement. 5. In joint interview, E1 and E4 acknowledged documentation of the verification of E2's and E3's skills and knowledge were not available for review. Technical assistance was provided on this Rule during the compliance inspection completed on October 24, 2022.

Based on observation, record review, and interview, the manager accepted and retained an individual without the ability to provide the assisted living services needed by the individual, for one of eight residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. The Compliance Officer observed R3's bedroom contained two square bricks on top of a plastic mat located on the floor, to the left side of R3's bed. 2. In an interview, E2 reported R3 used the bricks as an assistive device to get in and out of bed. E2 reported R3's bed was too high off the floor to get in and out of without the use of an assistive device. 3. In an interview, E2 reported R3 was initially bed bound when admitted into the facility and E2 used a hoyer lift to get R3 in and out of bed. E1 reported R3's primary care physician requested a lower bed to be provided to R3 through a durable medical equipment referral in October 2022. However, the facility had not received the requested bed for R3. 4. The Compliance Officer observed R3 was ambulatory. 5. In an interview, R3 reported R3 used the bricks as an assistive device to get in and out of bed since R3 was admitted into the facility. 6. A review of R3's medical record revealed an order signed and dated by a physician in June 2023 for the following: -Walker; -Wheelchair; -Gel mattress; and -Bariatric fully electric bed, low-rise. However, the Compliance Officer had not observed R3 had a bariatric fully electric bed, low-rise. 7. In a joint interview, E1 and E4 acknowledged the manager accepted and retained R3 without the ability to provide the assisted living services needed by the individual. 8. In an interview, E4 reported E4 was in the process of issuing R3 a 14-day termination notice for non-payment of fees.

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 A.A.C. R9-10-807(G), for four of eight residents sampled. Findings include: 1. A review of R1's, R2's, R3's, and R4's medical records revealed residency agreements. The residency agreements stated "Terminations ...a. The management will terminate the Residency Agreement without notice if: The resident exhibits behavior that is a real and/or immediate threat to the health and safety of the resident or other individuals in the assisted living Facility; The resident's medical or health needs require immediate transfer to another healthcare institution; The resident's care and service needs exceed the services the Facility is licensed to provide. The management will terminate the Residency Agreement after providing 14-days written notice to the resident and or the resident's representative for any of the following reasons: Documented failure to pay fees or charges; Documented non-compliance with the Residency Agreement or Internal Facility Requirements." However, documentation to indicate the residency agreements contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G) was not available for review. 2. A review of facility documentation revealed a policy and procedure titled "TERMINATION" (dated in 2015). The policy and procedure revealed compliance with A.A.C. R9-10-807(G). 3. In a joint interview, E1 and E4 acknowledged R1's, R2's, R3's, and R4's residency agreements did not include the correct provisions for an assisted living facility to terminate residency.

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 a resident's date of acceptance, for two of eight residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R2's (admitted in 2023) medical record revealed a written service plan was not available for review. Based on R2's date of acceptance, a written service plan was required. 2. A review of R4's (admitted in 2023) medical record revealed a written service plan was not available for review. Based on R4's date of acceptance, a written service plan was required. 3. In an interview, E1 reported E1 had not completed a service plan for R2 and R4. 4. In a joint interview, E1 and E4 acknowledged a written service plan for R2 and R4 was not completed within 14 calendar days after acceptance.

Based on record review and interview, the manager failed to ensure a caregiver provided assistance with activities of daily living according to the resident's service plan, for two of eight residents sampled. Findings include: R9-10-101.5. "Activities of daily living" means ambulating, bathing, toileting, grooming, eating, and getting in or out of a bed or a chair. 1. A review of R1's medical record revealed a service plan dated in July 2023 for directed care services. The service plan stated R1 was to receive assistance with "Three times a week shower and bed baths the remaining days." 2. A review of R1's activities of daily living chart dated September 2023 revealed R1 received assistance with showering on September 2, 2023, September 9, 2023, and September 16, 2023. However, documentation to indicate R1 received assistance with showering "Three times a week" was not available for review. 3. A review of R8's medical record revealed a service plan dated in July 2023 for personal care services. The service plan stated R2 was to receive assistance with "Bathing three time weekly." 4. A review of R8's activities of daily living chart dated in September 2023 revealed R8 received assistance with bathing on September 2, 2023, September 9, 2023, and September 16, 2023. However, documentation to indicate R8 received assistance with "Bathing three time weekly" was not available for review. 5. In a joint interview, E1 and E4 acknowledged the services had not been provided according to the service plan.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for eight of eight residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan and the department was provided false or misleading documentation. Findings include: 1. A review of R1's (admitted in 2020) medical record revealed a service plan dated in July 2023 for directed services. 2. A review of R1's activities of daily living chart dated in September 2023 revealed the following services were pre-filled for the following dates: -Shower (September 23, and 30, 2023); -Partial Bath (September 23, and 30, 2023); -Hair Washed (September 23, 30, 2023); and -Linen Change (September 23, 30, 2023). 3. A review of R2's (admitted in 2023) medical record revealed a service plan was not available for review. However, a review of R2's activities of daily living chart dated in September 2023 revealed the following services were pre-filled for the following dates: -Shower (September 21, 23, 26, 28, and 30, 2023); -Partial Bath (September 21, 23, 26, 28, and 30, 2023); -Hair Washed (September 21, 23, 26, 28, and 30, 2023); -Linen Change (September 21, 23, 26, 28, and 30, 2023); and -Dressing (September 21, 23, 26, 28, and 30, 2023). 3. A review of R3's (admitted in 2022) medical record revealed a service plan dated in April 2023 for personal care services. R3's service plan revealed R3 required "Extensive assistance" with "Personal Hygiene ...Brushes teeth BID." However, documentation to indicate the above mentioned assistance was provided to R3 on September 14, 2023 through September 17, 2023 (PM) was not available for review. 4. A review of R4's (admitted in 2023) medical record revealed a service plan was not available for review. However, a review of R4's activities of daily living chart dated in September 2023 revealed the following services were pre-filled for the following dates: -Shower (September 19, 21, 23, 25, 26, 28, and 30, 2023); -Partial Bath (September 19, 21, 23, 26, and 30, 2023); -Hair Washed (September 19, 21, 23, 26, and 30, 2023); and -Linen Change (September 20, 23, 27, and 30, 2023). 5. A review of R5's (admitted in 2013) medical record revealed a service plan dated in June 2023 for personal care services. 6. A review of R5's activities of daily living chart dated in September 2023 revealed the following services were pre-filled for the following dates: -Shower (September 20, 23, 25, 27, and 30, 2023); -Partial Bath (September 20, 23, 25, 27, and 30, 2023); -Hair Washed (September 20, 23, 25, 27, and 30, 2023); and -Linen Change (September 23, and 30, 2023). 7. A review of R6's (admitted in 2016) medical record revealed a service plan dated in June 2023 for personal care services. 8. A review of R6's activities of daily living chart dated in September 2023 revealed the following services were pre-filled for the following dates: -Sh

Based on record review and interview, the manager failed to ensure a resident's medical record contained the information required in R9-10-811.C.1-24, for one of eight residents sampled. Findings include: 1. A review of R2's medical record revealed the following: -Resident information to include the resident's name, and the resident's date of birth; -The date of acceptance; -The names, addresses, and telephone numbers of the resident's primary care provider and an individual to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency; -Documentation of medication administered to the resident; and -Documentation of assisted living services provided to the resident. However, R2's medical record had not contained the following: -The resident's signed residency agreement and any amendments -Other persons, such as a home health agency or hospice service agency, involved in the care of the resident; -An infectious tuberculosis test as required in R9-10-807(A); -Documentation of the resident's needs required in R9-10-807(B); -Documentation of general consent and informed consent, if applicable; -A copy of resident's health care directive, if applicable; -Resident's service plan; -A medication order from a medical practitioner for each medication administered to the resident; -If applicable, documentation of a determination by a medical practitioner that evacuation from the assisted living facility during an evacuation drill would cause harm to the resident; -Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. \'a7 36-406(1)(d); -Documentation of the resident's orientation to exits from the assisted living facility required in R9-10-818(B); -Documentation of any significant change in a resident's behavior, physical, cognitive, or functional condition and the action taken by a manager or caregiver to address the resident's changing needs; and -Documentation of the notification required in R9-10-803(G) if the resident is incapable of handling financial affairs. 2. In a joint interview, E1 and E4 acknowledged R2's medical record did not contain the aforementioned information required in R9-10-811.C.1-24.

Based on observation, 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 eight residents sampled. The deficient practice posed a risk if R3 experienced a change in condition due to improper medication administration. Findings include: 1. The Compliance Officer observed Sertraline HCL100mg Tab, take one tab by mouth once daily for anxiety and depression, pharmacy provided bubble pack, quantity 30, with 28 tabs left in the pack, belonging to R3. 2. A review of R3's medical record revealed a medication order dated in September 2023 for Sertraline 50mg tab, one daily by mouth. 3. A review of R3's medication administration record (MAR) dated September 2023 revealed R3 received medication administration of "Sertraline 50 mg tab, take one tab daily at bedtime." However, a medication order for the observed Sertraline 100 mg tab pharmacy provided bubble pack was not available for review. 4. In a joint interview, E1 and E4 acknowledged R3 received medication administration without a medication order.

Based on observation and interview, the manager failed to ensure a refrigerator used by the assisted living facility to store food or medication contained a thermometer. Findings include: 1. The Compliance Officer observed a refrigerator located outside on the backyard patio stored food and medication. However, the refrigerator did not contain a thermometer. 2. In a joint interview, E1 and E4 acknowledged the refrigerator did not contain a thermometer. Technical assistance was provided on this Rule during the compliance inspection completed on October 24, 2022.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk as R3 used two bricks to get in and out of bed. Findings include: 1. The Compliance Officer observed R3's bedroom contained two square bricks on top of a plastic mat located on the floor, to the left side of R3's bed. 2. In an interview, E2 reported R3 used the bricks as an assistive device to get in and out of bed. E2 reported R3's bed was too high off the floor to get in and out of without the use of an assistive device. 3. In an interview, E2 reported R3 was initially bed bound when admitted into the facility and E2 used a hoyer lift to get R3 in and out of bed. E1 reported R3's primary care physician requested a lower bed to be provided to R3 through a durable medical equipment referral in October 2022. However, the facility had not received the requested bed for R3. 4. The Compliance Officer observed R3 was ambulatory. 5. In an interview, R3 reported R3 used the bricks as an assistive device to get in and out of bed since R3 was admitted into the facility. 6. In a joint interview, E1 and E4 acknowledged the bricks used as an assistive device for R3 to get in and out of bed could cause R3 to suffer physical injury. 7. The Compliance Officer observed a common bathroom located in the hallway contained broken tiles and tiles missing on the wall above the left side of the vanity with exposed dry wall and wood trim. 8. In an interview, E4 reported a contractor had been out to the facility to discuss fixing the tiles in the above mentioned bathroom. 9. In a joint interview, E1 and E4 acknowledged the broken tiles and tiles missing on the wall in the common hallway bathroom could cause residents to suffer physical injury. Technical assistance was provided on this Rule during the compliance inspection completed on October 24, 2022.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in areas of the assisted living facility used by residents. The deficient practice posed a burn risk to residents. Findings include: 1. The Compliance Officer observed the hot water temperature to be 130\'b0 F in the sink of R2's and R5's shared bathroom, using a Department issued thermometer. 2. The Compliance Officer observed the hot water temperature to be 130.2\'b0 F in the sink of R3's private bathroom, using a Department issued thermometer. 3. The Compliance Officer observed the hot water temperature to be 133.5\'b0 F in the kitchen sink used by residents, using a Department issued thermometer. 4. In a joint interview, E1 and E4 acknowledged the hot water temperature was not maintained between 95\'b0 F and 120\'b0 F.

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of facility documentation revealed an undated policy and procedure titled "38 POLICY TOPIC: TUBERCULOSIS (TB) TESTING & EDUCATION." The policy and procedure was in compliance with R9-10-113.A.2. 2. A review of R2's and R4's medical revealed a baseline 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, and ii. determining if the individual has signs or symptoms of tuberculosis was not available for review. Based on R2's and R4's dates of admission, the documentation was required. 3. A review of E1's personnel record revealed documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 4. A review of facility documentation revealed documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis was not available for review. 5. In a joint interview, E1 and E4 acknowledged the health care institution had not implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Technical assistance was provided on this Rule during the compliance inspection completed on October 24, 2022.