Sky Vista

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of seven employees sampled. The deficient practice posed a potential TB exposure risk to residents. 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 E4's personnel record revealed a TB blood test that was dated after E4's date of hire. The test stated "Result Name: T-SPOT.TB Result: Borderline Comments Normal Value: Negative the patient's test result cannot be definitively as positive or negative. Retesting of the patient is recommended although there is no set guideline established for the time interval between an initial borderline result and a retest. The T-SPOT.TB is a diagnostic aid. If the test result remains borderline upon retesting, other diagnostics and/or epidemiologic information should be used to help to determine the Mycobacterium infectious tatus of the patient. The T-SPOT.TB test is qualitative and results are reported as positive, borderline or negative, given that the test controls perform as expected. In line with the Centers of Disease Control and Prevention's 2010 recommendation to report quantitative measurements along side the qualitative result, the laboratory provides spot counts for informational purposes only. The T-SOT.TB test should not be interpreted as as a quantitative test." No further documentation of freedom from infectious TB was available. 3. Documentation review revealed that E4 was on the facility's active employee roster. 4. In an exit interview, findings were reviewed with E1, E7, O1 and O2, and no additional information was provided.

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. Findings include: 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. 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.

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. Findings include: 1. A review of R2's and R4's records revealed no documentation showing that the pneumonia vaccination was offered or received. 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.

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.