cms_AZ
Data source: Big Local News · About: big-local-datasette
31 rows where "inspection_date" is on date 2014-01-30
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Suggested facets: facility_name, facility_id, address, city, zip, deficiency_tag, scope_severity, eventid, filedate, inspection_date (date), filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4372 | 4372 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 223 | D | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, staff and resident interviews, and review of facility policy and procedure, the facility failed to ensure that one resident's (#16) money was not misappropriated by a staff member (#1). Findings include: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's investigation report revealed that one of the resident's family members had reported that a certified nursing assistant (CNA #1) had been taking the resident's checks and cashing them. She had noticed large withdrawals from the resident's account. There were four checks dating from May 26, 2013 through May 29, 2013. The checks ranged in amount from $1,000 to $1,300 and totaled $4,300 over this time period. The family member also reported that the resident was worried that he would be kicked out of the nursing home for giving the staff member the money. The report included that the resident is alert and oriented. Continued review of the investigative report revealed that the resident had first denied that he gave the staff member money, but later said that he did give the staff member the checks and that he wanted to give her the money to help her in her personal life. He admitted that the CNA did not coerce him or even ask for the money. Staff explained to the resident that the CNA still had a responsibility to not accept the money. Further review of the investigative report revealed that the CNA was interviewed and in this interview, she admitted knowing that she should not engage with residents regarding her personal life and that she should not accept anything from them. Review of the investigation included copies of the checks filled out to the CNA. In an interview with the administrator at 10:10 a.m. on January 28, 2014, she said this was a difficult case and that the staff know that they should not take gifts or money and that the CNA should not have taken the checks f… | 2017-11-01 |
| 4373 | 4373 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 225 | D | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, staff and resident interviews, and review of facility policy and procedure, the facility failed to conduct a thorough investigation regarding two abuse allegations for two residents (#s 16 and 18). Findings include: -Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's investigation report identified that the certified nursing assistant (CNA #1) had been taking the resident's checks and cashing them. Further review of the investigation report revealed that statements from the resident, the alleged CNA, and other staff members were recorded. There was no evident documentation that any other residents were interviewed regarding the alleged staff member, their personal property, or this issue. In an interview with the director of nursing (DON) at 12:40 p.m. on January 29, 2014, she said that a thorough investigation includes interviewing witnesses, other staff members, the resident, and other residents. Other residents are interviewed to see if they have experienced the same or a similar type of issue. She said regarding this issue, she would expect that other residents would be interviewed because the CNA could be taking money from other residents as well. She said that the situation might have been unique and she would not have done this part of it since the resident was the one who wanted the CNA to cash the checks. She said that it could be that the interviews were done and that the documentation is just not available. In an interview with the administrator at 2:30 p.m. on January 29, 2013, she said that a thorough abuse investigation includes interviews with several different people including other residents who may have also have experienced the same issues as the resident making the allegation. She said that some situations do not seem to require this part of the investigation such as if she knows the event happened and th… | 2017-11-01 |
| 4374 | 4374 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 241 | D | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and resident interviews, and review of facility policy and procedures, the facility failed to ensure that one resident (#18) and and one random resident were treated with respect and dignity. Findings include: -Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility investigation revealed that on December 31, 2013, resident #18 informed staff that certified nursing assistant (CNA #2) had changed his brief. The resident had asked CNA #2 to be careful and stop and that CNA #2 had ignored his requests. Resident #18 also reported that CNA #2 did not respond to him while his brief was being changed, which especially distressed him as he is legally blind. The facility investigation further revealed that CNA #2 was placed on Administrative Leave and later suspended for this event. A letter dated January 13, 2014 which was addressed to CNA #2 stated the specific reasons for your suspension are .an investigation was conducted and . it was determined that your treatment of [REDACTED]. You failed to listen to him and adjust your behavior accordingly .Your actions were in violation of the .policy regarding Resident Rights, specifically the right of the resident 'to be treated with consideration, respect and full recognition of his dignity and individuality.' Resident #18 was interviewed on January 28, 2014 at 12:57 p.m. The resident revealed that he had asked CNA #2 to slow down and had told her he was blind and didn't know what she was doing and that CNA #2 did not slow down or respond to him. The resident revealed that he felt CNA #2 did not treat him with dignity and respect. The administrator was interviewed on January 28, 2014 at 1:30 p.m. She revealed that she thought the incident involving Resident #18 and CNA #2 was an issue of the resident not being treated with dignity. The director of nursing (DON) was interviewed on January 29, 2014 at 10:54 a.m. She revea… | 2017-11-01 |
| 4375 | 4375 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 246 | D | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff and family interviews, the facility failed to accommodate one resident's (#27) food preferences. Findings include: Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the significant change minimum data set (MDS) dated [DATE], revealed that the resident required total assistance with eating. The resident was also noted to have a short term and a long term memory problem and the resident is rarely understood. The resident was coded as needing a mechanically altered diet. Review of the clinical record revealed that the resident's responsible party was her daughter. The nutrition care plan dated May 14, 2013, was reviewed which revealed that the resident was noted to be on hospice. One of the approaches was to provide comfort foods as requested. Review of the hospice of the valley notes revealed that on November 22, 2013, the hospice staff wrote that the resident's daughter had food requests and that there was a list provided that showed some of the foods that the resident liked which included many items. A lot of these items were breakfast foods. The dietitian was notified and noted to have said that she has talked to the daughter on several occasions and explained that there are set meals with one alternate and that families can bring in other foods as they desire. Review of the nutrition notes revealed a note dated November 22, 2013 in which it was noted that the resident's daughter discussed her food requests with the facility. The meal options were shown to the daughter as well as the always available menu. The resident's food preferences were taken and noted on her meal ticket. The note concluded by saying that breakfast for dinner will be provided when it is on the menu. During an interview with the resident's daughter at 11:00 a.m. on January 27, 2014, she said that she felt as though the staff could … | 2017-11-01 |
| 4376 | 4376 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 247 | D | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure that one resident (#1) was notified of a roommate change. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an initial resident interview on January 27, 2014, the resident stated that he received a new roommate a week ago, but was not given notice prior to a new resident being moved into his room. Review of the resident's clinical records revealed no documented evidence that the resident was notified of a roommate change. An interview was conducted with social services on January 28, 2014. The social worker stated that this resident was not notified prior to getting a new roommate, as this was a new admit, so residents are not notified under these circumstances. An interview was conducted on January 29, 2014, with the administrator. The administrator stated that the social worker should have notified the resident prior to getting a new roommate. Review of the facility's policy on Room to Room Transfers revealed .A roommate will be informed of any new transfer into his/her room. Such information will include why the transfer is being made and any information that will assist the roommate in accepting his or her new roommate . | 2017-11-01 |
| 4377 | 4377 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 252 | B | 0 | 1 | V41E11 | Based on observations, and staff interviews, the facility failed to serve meals in a homelike manner in that one assisted table in the dining room did not have a tablecloth. Findings included: During an observation of the lunch meal at 1:20 p.m. on January 24, 2014, it was noted that one table of residents, who required assistance for meals, were sitting at a horseshoe shaped table. This table did not have a tablecloth on it. This was the only table in the dining room without a tablecloth. In an interview with the dietary consultant at 1:30 p.m. on January 24, 2014, she said that the staff told her that the tablecloth might be out for washing. In an interview with the unit manager at 1:40 p.m. on January 24, 2014, he said that the tablecloth became stained and wore out and that a new one was not available because dietary services have to custom order tablecloths for the horseshoe shaped tables. He said that since dietary has been going through a transition to a new contracted service, ordering this has been difficult. In an interview with the veterans dining liaison at 9:45 a.m. on January 28, 2014, she said there had been an order in for the tablecloth, but this was stopped when the new dietary contracted service came into the building. She said that new tablecloths were on order again. She further said that with the recent transition, there has also been some confusing on who is to take care of ordering items such as tablecloths and that this contributed to the missing tablecloth. A request for facility policy was made, but not policy was provided regarding providing a homelike environment during meals. | 2017-11-01 |
| 4378 | 4378 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 280 | D | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to revise the care plan for one resident (#75). Findings include: Resident #75 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the falls care plan revealed that a care plan was completed on June 20, 2013, with appropriate interventions. Review of the clinical records for resident #75 revealed that the resident fell on [DATE]. No injuries were noted. Review of the falls care plan dated June 20, 2013, revealed no documented evidence that the care plan for falls was revised after the resident fell on [DATE]. An interview was conducted on January 29, 2014, with a registered nurse (RN). The RN stated that the falls care plan should have been updated to include the date of the resident's fall and any additional interventions put into place. Review of the facility policy on Using the Care Plan revealed .CNA's and Nurses are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved, so that the care plan may be updated by the Nurse Supervisor .Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made . | 2017-11-01 |
| 4379 | 4379 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 281 | D | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and review of facility policy, the facility failed to develop an interim foley catheter care plan for one resident (#231). Findings include: Resident #231 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of admission orders [REDACTED]. Review of the resident's medical record did not reveal an interim care plan for a foley catheter. During an interview conducted on January 30, 2014 at 11:45 AM, the licensed practical nurse (LPN) stated the admission nurse or unit nurse manager is responsible for developing the interim care plan. During an interview conducted on January 30, 2014 at 12:00 PM, the Director of Nursing (DON) explained that an interim foley catheter care plan should have been developed for this resident. Review of the facility policy titled Using the Care Plan stated the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. | 2017-11-01 |
| 4380 | 4380 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 309 | E | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure that three residents (#s 126, 60, and 135) had pre and post [MEDICAL TREATMENT] assessments, and failed to ensure that one resident (#60) had a physician's orders [REDACTED]. Findings include: -Resident #60 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the clinical records revealed no documented evidence of a physician's orders [REDACTED]. Review of the care plan for activities of daily living (ADL) functional/rehabilitation potential dated August 15, 2013, with a goal that the resident will not develop complications related to [MEDICAL TREATMENT] through next review. One of the approaches was to complete pre and post [MEDICAL TREATMENT] assessments. Review of the clinical records revealed no documented evidence that pre and post [MEDICAL TREATMENT] assessments were completed since the resident's re-admission on November 20, 2013. An interview was conducted on January 29, 2014, with a licensed practical nurse (LPN). The LPN stated that there should be pre and post assessments done when the resident has [MEDICAL TREATMENT]. However, she stated that she had dropped the ball and no assessments had been done for this resident since his last admission on November 20, 2013. An interview was conducted on January 29, 2014, with a registered nurse (RN). The RN stated that there should be a physician's orders [REDACTED]. However, she also stated that she was unable to find an order for [REDACTED].>An interview was conducted on January 30, 2014, with the director of nursing (DON). The DON stated that there is a form the nurse should use for pre and post [MEDICAL TREATMENT]. She also stated that the nurse failed to transcribe the physician's orders [REDACTED]. -Resident #126 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of physicians orders dated December 9, 2013, reveal… | 2017-11-01 |
| 4381 | 4381 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 315 | D | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that the catheter was thoroughly cleaned for one resident (#178), and failed to ensure that care and services for his urinary catheter were provided as ordered by the physician. Findings include: Resident #178 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission order was written on July 11, 2013, for a suprapubic urinary catheter size 20 french with a 30 cubic centimeter (cc) balloon due to a [MEDICAL CONDITION] bladder. Catheter care to be provided every shift. Change catheter every month and as needed. Review of the Treatment Administration Record (TAR) for catheter care for November, 2013, revealed no documented evidence that the care was provided as ordered by the physician for eight shifts. Review of the TAR for December, 2013, for catheter care every shift revealed no documented evidence that the care was provided for seven shifts. Review of the certified nursing assistant (CNA) activities of daily living (ADL) Record dated December 30, 2013, revealed that the resident would receive catheter care every shift. During a catheter care observation on January 29, 2014, urinary catheter care was observed with a CNA. The CNA removed the old dressing from the base of the suprapubic catheter; the dressing was soiled with dried brown matter on the gauze. The catheter base was cleaned of dried brown matter where the catheter enters the lower abdomen using a wet wash cloth; no soap was used. The catheter base was then dried with a clean wash cloth. No observation was noted of the CNA cleaning the rest of the catheter. An interview was conducted with the CNA immediately following the observation on January 29, 2014. The CNA stated that she cleans the catheter when it needs it, but was unable to state how often that is done. She also stated that is how she usually provides catheter care for the residen… | 2017-11-01 |
| 4382 | 4382 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 318 | D | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident (#178) received range of motion (ROM) exercises. Findings include: Resident #178 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. An observation was made on January 27, 2014, that the resident had bilateral contractures of the hands with no splint devices in place. Review of the care plan for activities of daily living (ADL) functional/rehabilitation potential dated January 21, 2014, revealed a goal that the resident will not experience a decline in current muscle strength and range of motion. One of the approaches was to perform ROM exercises while assisting the resident to dress and undress. An interview was conducted with a certified nursing assistant (CNA) on January 29, 2014. The CNA stated that this resident does not let her do ROM exercises for him as it is too painful because of his MS. She also stated that this is not documented anywhere. She further stated that this resident has never had splint devices since his admission. Review of the facility's policy on Range of Motion Exercises revealed .The purpose of this procedure is to exercise joints and muscles .Notify the supervisor if the resident refuses the exercises . | 2017-11-01 |
| 4383 | 4383 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 329 | E | 0 | 1 | V41E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and review of facility policies, the facility failed to monitor and document behavioral symptoms for five residents (#s 92, 151, 43, 124, and 155). Findings include: -Resident #92 was admitted [DATE], with [DIAGNOSES REDACTED]. According to the residents' care plan for behavioral symptoms dated December 13, 2013, the resident was identified as having severe cognitive impairment, secondary to dementia. Also included was that the resident exhibited physically aggressive behaviors almost daily toward staff that included hitting and kicking staff during care. The goal included that the resident would be able to receive help with activities of daily living (ADL's), without harm to himself or others. Approaches included the following: redirect if attempts to hit or kick or retry at a later time, follow up with psych eval as ordered, observe for changes in behaviors or patterns of increased physical aggression and to document in the medical record. A review of the nursing progress note dated December 24, 2013, revealed the resident had severe cognitive impairment and exhibited physical behavioral symptoms such as; kicking and hitting staff. Review of the clinical record revealed there was no further documentation regarding the resident's behaviors, nor documentation of any ongoing monitoring for these behaviors that was done in December 2013. Further review of the clinical record revealed that from January 1, 2014 through January 21, 2014, there was no documentation of any behaviors exhibited by the resident, nor any ongoing monitoring of the resident's behaviors that was done. A psychiatric evaluation was completed on January 22, 2014, that noted the resident will hit staff when they are trying to change him, touch him or when giving him medications. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. According to the Behavior/Intervention Monthly Flow Recor… | 2017-11-01 |
| 4384 | 4384 | ARIZONA STATE VETERAN HOME-PHX | 35234 | 4141 NORTH S HERRERA WAY | PHOENIX | AZ | 85012 | 2014-01-30 | 431 | E | 0 | 1 | V41E11 | Based on observations, staff interviews and review of facility policy, the facility failed to dispose of expired medications in the medication carts. Findings include: During medication storage observations conducted on January 30, 2014, at approximately 9:00 AM, the following medications were found expired in medication carts: Clonidine 0.1 milligram (mg), expired November 8, 2013 Tramadol 50 mg, expired March 30, 2012 Promethazine 25 mg, expired September 30, 2013 Digoxin 125 micrograms (mcg), expired December 31, 2013 Cetirizine HCL 10 mg, expired January 28, 2014 Digoxin 125 mcg, expired December 31, 2013 Digoxin 125 mcg, expired December 31, 2013 Promethazine HCL 25 mg, expired November 15, 2012 Promethazine HCL 25 mg, expired November 15, 2012 Refresh tears, expired December, 2013 During an interview conducted on January 30, 2014 at 10:00 AM, the licensed practical nurse (LPN) explained that she would check her medication cart before beginning medication administration to the residents and remove any expired medications. During an interview conducted on January 30, 2014 at 10:30 AM, the Assistant Director of Nursing (ADON) stated all nurses need to check their medication carts at the beginning of the shift and remove any expired medications. Review of facility policy titled Storage of Medications included that outdated .medications .are immediately removed from stock, disposed of according to procedures for medication disposal . | 2017-11-01 |
| 4559 | 4559 | GOOD SAMARITAN SOCIETY-PEORIA GOOD SHEPHERD | 35183 | 10323 WEST OLIVE AVENUE | PEORIA | AZ | 85345 | 2014-01-30 | 157 | D | 0 | 1 | BF3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy, the facility failed to notify the physician of a change in condition regarding one resident (#128) in a timely manner. Findings include: Resident #128 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. According to the resident's bowel movement record from March 1, 2013 through March 9, 2013, the resident had 24 episodes of loose stool. Review of the nursing notes revealed that the Nurse Practitioner (NP) was not notified of the resident's change of condition until the evening of March 9, 2013. During an interview conducted on January 29, 2014 at 9:18 am, a Licensed Practical Nurse (LPN) was asked when she would contact the physician for a resident with loose stools that did not have an order for [REDACTED]. During an interview conducted on January 29, 2014 at 11:00 am, another LPN stated usually if it was an initial loose stool on her shift she would monitor. She reported if the resident had a second loose stool on her shift she would call the physician. She stated she would not let it be passed on to the next shift. An interview was conducted with the Director of Nursing (DON) on January 29, 2014 at 1:10 PM and he was asked when he would expect the nurses to notify the physician if a resident was having loose stools. He stated that he would expect the nurses to use clinical judgment. On the same day at 2:20 PM the DON was unable to explain why neither the NP nor physician was notified prior to March 9, 2013. During an interview conducted on January 29, 2014 at 3:15 PM, a Registered Nurse stated she would notify the physician after a resident had two or three loose stools. Review of the facility's procedure on SBAR physician/NP/physician assistant communication and progress note revealed that the purpose was to improve communication between nurses and primary care providers. One of the symptoms listed for nurses to document if applicable on … | 2017-09-01 |
| 4560 | 4560 | GOOD SAMARITAN SOCIETY-PEORIA GOOD SHEPHERD | 35183 | 10323 WEST OLIVE AVENUE | PEORIA | AZ | 85345 | 2014-01-30 | 225 | D | 0 | 1 | BF3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, review of facility documentation, and review of facility policies and procedures, the facility failed to report the final results of an investigation regarding misappropriation of resident (#72) property to the State survey and certification agency and failed to report the incident to the Arizona State Board of Nursing. The facility also failed to thoroughly investigate an allegation of abuse for one resident (#101) resident and failed to report the allegation of abuse to the State survey and certification agency. The sample size was eight. Findings include: -Resident #72 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility's Reportable Event Record Report dated December 26, 2012, documented The resident report (sic) that she went out to dinner with her family on Christmas Eve and was given 'a lot' of money, a gift certificate to (name of store), and a (name of store) gift card .The resident stated that she placed these items in her top drawer in her lock box .The resident also reported that $15 was also missing from a white envelope .The resident's lock box appeared to have been jimmied with and it was very difficult to turn the key .As of this deadline we have not reached a final conclusion to report but we will initiate additional steps to confirm the identity of the suspect and will notify agencies as appropriate. The facility submitted the Reportable Event Record Report dated December 26, 2012, to the State survey and certification agency. No further information was submitted to the State survey and certification agency. A review of a Corrective Action Notice dated January 2, 2013, which the facility delivered to a CNA (certified nursing assistant) documented Due to discrepancies in your statement and a review of video footage during the initial investigation of theft of resident property over the Christmas Holiday, you are being placed on suspension… | 2017-09-01 |
| 4561 | 4561 | GOOD SAMARITAN SOCIETY-PEORIA GOOD SHEPHERD | 35183 | 10323 WEST OLIVE AVENUE | PEORIA | AZ | 85345 | 2014-01-30 | 226 | D | 0 | 1 | BF3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, review of facility documentation, and review of facility policies and procedures, the facility failed to implement their abuse policy and procedure regarding the investigation and reporting of two allegations of abuse for one resident (#101) and an allegation of misappropriation of resident property for another resident (#72). The sample size was the review of eight abuse investigations. Findings include: -Resident #72 was admitted to the facility on [DATE]. Review of a facility Reportable Event Record Report dated December 26, 2012 revealed that money, a gift certificate, and a gift card had been taken from the resident's room. An interview was conducted with the administrator on January 29, 2014. The administrator stated that the State survey and certification agency and the Arizona State Board of Nursing were not notified of the certified nursing assistant (CNA) involved because she had a problem with putting a staff member's name in writing when she did not have proof, only suspicion. The administrator stated that the facility's investigation reached a conclusion and the CNA was terminated. The administrator further stated that the facility did not report the conclusion of the facility's investigation to the State survey and certification agency. -Resident #101 was admitted to the facility March 23, 2012. Review of internal investigation documentation provided by the administrator included a form titled Suggestion or Concern dated March 5, 2013, from the resident's wife, who also resides in the facility. The report of concern included that she had asked to speak in private and that she felt her spouse was being abused by a black male CNA, and stated that there was a bruise on the resident's hand to prove it. Another allegation was also made that two black female CNA's mistreat the resident by laughing at him. Continued review of the internal investigation, reverse side of the Suggestion … | 2017-09-01 |
| 4562 | 4562 | GOOD SAMARITAN SOCIETY-PEORIA GOOD SHEPHERD | 35183 | 10323 WEST OLIVE AVENUE | PEORIA | AZ | 85345 | 2014-01-30 | 246 | D | 0 | 1 | BF3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and reviews of a clinical record and facility policy and procedures the facility failed to ensure one resident (#59) received showers with reasonable accommodations of individual needs and preferences. Findings include: -Resident #59 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set assessment dated [DATE], revealed that the resident was totally dependent on one person physical assist with bathing. A review of the comprehensive care plan revealed The resident has an ADL (Acts of Daily Living) self care performance deficit R/T (related to) [MEDICAL CONDITION], [DIAGNOSES REDACTED] and incontinence E/B (evidenced by) needs assist with bathing, dressing and oral care. The approaches included BATHING: Resident requires 1 staff participation with bathing. Offer shower/bath 2x /week. Skin checks with showers, notifying nurse of alterations in skin integrity. A review of the Intervention/Task for December 2013, revealed the resident received showers on December 5, 12, and 19, 2014. The forms also revealed no further showers were given or offered from December 20 through 31, 2013. A review of the Intervention/Task for January 2014, revealed no documented evidence that showers were given or offered from January 1 through 8, 2014. Revealing that the resident was not provided with a shower for approximately twenty days. The resident was provided a shower on January 9 and 16, 2014, and refused a shower on January 23, 2014. A review of the form revealed no showers were offered on the days following the resident's refusal and the resident had not had a shower for approximately 12 days. A review of the clinical record revealed no documented evidence to indicate why the resident was not offered showers from December 20, through January 8, 2014, or why the resident refused a shower on January 23, 2014, and no other showers were offered. During an interview conducte… | 2017-09-01 |
| 4563 | 4563 | GOOD SAMARITAN SOCIETY-PEORIA GOOD SHEPHERD | 35183 | 10323 WEST OLIVE AVENUE | PEORIA | AZ | 85345 | 2014-01-30 | 279 | D | 0 | 1 | BF3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and reviews of clinical records and a facility policy and procedure the facility failed to develop a care plan for [MEDICAL CONDITION] drug use for one resident (#72) and failed to develop care plans to address two residents' (#s 102 and 65) impaired vision per the comprehensive assessment. Findings include: -Resident #102 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident's vision was impaired and the resident used corrective lenses. A review of the admission MDS assessment Care Area Assessment (CAA) revealed that Visual Functioning triggered as a problem area. Further review of the CAA revealed the Care Plan decision was yes. However, a review of the comprehensive plan of care revealed no care plan to address the resident's impaired vision and use of corrective lenses. During an interview conducted at 3:45 p.m. on January 29, 2014, the Registered Nurse/MDS Coordinator stated that she had determined that the resident's vision was a problem and should be addressed on the comprehensive care plan. She also stated, after looking at her notes, that she changed her mind and did not address the resident's impaired vision on the care plan. She further stated that the resident used his glasses intermittently and often took his glasses off. She said that he could only read large print, and the resident stated that he did not want large print materials provided. -Resident #65 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change of Condition MDS assessment dated [DATE] revealed that the resident's vision was impaired and the resident did not use corrective lenses. A review of the Significant Change of Condition MDS assessment CAA revealed that Visual Functioning triggered a s a problem area. Further review of the CAA revealed a care plan was to be implemented. Rev… | 2017-09-01 |
| 4564 | 4564 | GOOD SAMARITAN SOCIETY-PEORIA GOOD SHEPHERD | 35183 | 10323 WEST OLIVE AVENUE | PEORIA | AZ | 85345 | 2014-01-30 | 327 | G | 0 | 1 | BF3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of hospital records, the facility failed to ensure adequate monitoring and sufficient fluids were provided to one resident (#128) to maintain proper hydration. Findings include: Resident #128 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed the resident was receiving antibiotics upon admission for a urinary tract infection and pneumonia. admission orders [REDACTED]. Review of the resident's potential for weight loss care plan from February 14, 2013, revealed that staff were to encourage intake of food and fluids, and also to monitor and record intake daily. According to the nutrition assessment dated [DATE], the resident's estimated daily fluid needs were 2,010 milliliters (ml). Review of the resident's bowel movement (BM) record revealed that from admission through February 28, 2013, the resident had a total of eight episodes of loose stools. According to the BM record from March 1 through March 7, 2013, the resident had multiple episodes of loose stool. There was no documentation in the nurse's notes regarding the loose stools. Review of the Medication Administration Record [REDACTED]. Review of the dining intake record for March 2013, which included food, fluids, nourishments, and supplements, revealed the following daily grand total fluid intake amounts: March 1 = 780 ml, March 2 = 560 ml, March 3 = 240 ml, March 4 = 240 ml, March 5 = 360 ml and March 6 = 120 ml. According to the nurse's note dated March 7, 2013 at 10:00 a.m., the resident's color was very pale and was she was very weak. At that time, the resident was encouraged to drink water and drank 480 ml. For this same date, the dining intake record showed that the resident received an additional amount of 360 ml of fluid. Review of the BM record from March 7, 2013, revealed that the resident had four episodes of loose stool on the day shift and three epi… | 2017-09-01 |
| 4565 | 4565 | GOOD SAMARITAN SOCIETY-PEORIA GOOD SHEPHERD | 35183 | 10323 WEST OLIVE AVENUE | PEORIA | AZ | 85345 | 2014-01-30 | 520 | D | 0 | 1 | BF3711 | Based on staff interview, and review of facility documentation, the facility failed to implement plans of action to identified quality deficiencies. Findings include: During the survey it was revealed that allegations of abuse and misappropriation of property had not been thoroughly investigated and or reported to the State survey and re-certification agency. January 30, 2013, at 12:45 p.m., an interview regarding the facility's Quality Assessment and Assurance (QAA) committee was conducted with the administrator. When asked whether the identified problem area of abuse investigation and reporting were being addressed in their QAA committee, the administrator stated that that was an area of an ongoing process. They monitor in the QAA agenda, the number of reports, abuse, and investigations. All concerns and comments are discussed in QAA and the reports are reviewed. Because of this survey we will enhance our review because really thought we solved concerns that we had. It became apparent that we haven't solved that problem. She also stated that they were not in 100% compliance and that it was an ongoing process. | 2017-09-01 |
| 4583 | 4583 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 154 | D | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to inform one resident (#153) with of the risks verses benefits of [MEDICAL CONDITION] medications. Findings include: -Resident #153 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the January 2014, recapitulation of physician's orders [REDACTED]. -[MEDICATION NAME] 50 mg (milligrams) by mouth daily for depression. -[MEDICATION NAME] 15 mg by mouth prn (as needed) every night for [MEDICAL CONDITION]. -[MEDICATION NAME] 1 mg by mouth prn daily for anxiety. The January 2014, Medication Administration Record [REDACTED]. A continued review of the clinical record revealed a facility form titled, Psychoactive Medication Consent. Although this form included documentation of the above medications, their use, and the potential side effects and benefits, the form did not include any documented evidence the resident or the responsible party had actually consented to the use of the medications. The section of this form that indicated consent or refusal of the medications was blank. In addition, the clinical record did not include documented evidence that an informed consent for the use of the [MEDICATION NAME], or [MEDICATION NAME] had actually been obtained. An interview was conducted on January 29, 2014, with the Director of Nursing. Following a review of the clinical record, inclusive of the Psychoactive Medication Consent form, she stated that the form should have included whether consent or refusal of the medication was obtained. At this time, she also agreed that based on the lack of clinical record documentation, she was unable determined if an informed consent had actually been obtained prior to the use of the above medications. Although the facility provided a policy titled, Psychoactive Drug Policy, which included that a consent form was to be signed by the resident or responsible party, the policy did not address the authorization … | 2017-08-01 |
| 4584 | 4584 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 241 | D | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, review of the facility's documentation and the facility's policy, the facility failed to ensure dignity for one resident (#165). Findings Include: Resident #165 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an Initial Visit Physician's Note dated January 21, 2014 which documented that the resident had recently been treated for [REDACTED]. The patient developed severe diarrhea, abdominal pain, the antibiotics were stopped and the pt was seen by a [MEDICATION NAME] for diarrhea, abdominal pain .and to initiate TPN due to severe PCM (protein-calorie malnutrition). A physician's progress note dated January 22, 2014, documented that the resident was recently diagnosed with [REDACTED]. Patient advised TPN via PICC line. For her diarrhea she has been on [MEDICATION NAME] and [MEDICATION NAME] (antidiarrheals). She failed out-patient management and admitted to SNF (skilled nursing facility). Patient scheduled to undergo colonoscopy on January 23, 2014. an order for [REDACTED]. The admission nursing assessment dated [DATE] documented that the resident's last bowel movement had been diarrhea A Daily Flow Sheet dated January 20, 2014, at 11:30 p.m. documented that the resident stated that she wanted her light answered as soon as she turned it on or else there would be diarrhea all over this place. A daily flow sheet dated January 22, 2014, stated that the resident was, alert and oriented . R arm PICC line is intact. Pt requested to start her IV TPN at 6:00 p.m. tonight because she wants to be prepared before apt @ 0800. Further review of the clinical record revealed instructions for the Suprep (an osmotic laxative indicated for cleansing the colon as a prep for colonoscopy in adults) dated January 15, 2014, instructed that the resident was to begin drinking the liquid at 5:00 p.m. the evening before her colonoscopy exam. An interview was cond… | 2017-08-01 |
| 4585 | 4585 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 247 | D | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical records and facility documentation, staff and resident interviews, and review of facility policy, the facility failed to ensure that notifications of a room and roommate change were provided for two residents (#s 6 and 21). The sample size was three. Findings include: -A review of the clinical record and facility documentation revealed that resident #6 had a room change on December 28, 2013. According to the documentation the resident was moved from room [ROOM NUMBER] B to 87 B. However, the clinical record did not include any documented evidence that notification was provided to the resident prior to the room change. During a resident interview conducted on January 21, 2014, the resident stated that she was not provided notification prior to a room change. An interview was conducted with social service staff on January 29, 2014. Following a review of the clinical record she stated that December 28, 2013, was a Saturday, and that social service staff would not have been on duty at that time, therefore, it would have been nursing staff's responsibility to notify the resident of the room change, and then document it in the clinical record. -A review of the clinical record and facility documentation revealed that resident #21 had a roommate change on August 7, 2013. However, the clinical record did not include any documented evidence that the resident was provided notification of the roommate change. An interview was conducted on January 29, 2014, with social service staff, who stated that she usually notifies residents of roommate changes and then documents the notification in the social service progress notes in the clinical record. Following a review of the clinical record, she acknowledged that the clinical record did not include any documented evidence that notification was provided. A resident interviews were conducted on January 29, and 30, 2014, and according to the resident she was only provided notice … | 2017-08-01 |
| 4586 | 4586 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 280 | D | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, observations, and review of facility policies and procedures the facility failed to ensure that a care plan had been revised to include the placement of a wanderguard for one resident, (#52). The sample size was three. Findings include: Resident #52 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the current elopement risk assessment dated [DATE], revealed the resident was assessed to not be at risk for elopement. A current care plan identified a problem that the resident was on elopement precautions as a history indicated that he had previously made statements about wanting to go home and asking about transportation. The goal was that the resident would have no episodes of leaving the facility unattended and the interventions included frequent monitoring of his whereabouts. On the care plan there was no evidence of the use of a wanderguard to alert staff if the resident attempted to leave the facility. According to a facility wanderguard log that was completed nightly by licensed staff the resident's name was listed and further documentation revealed the resident's wanderguard was checked nightly to ensure the wanderguard was functioning. An interview was conducted with a LPN (Licensed Practical Nurse) on January 29, 2014. She stated she was unaware that resident (#52) had a wanderguard in place despite the wanderguard log that listed the resident as having a wanderguard. Immediately following the interview an observation was made with the LPN of resident (#52) on January 29, 2014 at approximately 4:00 P.M. The LPN stated the resident did have a wanderguard placed on his wrist. The LPN further stated that the resident obviously had a wanderguard in place despite the lack of this intervention documented on the current care plan. An interview was conducted with the LPN unit manager on January 29, 2014. She stated that the resident's care plan needed a revision to include the pla… | 2017-08-01 |
| 4587 | 4587 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 281 | E | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, hospital and facility documentation and policy review, the facility failed to ensure services provided met professional standards of quality, by staff failing to notify the nurse practitioner (NP) that one resident (#23) received a medication in error which he was allergic too, and a licensed nurse (staff #1) failed to utilize the proper methods to identify residents prior to administering medications. The facility also failed to ensure that proper technique was utilized for a subcutaneous injection for one resident (#23) and failed to ensure an interim care plan was developed for one resident (#153). The sample size was six. Findings include: -Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed there were multiple areas that documented that the resident was allergic to [MEDICATION NAME]. Review of the December 2013 physician orders [REDACTED]. The orders did not include that the resident was to receive [MEDICATION NAME]. Review of the clinical record and the facility's investigation revealed that staff #1 was performing a medication pass and became distracted, and administered 90 milligrams (mg) of [MEDICATION NAME], and 84 units of [MEDICATION NAME] (40 units of insulin were ordered) to resident #23. The documentation included that the resident was allergic to [MEDICATION NAME]. The report further explained that staff #1 also attempted to give the resident a nasal spray, however, the resident told the nurse that he did not get a nasal spray and that is when the nurse realized that she gave the wrong medications to the resident. The NP was notified and orders were received. However, the nurse had not informed the NP that the resident was allergic to [MEDICATION NAME]. On January 6 at approximately 2 p.m., the resident experienced a change of condition, and subsequently was admitted to the hospital … | 2017-08-01 |
| 4588 | 4588 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 315 | D | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interviews and facility policies the facility failed to provide a medical [DIAGNOSES REDACTED].#163). The sample size was three. Findings include: Resident #163 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. He had an indwelling catheter on admission. The signed Physician admission orders [REDACTED]. The Foley Catheter Initial Assessment Tool completed by the nurse on January 8, 2014, states the resident needs a catheter because of decreased mobility related to surgery and this form was signed by the nurse. The Resident Nursing Care Plan dated January 8, 2014, states the resident needs a Foley catheter for medical management due to decreased mobility status [REDACTED]. A Bowel and Bladder assessment dated [DATE], reflects a score of 0 on the assessment which indicates the resident is a good candidate for bladder retraining. The facility was unable to show where this was addressed by the physician. In an interview on January 28, 2014, the staff nurse was unable to find a medical justification or [DIAGNOSES REDACTED]. In an interview on January 28,2014, the Director of Nursing (DON) states she would expect a medical [DIAGNOSES REDACTED]. In another interview on January 28,2014 with the DON and Unit Manager, the Unit Manager stated the facility uses the nursing care plan as the documentation for medical justification and [DIAGNOSES REDACTED]. The facility policy Catheter Utilization Policy states .a resident admitted with an indwelling catheter in place shall have documentation showing the medical necessity or shall be evaluated for catheter removal. | 2017-08-01 |
| 4589 | 4589 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 323 | D | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility video surveillance and documentation, and policy review, the facility failed to ensure adequate supervision was provided for one resident (#166), which resulted in an elopement. The sample size was three. Findings include: Resident #166 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed an elopement risk assessment dated [DATE], which assessed for cognitive impairment, any [DIAGNOSES REDACTED]. Per this assessment, the resident was not identified to be an elopement risk. The elopement risk assessment was updated on December 17, 2012, and again the resident was not identified to be at risk for elopement. Per the quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident was assessed to be able to make needs known, understand others, and had disorganized and delusional thinking. The resident was assessed to be ambulatory and had repetitive behaviors of pacing the hallways. A nursing note dated January 22, 2013, documented that staff reported the resident had walked out the north door with a bag in his hand, and walked to the fence in the far north parking lot, and dropped the bag and then came back into the facility. The staff retrieved the bag and found it was full of BM. The NP was informed and the resident was to have a psychiatric follow up appointment on January 30, 2013. Another elopement risk assessment was completed on January 22, 2013. Despite the resident leaving the facility, the resident was not identified to be at risk for elopement. Documentation also included that a wanderguard was not appropriate, due to having a negative reaction to loud unanticipated noises. Additional comments included that the resident ambulates at will throughout the facility for exercise and pleasure, with no expressed desire to elope. The documentation included the resident has been frustrated with the toilet overflowing on a fe… | 2017-08-01 |
| 4590 | 4590 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 333 | G | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility and hospital documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#23) was free of significant medication errors. Findings include: Resident #23 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed documentation that the resident was alert and oriented, able to communicate needs, and had the ability to understand others. The documentation also included the resident was allergic to [MEDICATION NAME]. Review of the December 2013 physician orders [REDACTED]. The orders did not include the resident was to receive [MEDICATION NAME]. The current care plans addressed an identified problem related to diabetes. Interventions included the resident would be administered all medications as ordered. In addition, a care plan had been developed that addressed the resident's allergy to [MEDICATION NAME]. The goal was to not administer [MEDICATION NAME] to the resident, with the following interventions: 1) Place allergy sticker in front of chart, 2) Label physician's orders [REDACTED]. A nurse's note dated January 5, 2014 at 7:45 p.m., included that an error in the administration of insulin and an oral medication ([MEDICATION NAME]) had occurred. The NP (nurse practitioner) was notified and new orders were obtained. This entry was signed by a Licensed Practical Nurse (staff #1). Continued in the nurse's note was that immediately following the medication errors, the resident was alert and oriented and regularly scheduled neurological checks, vital signs, and blood sugar levels were initiated. A nurse's note dated January 6 at 5:00 a.m., documented the resident was alert and oriented, aroused easily for cares, and Accuchecks and neurological checks were normal. Later that afternoon at 2:00 p.m., the documentation included that the resident was difficult to arouse, oxygen saturation… | 2017-08-01 |
| 4591 | 4591 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 353 | E | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide adequate staff to ensure that resident cares were provided and call lights were answered in a timely manner for four residents (#s 6, 21, 22, and 23). The sample size was 11 Findings include: An interview was conducted on January 28, 2014, with the person responsible for daily staffing. A review of the staffing sheets for the past three months revealed consist staffing on both hallways with little or no variation in staffing levels. The staffing person stated that the staff on the long-term hallway (front hallway) rarely changes and the Medicare hallway (back hallway) will sometime reflect the addition of one staff based on admission acuities. The staffing person stated that regardless of staffing levels or assignments, all staff are expected to answer call lights timely. Resident #23 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a care plan dated January 7, 2014, for alteration in functional ADL (activities of daily living) abilities related to [MEDICAL CONDITION], decreased functional mobility, and depression. The care plan documented that the resident required two staff to transfer the resident via a mechanical lift, required extensive assistance of two staff for toileting needs, and for staff to anticipate the resident's needs and answer alarms and call lights. An interview was conducted with resident #23 on January 28, 2014. The resident stated it can take staff an hour or longer to answer his call light. The resident stated he needs assistance with urinary and bowel incontinence care and that he has soiled himself due to staff not responding to his call light in a timely manner. The resident also stated that call lights have been discussed in resident council meetings without resolution. A review of the Resident Council minutes for October and November 2013 and January 2014, revealed documentation of resident complaints of excessive call light wait… | 2017-08-01 |
| 4592 | 4592 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 441 | D | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, and review of facility policy, the facility failed to ensure that isolation precautions were maintained for two residents (#s 84 and 148). Findings include: -During random observations conducted on unit C, a cautionary sign was observed posted on the door of room [ROOM NUMBER]. A bedside table was also observed outside the resident's room in the hallway. On top of the bedside table were a box of mask and gloves, a bag of disposable gowns, and an unpackaged, disposable blood pressure cuff and stethoscope. The blood pressure cuff and stethoscope was not covered and were laying across the bag of gowns. A review of the facility's January 2014, infection control logs revealed that this resident was identified to have[DIAGNOSES REDACTED] (Clostridium Difficile) and MRSA (Methicillin Resistant Staphylococcus Aureus) in the urine. An interview was conducted on January 30, 2014, with the LPN (Licensed Practical Nurse), who stated that the resident was on contact isolation precautions for[DIAGNOSES REDACTED] and MRSA. The LPN stated that the prior to entering the resident's room, staff were required to put on a gown and gloves, and then dispose of those items before exiting the resident's room. He also stated that any equipment, such as a blood pressure cuff, stethoscope, and thermometer were to remain in the resident's room. At this time, the LPN was unable to confirm if the blood pressure cuff and stethoscope had been used, since it was unpackaged, however, he was able to confirm that a blood pressure had been obtained this morning by the CNA (Certified Nursing Assistant). An interview was conducted with the CNA on January 30, who confirmed that she had obtained the resident's blood pressure and had used the same blood pressure cuff and stethoscope that was observed sitting outside the resident's room on the bedside table. She stated that she had cleaned the ear piece on the stethoscop… | 2017-08-01 |
| 4593 | 4593 | APACHE JUNCTION HLTH CENTER | 35112 | 2012 WEST SOUTHERN AVE | APACHE JUNCTION | AZ | 85120 | 2014-01-30 | 514 | D | 0 | 1 | SH9P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy review, the facility failed to maintain clinical records that are complete, by failing to ensure two residents (#s 23 and 153) had consents that were thoroughly completed related to [MEDICAL CONDITION] medications. Findings include: -Resident #23 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the recapitulation of physician's orders [REDACTED]. The Informed Consent For Use of [MEDICAL CONDITION] Medications form dated June 22, 2012, addressed the use of the anti-anxiety medication. The form was signed by the resident, however, the area to check for either giving consent for the use of the [MEDICAL CONDITION] medication or not consenting to the use of [MEDICAL CONDITION] medication was left blank. In an interview, the DON stated that the area on the form needed to be checked to be completed. | 2017-08-01 |
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CREATE TABLE [cms_AZ] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );