cms_AZ
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37 rows where "inspection_date" is on date 2018-10-11
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1207 | 1207 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 550 | D | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interviews, and policies and procedures, the facility failed to ensure one resident (#28) was allowed to exercise her right regarding the use of bedrails. Findings include: Resident #28 was admitted to the facility on (MONTH) 27, 2014 with [DIAGNOSES REDACTED]. Review of the current resident fact sheet data which contained all pertinent resident identifying information revealed that the responsible party for the resident was listed as SELF. Review of the quarterly Minimum Data Set assessment dated (MONTH) 26, (YEAR) revealed the resident had long and short term memory problems and had modified independence with cognition, indicating some difficulty in decision making in new situations only. The resident required extensive two person assistance for bed mobility. A current care plan with a revision date of (MONTH) 2, (YEAR) documented the resident wanted to return to bed immediately after meals. Review of a bedrail risk assessment dated (MONTH) 28, (YEAR) and signed by a Physical Therapist (PT), revealed a decision had been made for bedrails to be used and that the resident had been consulted regarding their use. Review of a consent form for the use of bedrails dated (MONTH) 20, (YEAR) revealed the resident was mentally capable of participation in her own health care decisions. The consent form was signed by the resident. Review of a nursing note dated (MONTH) 26, (YEAR) revealed the resident was in her room and was yelling and throwing water, and was upset that she could not have the bedrails raised up. An observation was conducted with a Certified Nursing Assistant (staff #24) on (MONTH) 11, (YEAR). After entering the room of resident #28, staff #24 stated the right bedrail was tied to the bed frame and could not be moved. Staff #24 stated the left bedrail was up and placed tightly against the wall. Staff #24 said that he did not know why the resident would not be able to use a bedrail if th… | 2020-09-01 |
| 1208 | 1208 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 552 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policies and procedures, the facility failed to ensure four residents (#'s 28, 31, 33, and 225) were informed of the risks/benefits, including potential side effects regarding the use of [MEDICAL CONDITION] medications. Findings include: -Resident #28 was admitted to the facility on (MONTH) 27, 2014 with [DIAGNOSES REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) physician orders [REDACTED]. Review of the clinical record revealed a psychoactive medication consent (with a date of (MONTH) 11, (YEAR)) for [MEDICATION NAME] which included a section for the resident to sign and date, indicating consent to the treatment. Further review revealed the consent was signed by a staff member, however, it was not signed by the resident/representative. There was no current consent in place for the use of [MEDICATION NAME]. According to the Medication Administration Records for the past 6 months, the resident was administered [MEDICATION NAME] as ordered. An interview was conducted with a Licensed Practical Nurse (LPN/staff #70) on (MONTH) 11, (YEAR) at 9:15 a.m. He stated that all consents, including consents regarding risks/benefits for the use of psychoactive medications have to be signed and dated by the resident and/or representative. He stated this form had not been completed for this resident and needed to be completed right away. An interview was conducted with the Assistant Director of Nursing (ADON/staff #32) on (MONTH) 11, (YEAR) at 9:59 a.m. She stated the consent regarding the risks/benefits of [MEDICATION NAME] was not signed by the resident and the resident is the responsible person to sign it. Staff stated the resident does not have a legal guardian and has not been declared incompetent, so the resident would sign the form. Staff stated there is currently no system in place to ensure that all consent forms are completed timely. -Resident #33 was admitted to the facility on [DATE] and r… | 2020-09-01 |
| 1209 | 1209 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 578 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure the physician's order and additional clinical record documentation regarding advance directives were accurate for one resident (#29). Findings include: Resident #29 was admitted to the facility on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. The advance directive form dated (MONTH) 13, (YEAR) indicated that the resident was a full code. On the side of the form was a handwritten note changed to DNR (Do Not Resuscitate) on (MONTH) 7, (YEAR). A social services note dated (MONTH) 7, (YEAR) documented the resident had a full code status and decided to change it to a DNR status. Review of the Care Plan Conference Summary dated (MONTH) 7, (YEAR) revealed the resident's code status had changed from full code to DNR. The narrative section included that full code was explained to the resident and the resident wanted to not have chest compressions. The summary included that the resident signed the orange DNR form. The Medical Care Directive signed by the resident dated (MONTH) 7, (YEAR), indicated that in the event of cardiac or respiratory arrest, the resident refused any resuscitation measures, administration of advanced cardiac life support drugs and related emergency medical procedures. The Care Plan Conference Summaries dated (MONTH) 9, (YEAR) and (MONTH) 9, (YEAR) indicated that the resident was a DNR status. The Certified Nursing Assistant (CNA) pocket plan of care also indicated the resident was DNR. However, despite these documents that the resident was a DNR, the physician's order recaps from (MONTH) through (MONTH) (YEAR) indicated that the resident was a full code status. Also, the clinical record facesheet and the current comprehensive care plan indicated the resident was a full code status. During an interview with two CNA's (staff #8 and #41) conducted on (MONTH) 4, (YEAR) at 1:50 p.m., they both stated that the res… | 2020-09-01 |
| 1210 | 1210 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 582 | D | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and policy review, the facility failed to ensure that one resident (#45) received the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC), prior to the service end date. Resident #45 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of the SNFABN form revealed that the resident signed the form, however, there was no date on the form. Review of the NOMNC form revealed that the resident signed the form, however, there was no date on the form. An interview was conducted on (MONTH) 10, (YEAR) at 8:42 a.m. with a social worker (staff #16). She stated that she was responsible for giving the SNFABN Form and the NOMNC Form to the residents at the facility. She stated that she gives the forms to the residents no later than two days prior to their medical coverage ending. She stated that if the forms are not dated by the resident, she would not be able to tell when the forms were given to the resident. Staff #16 then reviewed the SNFABN Form and the NOMNC Form and agreed that the resident had not dated either form, therefore; she could not tell if the forms were given to the resident two days prior to the resident's medical insurance ending. Review of the Skilled Nursing Facility Advance Beneficiary Notice Form Policy revealed that the form must be signed and dated by the resident or authorized representative. | 2020-09-01 |
| 1211 | 1211 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 584 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure that mechanical lifts were maintained in a clean and sanitary manner for resident use. Findings include: An observation was conducted in the hallway in the area outside of room [ROOM NUMBER] on 10/01/18 at 12:09 p.m. At this time, a sit-to-stand mechanical lift, model #350 was heavily soiled with black and gray dirt on the framework and lower bars and had loose debris on the base. Another observation was conducted on 10/02/18 at 8:26 a.m. in the area of room [ROOM NUMBER]. A Hoyer lift, model #450 was just removed from a resident's room and was placed in the hall way. The framework was heavily soiled with black and gray dirt, there was loose debris and what appeared to be dried liquids on the base. In addition, there was a sit-to-stand lift, model #350, in the same hall and the frame was soiled with black and gray dirt, loose debris on the base, and the blue sling was soiled with gray dirt and what appeared to be dried liquids. Two additional observations were made on 10/03/18 of the Hoyer lifts and sit-to stand lifts in the hallways and those that had been placed in empty rooms to store. The observations included that the lifts were heavily soiled on the frames, had loose debris on the bases and the slings were soiled. In an interview conducted on 10/04/18 at 12:36 p.m. with a Housekeeper (staff #14), who stated that she was not sure whose responsibility it was to clean the mechanical lifts. Staff #14 stated if she saw one that was dirty, she would clean it. In an interview conducted on 10/04/18 at 12:40 p.m. with a Certified Nursing Assistant (CNA/staff #53), she stated that she did not know who was supposed to clean the mechanical lifts. An observation of three Hoyer lifts and two sit-to-stand lifts was conducted with the Director of Nursing (DON/staff #118) on 10/04/18 at 12:45 p.m. All of the lifts were observed to have black and gray dirt on the framework, with dr… | 2020-09-01 |
| 1212 | 1212 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 600 | G | 1 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#16) was free from neglect and failed to ensure that one resident (#41) was free from verbal abuse by a staff member. Findings include: -Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician History and Physical dated 06/09/18, revealed the resident was admitted to the facility following hospitalization for a right distal femur fracture, multiple falls, a right ankle fracture and head contusion. The resident was complaining that his hands don't work and had upper extremity weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS also included the resident required total dependence with bed mobility, transfers, eating and toileting. Review of the care plan dated 6/13/18 revealed the resident had self-care deficit. Approaches included the resident is non ambulatory and requires extensive assistance of two staff for bed mobility and transfers. A physician note from the orthopedic physician office visit on 06/20/18 indicated the resident was being evaluated for a right distal fibula fracture that occurred from a fall. A CNA (Certified Nursing Assistant) accompanied the resident to the appointment from the facility. The resident was wearing a Controlled Ankle Movement (CAM) boot. The resident is to have repeat x-rays of the fracture around 7/11/18. The resident is to remain in the boot for another three weeks and follow-up again after the x-rays are completed in three weeks. A nurse's progress noted dated 7/16/18 at 8:40 a.m. documented the resident left the facility for an orthopedic physician appointment and was transported by a contracted transport company. Another nurse's progress note … | 2020-09-01 |
| 1213 | 1213 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 603 | D | 1 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure one resident (#65) was free from involuntary seclusion. Findings include: Resident #65 was readmitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigation revealed that room trays were being passed around 6:00 p.m. on (MONTH) 8, (YEAR), by a Certified Nursing Assistant (CNA/staff #112). At this time, resident #65 was in her room and was yelling for pain medication which she does frequently, but it was too early for any pain medication. Per the report, staff #112 slammed the resident's room door closed, and continued to pass the room trays. The incident was witnessed by the unit clerk (staff #3). Staff #3 reported that she was at the nurses station setting up a transport. She said resident #65 was yelling for staff #112 and staff #112 whipped around and slammed resident #65's door shut. Staff #3 did not hear if staff #112 said anything to the resident. She stated that staff #112 came to her about 5 to 10 minutes later and told her she had to close resident #65's door, because she was screaming. Staff #3 immediately reported the incident to the registered nurse on shift (RN/staff #111) and the Director of Nursing (DON/staff #118). Staff #111 then opened resident #65's door and checked on her. The resident reported that she was in her bed and was calling an aide for assistance, when the door was slammed shut. The resident stated that she heard the aide comment that will teach her. According to a statement from staff #112, resident #65 was yelling at her because she wanted pain pills, even after she told the resident that it was not time for her medication yet. Staff #112 stated the resident continued to yell and it was beginning to upset surrounding residents, so she made the decision to close resident #65's door. Further review of the facility's report revealed that staff #112 was … | 2020-09-01 |
| 1214 | 1214 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 607 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to implement their abuse policy, by failing to thoroughly investigate an allegation of abuse and report an allegation of misappropriation of resident property to the State Agency and to Adult Protective Services (APS) for one resident (#41), by failing to report an incident of neglect to the State Agency within the required timeframe for one resident (#16), and by failing to investigate an allegation of abuse and report it to the State Agency and APS, within the required timeframe for one resident (#65). Findings include: -Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility's investigative report dated 7/21/18 revealed that on the morning of 7/16/18, resident #16 was transported to a local physician's office for an appointment, by a transport company. A CNA (staff #64) from the facility accompanied the resident for assistance with Activities of Daily Living (ADL) as needed. Per the report, the transport driver parked the van facing the doctor's building, then released the front safety belt to the wheelchair and proceeded to the back of the van to lower the ramp, and then released the back lower buckles to the wheelchair. When the driver released the lower safety belt, the resident began to go backward over the wheelchair. The transport driver and the CNA tried to grab the back of the chair, but the resident continued to fall over and hit the ramp. Paramedics arrived and transported resident #16 to the hospital. The resident sustained [REDACTED]. gate, and the weight of the resident caused an imbalance and the resident fell out of the wheelchair. The CNA noted that the resident's legs were extended for comfort due to the fractured ankle. The report included that it was the responsibility of the transport driver to ensure the safety of patients when loading and unloading, an… | 2020-09-01 |
| 1215 | 1215 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 609 | E | 1 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that an incident of neglect was reported to the State Agency and Adult Protective Services (APS) for one resident (#16), failed to ensure that an allegation of misappropriation of resident property was reported to the State Agency and APS within the required timeframes for one resident (#41), and failed to ensure that an allegation of physical abuse was investigated and reported to the State Agency for one resident (#65). Findings include: -Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility's investigative report dated 07/21/18 revealed that on the morning of 07/16/18, resident #16 was transported to a local physician's office for an appointment by a transport company. A CNA (staff #64) from the facility accompanied the resident for assistance with Activities of Daily Living (ADL) as needed. Per the report, the transport driver parked the van facing the doctor's building, then released the front safety belt to the wheelchair and proceeded to the back of the van to lower the ramp, and then released the back lower buckles to the wheelchair. When the driver released the lower safety belt, the resident began to go backward over the wheelchair. The transport driver and the CNA tried to grab the back of the chair, but the resident continued to fall over and hit the ramp. Paramedics arrived and transported resident #16 to the hospital. The resident sustained [REDACTED]. gate, and the weight of the resident caused an imbalance and the resident fell out of the wheelchair. The CNA noted that the resident's legs were extended for comfort due to the fractured ankle. The report included that it was the responsibility of the transport driver to ensure the safety of patients when loading and unloading, and to ensure a safe entry to any building or facility. Further review of… | 2020-09-01 |
| 1216 | 1216 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 610 | D | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility documentation and policy review, the facility failed to ensure that an allegation of physical abuse for one resident (#41) was thoroughly investigated. Findings include: Resident #41 was readmitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative report revealed that on (MONTH) 24, (YEAR) at 1:35 a.m., the resident reported to a certified nursing assistant (CNA/staff #116) that a CNA (staff #114) had been verbally abusive to her yesterday. Per the report, the resident stated that staff #114 mocks her when she complains of pain, is quick tempered and sometimes throws things around her room. The resident reported that on (MONTH) 23, (YEAR) on the evening shift, the resident put on her call light as she needed a pain pill and staff #114 answered it. The resident said that staff #114 started yelling at her in her face, so she told him to shut up and get out of her face or she would hit him. She reported that staff #114 said go ahead and hit me and you will get kicked out of here. The facility's report further included that staff #114 was suspended pending the investigation. Per the report, the allegation was substantiated and staff #114 was terminated on (MONTH) 27, (YEAR). However, further review of the facility's investigation revealed that the investigation was not thorough, as there was no evidence of a statement from the alleged perpetrator (staff #114) or documentation that staff #114 was interviewed regarding the incident. During an interview with the Administrator (staff #119) conducted on (MONTH) 9, (YEAR) at 12:29 p.m., she stated that all staff are instructed to report any type of abuse, including missing money to the charge nurse, the Director of Nursing (DON) or to her. She stated that she and the DON let each other know about allegations of abuse. She further stated that during an investigation, they will determine who were involved and… | 2020-09-01 |
| 1217 | 1217 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 623 | E | 1 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews and staff interviews, the facility failed to ensure that the State ombudsman's phone number and address were included on the discharge notice for three residents (#126, #127 and #128). Findings include: -Resident #126 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's discharge notice revealed the resident discharged home on (MONTH) 27, (YEAR). Further review of the discharge notice revealed there was no documentation of the ombudsman's phone number and address. -Resident #127 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's discharge notice revealed the resident was discharged to an assisted living facility on (MONTH) 3, (YEAR). Further review of the discharge notice revealed there was no documentation of the ombudsman's phone number and address. -Resident #128 was admitted to the facility on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's discharge notice revealed the resident was discharged to an assisted living facility on (MONTH) 11, (YEAR). Further review of the discharge notice revealed there was no documentation of the ombudsman's phone number and address. On (MONTH) 2, (YEAR) at 1:45 p.m., the facility's assigned ombudsman (#113) was interviewed. She stated that she has informed the facility that the discharge notice needs to include the ombudsman's name, address and phone number. She reported this information is not being included on the discharge plans that she receives from the facility. She also stated that she has discussed this with the administrator and social services director regarding what needs to be documented on the discharge summary, however, it still isn't being done. On (MONTH) 11, (YEAR) at 12:42 p.m., an interview was conducted with the administrator (staff #119). She stated that when a resident is to leave the facility, the physician will write an orde… | 2020-09-01 |
| 1218 | 1218 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 636 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed within the required time frames for three residents (#43, #125 and #225). Findings include: -Resident #225 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had an Entry Tracking MDS assessment completed on 8/08/18. Further review of the clinical record revealed the resident did not have a completed MDS assessment since the entry record. An interview was conducted on 10/03/18 at 2:08 p.m. with the Registered Nurse/Minimum Data Set coordinator (RN/MDS/staff #70). He stated the only MDS found in the clinical record was the Entry tracking MDS which was completed on 8/08/18. He was unable to find any other MDS assessments which had been completed. He stated MDS staff missed completing the resident's MDS assessments since she was admitted . He said that the resident was admitted on hospice, but this does not change the process and an MDS should have been completed. -Resident #125 was admitted to the facility on (MONTH) 3, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had an Entry Tracking MDS Assessment completed on (MONTH) 3, (YEAR). Further review of the clinical record revealed the resident has not had a completed MDS assessment since. An interview was conducted the MDS coordinator (staff #70). He stated the only MDS found in the clinical record was the Entry tracking MDS which was completed on (MONTH) 3, (YEAR). He was unable to find any other MDS assessments which had been completed. He stated MDS staff must have missed completing the resident's MDS assessments. An interview was conducted with the director of nursing (DON/staff #118) on (MONTH) 5, (YEAR) at 7:58 a.m. She stated the facility requirement is to have the MDS completed within a… | 2020-09-01 |
| 1219 | 1219 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 637 | D | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, review of the Resident Assessment Instrument (RAI) manual and policy and procedures, the facility failed to ensure that Significant Change in Status (SCSA) Minimum Data Set (MDS) assessments were completed within 14 days of the significant change for two residents (#225 and #43). Findings include: -Resident #225 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted to the facility on hospice services. Review of the clinical record revealed the resident had an Entry Tracking MDS assessment completed on 8/08/18. A physician's orders [REDACTED]. Since the resident was removed from hospice services, this constituted a significant change of condition. However, no Significant Change in Status MDS assessment was completed. An interview was conducted with the MDS coordinator (staff #70) on 10/03/18 at 2:08 p.m. He stated the only MDS found in the clinical record was the Entry Tracking MDS, which was completed on 8/08/18. He stated that MDS staff missed completing the SCSA MDS assessment, when the resident came off hospice services and that one should have been completed. -Resident #43 was admitted to the facility on (MONTH) 28, 2013 and readmitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment for resident #43 dated (MONTH) 20, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. The assessment did not indicate that the resident had any pressure ulcers. A discharge MDS assessment dated (MONTH) 18, (YEAR) included that the resident had no pressure ulcers. The assessment indicated the resident was discharged to the hospital and that the resident's return to the facility was anticipated. Review of the nursing evaluation dated (MONTH) 22, (YEAR) revealed the resident had stage 2 pressure ulcers to both the right and left buttock upon re-admission from th… | 2020-09-01 |
| 1220 | 1220 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 638 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of the Resident Assessment Instrument (RAI) manual and policy and procedures, the facility failed to complete the required quarterly Minimum Data Set (MDS) assessments in a timely manner for one resident (#43). Findings include: -Resident #43 was admitted to the facility on (MONTH) 28, 2013, with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 20, (YEAR), revealed the assessment was signed by a Licensed Practical Nurse (LPN/staff #82) and a dietary manager (staff #56) on (MONTH) 19, (YEAR) and the Director of Nursing (DON/staff #118) on (MONTH) 26, (YEAR). The assessment was signed as complete under section X1100 instead of section Z0500 on (MONTH) 26, (YEAR), which was 22 days after the assessment should have been signed. A quarterly MDS assessment dated (MONTH) 20, (YEAR), revealed the assessment was signed by an LPN (staff #82), a dietary manager, and staff #118 on (MONTH) 12, (YEAR). The assessment was signed as complete under section X1100 instead of section Z0500 on (MONTH) 12, (YEAR); which was 6 days after the assessment should have been signed. Review of a quarterly MDS assessment dated (MONTH) 17, (YEAR) revealed the assessment was signed by an LPN (staff #82), a dietary manager, and staff #118 on (MONTH) 27, (YEAR). The assessment was signed as complete under section X1100 instead of section Z0500 on (MONTH) 27, (YEAR); which was 27 days after the assessment should have been signed. An interview was conducted with the Registered Nurse/MDS nurse (staff #70) on (MONTH) 3, (YEAR). He stated that he coordinates with the other disciplines in the facility to complete and sign the MDS assessments on time. He stated that an MDS needs to be completed within 14 days of the Assessment Reference Date (ARD) and needs to be transmitted within a week of completion. He stated that the facility follows the MDS 3.0/RAI manual for direction, including timing and signat… | 2020-09-01 |
| 1221 | 1221 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 640 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure MDS (Minimum Data Set) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) System within 14 days after completion for two residents (#5 and #43). Findings include: -Resident #5 was admitted on (MONTH) 25, (YEAR) and discharged on (MONTH) 22, (YEAR). A review of the facility's MDS assessment transmittal documentation revealed the discharge MDS assessment dated (MONTH) 22, (YEAR) had not been electronically transmitted to the CMS System. An interview was conducted on (MONTH) 4, (YEAR) at 12:37 p.m., with the MDS staff (#82, #13, and #70). After reviewing the MDS assessment transmittal logs, they stated that the discharge MDS assessment for this resident was not transmitted to the CMS System. They also stated that the discharge MDS assessment should have been transmitted within 14 days after completion. -Resident #43 was admitted to the facility on (MONTH) 28, 2013 with [DIAGNOSES REDACTED]. Review of a printed hand signed annual MDS assessment dated (MONTH) 18, (YEAR), revealed the completion date was (MONTH) 25, (YEAR); however, the annual MDS assessment was not transmitted to the CMS System until (MONTH) 17, (YEAR). Review of a printed hand signed quarterly MDS assessment dated (MONTH) 20, (YEAR), revealed the completion date was (MONTH) 12, (YEAR); however, the quarterly MDS assessment was not transmitted to the CMS System until (MONTH) 20, (YEAR). An interview was conducted with the Registered Nurse/MDS staff (#70) on (MONTH) 3, (YEAR). He stated that the MDS assessments need to be transmitted within a week of signing. He also stated that they follow the RAI manual for direction, timing, and signature requirements. During an interview conducted with the Administrator (staff# 119) on (MONTH) 3, (YEAR) at 12:59 p.m., she stated that the RA… | 2020-09-01 |
| 1222 | 1222 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 641 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy, the facility failed to ensure the MDS (Minimum Data Set) assessments for 8 residents (#28, #33, #40, #43, #53, #65, #69, and #77) accurately reflected the residents' status. Findings include: -Resident #28 was readmitted on (MONTH) 27, 2014, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated (MONTH) 26, (YEAR), revealed the resident had received an anticoagulant during the 7 day look-back period. Further review of the clinical record did not reveal a physician's orders [REDACTED]. An interview was conducted on (MONTH) 4, (YEAR) at 10:48 a.m., with a MDS staff (#82), who stated that she had coded the [MEDICATION NAME] (antiplatelet) that the resident had been administered as an anticoagulant. She further stated that she did not know this medication was not classified as an anticoagulant when she coded the assessment. She stated that the MDS assessment was coded incorrectly regarding administration of an anticoagulant. -Resident #40 was readmitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a Bedrail Risk assessment dated (MONTH) 28, (YEAR) that did not indicate whether the bedrails were a restraint. A review of the clinical record revealed a quarterly MDS assessment dated (MONTH) 3, (YEAR), that the resident had bedrails that were used as restraints daily. The MDS assessment also included the resident needed the assistance of one staff for bed mobility and transfers. Further review of the clinical record did not reveal any documentation of a physician's orders [REDACTED]. During an interview conducted on (MONTH) 4, (YEAR) at 12:47 p.m. with MDS staff (#82, #13, and #70), staff #82 stated she that was unaware of the criteria for coding restraints on the MDS assessment. Staff #82 stated that she coded the bedrail as a restraint because the resident had a 1/2 bedrail. Staff #13 stated that the resident co… | 2020-09-01 |
| 1223 | 1223 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 642 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessments for one resident (#43) were consistently and accurately signed and dated. Findings include: Resident #43 was admitted to the facility on (MONTH) 18, 2013 with [DIAGNOSES REDACTED]. On (MONTH) 2, (YEAR), the required previous 15 months of completed MDS assessments for this resident was requested and obtained from the MDS staff. -Review of the annual MDS assessment with an Assessment Reference Date (ARD) of (MONTH) 18, (YEAR) conducted on (MONTH) 2, (YEAR), revealed the MDS/Licensed Practical Nurse (LPN/staff #82), activities (staff #67), and the dietary manager (staff #56) signed their section as completed on (MONTH) 25, (YEAR). The section for the signature of the RN (Registered Nurse) assessment coordinator verifying the assessment was complete revealed a signature with a typed date of (MONTH) 25, (YEAR). The space for the signature of the RN assessment coordinator attesting to the correction of the assessment revealed it was signed on (MONTH) 25, (YEAR). A copy of the assessment was requested. Review of the requested copy of the annual MDS assessment with an ARD of (MONTH) 18, (YEAR) conducted on (MONTH) 3, (YEAR), revealed social service (staff #24), dietary manager/kitchen supervisor (staff #46), and activities (staff #67) signed their section as completed on (MONTH) 18, (YEAR). These signatures and date were different from the assessment reviewed on (MONTH) 2, (YEAR). The section for the signature of the RN assessment coordinator verifying the assessment was complete was blank with a typed date of (MONTH) 25, (YEAR). The section for the signature of the RN assessment coordinator attesting to the completion of the correction request revealed it was signed by the DON (staff #118) on (MONTH) 18 with a line drawn through the signature and the date. The signature s… | 2020-09-01 |
| 1224 | 1224 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 655 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy and procedure, the facility failed to develop a baseline care plan that met professional standards of quality care for two residents (#225 and #31) and failed to ensure four residents (#225, #31, #77 and #69) and their representative were provided with a summary of the baseline care plan. Findings include: -Resident #225 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. The orders also revealed an order for [REDACTED]. Review of the admission assessments dated 08/08/18 revealed the resident was at high risk for pain and at high risk for falls. A document titled Interdisciplinary Care Plan had some initial assessment components checked off, but no resident care needs were identified and no care plan goals or interventions were developed. The form was not signed. The clinical record contained a fall care plan and an anticoagulant care plan, however, there was no date of initiation and none of the potential options on the forms were selected. There was a signature without credentials. Review of the baseline care plan did not reveal instructions needed to provide effective and person-centered care and did not include the minimum information necessary to properly care for the resident. Review of the clinical record did not reveal evidence the resident and their representative were provided a summary of the baseline care plan. An interview was conducted on 10/03/18 at 02:34 PM with the MDS (Minimum Data Set) Coordinator (staff #82). Staff #82 stated information is obtained from the clinical record, the resident, and the staff to develop a care plan. Staff #82 stated that the care plan is developed based on the resident's needs. During an interview conducted on 10/05/18 at 07:58 AM with the Director of Nursing (DON/staff #118), the DON stated the admitting nurse develops the 48 hour (baseline) care plan based on the resident's ne… | 2020-09-01 |
| 1225 | 1225 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 656 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record reviews, facility documentation, and policy, the facility failed to ensure that a comprehensive person-centered care plan was developed for four residents (#125, #29, #41, and #69). Findings include: -Resident #29 was admitted on (MONTH) 24, (YEAR) with a [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated (MONTH) 1, (YEAR) indicated that the resident had impairment to both sides of her upper extremities. The monthly nursing summary dated (MONTH) 4, (YEAR), (MONTH) 4, (YEAR), (MONTH) 4, (YEAR), and (MONTH) 4, (YEAR) revealed the resident had bilateral hand contractures. The OT (occupational therapy) evaluation dated (MONTH) 18, (YEAR) revealed a medical [DIAGNOSES REDACTED]. The monthly nursing summary dated (MONTH) 3, (YEAR) revealed the resident had hand contractures. The quarterly MDS assessment dated (MONTH) 1, (YEAR) revealed impairment on one side of the upper extremity. Review of the restorative nursing note dated (MONTH) 29, (YEAR) revealed the need for upper and lower extremities ROM (range of motion) to prevent contractures. The month nursing summary dated (MONTH) 2, (YEAR) included the resident had contractures in both hands. The physician progress notes [REDACTED]. However, review of the care plans did not reveal a care plan was developed to address the resident's contractures. -Resident #41 was readmitted at the facility on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 26, (YEAR) revealed a wound to the left buttocks with 2 small pinpoint holes surrounded by a hard lump. Per the documentation, there was small to moderate amount of blood leaking out and there was a small amount of purulent discharge at the lower portion of the wound bed. The skin assessment dated (MONTH) 1, (YEAR) included the resident had a sore to the left buttocks. The quarterly MDS assessment dated (MONTH) 4, (YEAR) revealed the resident had an open lesion other than ulc… | 2020-09-01 |
| 1226 | 1226 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 658 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of policy and procedures, the facility failed to meet professional standards of quality regarding the storage of narcotic medication. Findings include: During a medication administration observation on 10/02/18 at 9:08 a.m. with a Registered Nurse (staff #7), one Individual Resident's Controlled Substance Record (CSR) was reviewed. The prescription label on the CSR read for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, give 0.5 tablet by mouth every 6 hours as needed for pain and 1 tablet by mouth every 6 hours as needed for pain. The CSR showed that a whole tablet was administered five times and a 0.5 tablet was administered 24 times, with each entry reduced by 0.5 (i.e. 14 tabs left, 13.5 tabs left, 13 tabs left, 12.5 tabs left). During the observation, the corresponding [MEDICATION NAME]-[MEDICATION NAME] dose pack revealed there had been a total of 20 whole tablets which had been dispensed, and two whole tablets were remaining. On the back of the dose pack were pieces of tape to cover up several of the punch holes. At this time, an interview was conducted with staff #7, who stated that if the narcotic medication is cut, the remaining half should be wasted. Staff #7 stated that the nurses should not be using tape to hold a 1/2 of a pill in the dose pack. An interview was conducted on 10/03/18 at 9:45 a.m., with the Director of Nursing (DON/staff #118). Staff #118 stated that staff should not be breaking those tablets and saving the other half, and that the narcotic medication should be wasted and signed off by two nurses. A telephonic interview was conducted on 10/03/18 at 12:50 p.m. with the Consulting Pharmacist (staff #124), who stated that if an order is written for 1/2 tablet, the pharmacy should dispense 1/2 tablets. He stated that staff should never break those tablets. He stated if the nurses are breaking the narcotic pills, they should waste the medication and document that it wa… | 2020-09-01 |
| 1227 | 1227 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 677 | E | 1 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record reviews, staff interviews and policy review, the facility failed to ensure there was documentation that Activities of Daily Living (ADL) care was provided to two residents (#41 and #43), and failed to ensure that one resident (#28) was provided assistance and supervision during meal service. Findings include: -Resident #41 was readmitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. According to the monthly nursing summaries from (MONTH) (YEAR) through (MONTH) (YEAR), the resident was incontinent of bowel and bladder, was bed or chair bound and had left sided paralysis. The documentation included the resident needed assistance with incontinence and required total care with grooming and oral hygiene. Review of the Care Plan Conference Summaries dated (MONTH) 16, (YEAR) and (MONTH) 22, (YEAR), revealed the resident was incontinent of bowel and bladder and was dependent for all cares. Review of the monthly nursing summaries from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the resident was incontinent of bowel and bladder, was bed or chair bound and had left sided paralysis. The documentation included the resident needed assistance with incontinence, and required total care with grooming and oral hygiene. Review of a comprehensive care plan revealed the resident had a self-care deficit, due to a history of [MEDICAL CONDITION], with left sided weakness. The care plan included the resident was incontinent related to loss of control. The goal was to meet the resident's needs. Approaches included the following: 2-3 person assistance with turning, repositioning, bed mobility and transfers; required total assistance with showers and dressing; check and change resident every 2 hours; and toilet resident every 2 hours and as needed. However, review of the clinical record, including the CNA (Certified Nursing Assistant) ADL records revealed there was no evidence of any daily care which was prov… | 2020-09-01 |
| 1228 | 1228 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 679 | D | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff and resident interviews and policy review, the facility failed to ensure that an individualized activities program was provided to meet the interests of three residents (#'s 18, 28 and 225). Findings include: -Resident #18 was admitted to the facility on (MONTH) 3, 2014, with a [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated (MONTH) 10, (YEAR), revealed the resident was assessed to have moderate cognitive impairment, with disorganized thinking and delusions. The MDS included the resident could sometimes understand others and be understood, and had moderate visual impairment. Under the Activity section, it was noted that the resident liked to listen to music. A care plan regarding activities dated (MONTH) 10, (YEAR) included a goal that the resident would be content with her leisure time. Approaches included for staff to invite her to activities and transfer her as needed, that she likes music and will sing along, and that she enjoys visits with others. A care plan conference summary dated (MONTH) 11, (YEAR) revealed the resident was alert, confused, and was dependent on staff for all care. The documentation included that the resident's needs are anticipated and that she wanders throughout the facility carrying a doll, and that the resident likes to sing. An activity progress note dated (MONTH) 11, (YEAR) revealed the activity plan was to continue with individual one to one visits from activity staff and to invite the resident to organized activities. During the survey, multiple observations of the resident were conducted and there were no observations of the resident being provided any activities. Observations also revealed the following: October 1, (YEAR) at 1:51 p.m: The resident was observed sitting in a wheelchair by the nursing station. October 1, (YEAR) at 2:03 p.m: The resident was observed in the hallway by the nursing station, staring at the wall… | 2020-09-01 |
| 1229 | 1229 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 680 | E | 0 | 1 | 80M411 | Based on personnel file review, staff interview, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. Findings include: A review of the personnel file for the activity director (AD/staff #67) revealed she was hired on 03/13/08 and that she had no experience in a social, recreational, or therapeutic activities program. The personnel file also revealed the facility administrator signed a purchase order and paid for an Activities Director Certification Course on 09/17/12, which was an on-line 16-week course. There was no evidence of completion of the course in the personnel file. Review of the job description for the AD (updated 01/94) revealed the AD should have the aptitude for and some training in arts and crafts and must have some understanding of the social, psychological, and recreational needs of the aged. During an interview conducted on 10/04/18 at 10:35 AM with the AD, the AD stated that she never completed the training. | 2020-09-01 |
| 1230 | 1230 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 684 | D | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, facility documentation, and policy, the facility failed to ensure treatment for one resident (#41) was administered as ordered and failed to ensure two residents (#65 and #22) received treatment and care in accordance with their comprehensive person-centered care plan. Findings include: -Resident #41 was readmitted on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. An undated interdisciplinary care plan revealed preventive measures for skin condition included barrier cream. The current comprehensive care plan included the resident had self-care deficit and incontinence. The goal was to have no skin breakdown due to incontinence. Approaches included good incontinence care and application of barrier cream after each incontinent episode. A nursing note dated (MONTH) 26, (YEAR) revealed the resident was refusing to let staff change her and was screaming at staff. It also included the resident screamed, kicked, and told staff to stop the dressing of her wound. The note also included the physician was notified and an order for [REDACTED]. Another nursing note dated (MONTH) 26, (YEAR) revealed the resident had a wound to the left buttocks with 2 small pinpoint holes surrounded by a hard lump. Per the documentation, there was small to moderate amount of blood leaking out and there was a small amount of purulent discharge at the lower portion of the wound bed. RE: Keflex (antibiotic) A physician's orders [REDACTED]. The order was transcribed onto the MAR (medication administration record) and administered as ordered. A Skin assessment dated (MONTH) 29, (YEAR) revealed the resident had a firm purple area on the left buttocks with small pinpoint opening. A nursing note dated (MONTH) 2, (YEAR) included starting Keflex three times a day for 10 days on (MONTH) 4, (YEAR). Review of the MAR dated (MONTH) (YEAR) revealed Keflex 500 mg three times a day for 10 days was transcribed and that the order … | 2020-09-01 |
| 1231 | 1231 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 686 | D | 1 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, staff interviews, and policy and procedures, the facility failed to provide care and services to prevent pressure ulcer development and to heal existing pressure ulcers. Findings include: Resident #43 was admitted to the facility on (MONTH) 28, 2013, with [DIAGNOSES REDACTED]. Review of a care plan for at risk for pressure ulcers dated (MONTH) 17, (YEAR), revealed a goal that the resident would be free from pressure ulcers. Approaches included that the resident was incontinent of bowel and bladder and for staff to check and change the resident every 2 hours and as needed. Additional approaches were to provide good incontinence care and apply barrier cream after each episode, encourage resident to turn and reposition and full body assessments to be done weekly. The care plan also noted that the resident did not have any pressure ulcers at this time. A Braden Scale Assessment for Pressure Ulcer Risk dated (MONTH) 15, (YEAR), revealed a risk score of 15, which indicated that the resident was at mild risk for pressure ulcer development. The reference tool for the assessment included frequent turning and managing moisture. A quarterly Minimum Data assessment (MDS) dated (MONTH) 20, (YEAR), revealed the resident was totally dependent for bed mobility, transfers, and toilet use, and was always incontinent of bowel and bladder. The assessment also indicated the presence of moisture associated skin damage. Per the MDS, the resident was at risk for pressures, but did not have any. A care plan conference summary note dated (MONTH) 22, (YEAR), revealed the resident was incontinent of bowel and bladder, required a mechanical lift and rarely got up. Review of the shower notes for resident #43 dated (MONTH) 11, (YEAR) revealed an entry which included that the resident's peri area was red. According to the (MONTH) (YEAR) Treatment Record (TAR), barrier cream was to be applied to the buttocks four tim… | 2020-09-01 |
| 1232 | 1232 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 688 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that two residents (#29 and #225) with limited range of motion (ROM), received treatment and services to increase ROM and/or to prevent further decline. Findings include: -Resident #29 was readmitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of a fall care plan revealed the resident has a potential for injury related to falls. An approach included for a paddle call light for easy use, due to bilateral hand contractures. However, review of the resident's care plans revealed there was no care plan that was developed to included specific goals and interventions related to contractures. Review of the Restorative Nursing Program documentation dated (MONTH) 7, (YEAR), revealed the resident required PROM (passive range of motion) and splinting to ensure that gains made on OT (occupational therapy) are not lost and further contracture does not occur. Treatment included for PROM to all digits, hand rolls and for [MEDICATION NAME] and finger separators and rolls 3 x week. Per the documentation, this plan was ongoing and was not to be discontinued, without the approval of the therapist. A physician's orders [REDACTED]. Review of the Restorative Service Delivery Record for (MONTH) through (MONTH) (YEAR), revealed the following: PROM to all digits and hand rolls 5 x week; [MEDICATION NAME] 3 times a week and finger spacer and rolls to be applied after gentle PROM of the digits. Continued review of the Restorative Service Delivery Record revealed that although there were multiple occasions when the resident refused the [MEDICATION NAME] and finger spacers, the record also included that the treatment for [REDACTED]. There was also no clinical record documentation including the restorative nursing documentation, as to why the above treatments were not administered on multiple occasions during … | 2020-09-01 |
| 1233 | 1233 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 690 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, an observation, a staff interview, and review of a facility policy, the facility failed to ensure that one resident (#69) with an indwelling catheter had physician's orders [REDACTED]. Findings include: Resident #69 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's 48 hour (baseline) care plan dated (MONTH) 13, (YEAR), revealed that the resident was admitted with an indwelling urinary catheter. A daily skilled nursing note dated (MONTH) 16, (YEAR) noted that the resident continued to have the urinary catheter. A review of the resident's admission MDS assessment dated (MONTH) 20, (YEAR), revealed documentation that the resident did not have a urinary catheter. The resident scored a 9 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. The comprehensive care plans developed on (MONTH) 20, (YEAR) did not indicate that the resident had a urinary catheter. The daily skilled nurse's notes were reviewed for (MONTH) 28, (YEAR) and the resident continued to have the urinary catheter. Review of the physician's orders [REDACTED]. Physician's progress notes were reviewed and revealed no evidence of a [DIAGNOSES REDACTED]. The clinical record revealed no evidence that the resident had been assessed for clinical indications to continue the use of a urinary catheter. There was also no evidence that catheter care had been completed or when the catheter tubing should have been changed or if it had been changed. An observation on (MONTH) 4, (YEAR), at 11:11 AM, revealed that the resident continued to have a urinary catheter. An interview was conducted on (MONTH) 5, (YEAR) at 7:58 AM with the Director of Nursing (DON/staff #118). She stated that if a resident was admitted to the facility with a urinary catheter, the expectation would be that upon admission or shortly after, the resident would be assessed for a reason to continue the catheter. She … | 2020-09-01 |
| 1234 | 1234 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 693 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interviews, the facility failed to ensure that physician's orders were followed for treatments and water flushes for one resident (#18) with a gastric tube. Findings include: Resident #18 was admitted to the facility on (MONTH) 3, 2014, with [DIAGNOSES REDACTED]. A physician's progress note dated (MONTH) 2, (YEAR), revealed the resident had a gastric tube which was being used for medications only. The note further stated that care and maintenance would continue to be provided to the gastric tube. Review of the physician's orders from (MONTH) through (MONTH) (YEAR), revealed to flush the gastric tube four times a day with water to maintain patency, and to cleanse the gastric tube insertion site wound with hydrogen peroxide and apply a dry dressing daily. Review of the Treatment Administration Record (TAR) from (MONTH) 1, (YEAR) through (MONTH) 3, (YEAR), revealed 13 instances with no documentation that the gastric tube was flushed with water. In addition, there were approximately 42 days with no documentation that the gastric tube site treatment was done. An interview was conducted on (MONTH) 3, (YEAR) at 12:58 p.m., with a Licensed Practical Nurse (LPN/staff #34). She stated if the treatment documentation on the TAR was left blank, that meant the treatment had not been performed. An observation was conducted on (MONTH) 3, (YEAR) at 1:38 p.m., of a LPN (staff #34) performing a water flush of the resident's gastric tube. When staff #34 removed the plug from the end of the gastric tube, black discoloration was observed inside the tube. The discoloration was also visible on the outside of the tube and extended approximately 4 inches from the end of the tube toward the insertion site. An interview was conducted on (MONTH) 5, (YEAR) at 7:58 a.m., with the Director of Nursing (DON/staff #118). She stated that if a resident has a gastric tube, she would expect that it would be cleaned and maintai… | 2020-09-01 |
| 1235 | 1235 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 727 | E | 0 | 1 | 80M411 | Based on review of facility documentation, staff interviews and review of policies and procedures, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Findings include: Review of the nurse staffing records for (MONTH) (YEAR) revealed that on (MONTH) 1, 2, 3, and 4, there was no RN who provided services for at least eight hours each day. Review of the nurse staffing records for (MONTH) (YEAR) revealed that on (MONTH) 1, 2, 4, and 7, there was no RN who provided services for at least eight hours each day. Review of the nurse staffing records for (MONTH) (YEAR) revealed that on (MONTH) 2, 3, 4, 5, 6, and 7, there was no RN who provided services for at least eight hours each day. An interview was conducted on (MONTH) 4, (YEAR) at 11:33 a.m. with the Assistant Director of Nursing (staff #32). Staff #32 stated that the facility schedules an RN to provide services for 8 hours per day. During interviews conducted on (MONTH) 4, (YEAR) at 1:47 p.m. and 2:40 p.m. with the Director of Nursing (staff #118), staff #118 stated that she was aware of the requirement that there must be an RN on duty for at least eight hours per day. She reviewed the nurse staffing for the days identified in July, (MONTH) and (MONTH) that did not meet the minimum requirement for RN staffing, and stated that she was unable to provide any additional documentation that an RN had provided services for the required eight hours per day on those days. Review of a policy titled, Staffing included that licensed registered nursing and licensed nursing staff are available to provide and monitor delivery of care services. Review of a policy titled, RN Staffing included that it is the policy of this facility to comply with the Federal requirement for RN staffing. The minimum requirement is at least one RN for 8 hours, 7 days a week. | 2020-09-01 |
| 1236 | 1236 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 740 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure that the necessary behavioral health care and services were provided for two residents (#22 and #65). Findings include: -Resident #65 was readmitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 24, (YEAR) revealed Resident yelling every time someone walks past her room. Review of the recapitulation of physician's orders [REDACTED]. A physician's orders [REDACTED]. A nursing progress notes dated (MONTH) 14, (YEAR) included, Resident continues to yell at everyone walking past room. Nurse wrote an order for [REDACTED]. A nutrition care plan dated (MONTH) 23, (YEAR) included to not speak with the resident about her weight especially if she gained weight, because she has been bulimic in the past and if she thinks she has gained weight, she will start binging and throwing up. A nurses note dated (MONTH) 12, (YEAR) included the resident was yelling at a nurse in the hall while the nurse was speaking with a visitor. The resident started yelling at the top of her lungs the nurses name and to stop ignoring her. Review of a Minimum Data Set (MDS) quarterly assessment dated (MONTH) 15, (YEAR), revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS also included that resident had moderate depression and displayed verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others during 4 to 6 days out of 7 days of the look back period. Review of the nurses notes dated (MONTH) 27, (YEAR), revealed the resident was wanting to be changed every 30 minutes and was yelling out to staff in the hall. She began yelling at the top of her lungs that she was in pain and threw a cup on the floor, and yelled out to tell the nurse that she is not a liar. The resident started yelling again and said… | 2020-09-01 |
| 1237 | 1237 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 756 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation, and policy, the facility failed to ensure pharmacy recommendations were acted upon timely for four residents (#'s 28, 33, 31, and 65). Findings include: -Resident #28 was admitted to the facility on (MONTH) 27, 2014 with [DIAGNOSES REDACTED]. Review of the current recapitulation of physician orders [REDACTED]. Review of a pharmacy consultation report dated (MONTH) 3, (YEAR) revealed a repeated recommendation from (MONTH) 6, (YEAR) to please respond promptly to assure facility compliance with Federal regulations. The report included the resident had received [MEDICATION NAME] 2.5 mg at bedtime for [MEDICAL CONDITION]/mood disorder since at least (MONTH) 13, (YEAR). The recommendation was to please consider a trial discontinuation and monitor behaviors. Further review of the report did not reveal evidence of a physician's response as to whether the recommendation would be accepted or declined. The section for physician's signature and date was not completed. A pharmacy consultation report for the timeframe of (MONTH) 1 through 10, (YEAR) revealed the pharmacist reviewed the medication regimen for resident #28. Review of the pharmacy consultation report dated (MONTH) 2, (YEAR) revealed another recommendation to consider a trial discontinuation of the [MEDICATION NAME] and monitor behaviors. The report included the physician accepted the recommendation and signed the report on (MONTH) 28, (YEAR). An interview was conducted with the Director of Nursing (DON/staff #118) on (MONTH) 10, (YEAR) at 10:15 a.m. She stated she had been aware the physician had not been reviewing and signing the pharmacy consultations in a timely manner. The DON stated no further action had been taken by the administrative staff, herself, or by the pharmacist. -Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A review of the … | 2020-09-01 |
| 1238 | 1238 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 758 | E | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure two residents (#28 and #33) had a diagnosed condition and clinical rationale to support the use of psychoactive medications, failed to ensure one resident (#25) was being monitored for behaviors related to the use of a hypnotic medication, failed to ensure there was a stop date in place for one resident (#65) who was receiving an as needed antianxiety medication and that there was documentation of the clinical rationale for extending the time frame for its use and failed to ensure an antipsychotic medication dose was reduced for one resident (#31), as recommended by the pharmacist and agreed upon by the physician. Findings include: -Resident #28 was admitted to the facility on (MONTH) 27, 2014, with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. A care plan dated (MONTH) 1, (YEAR) identified negative behaviors such as; throws medications and food on floor and will physically abuse staff (i.e. hit, kick, scratch and bite). Goals included for reduced episodes of negative behaviors and that the resident will respond to calming interventions at earliest sign of aggressive tendencies. The approaches included to explain to resident that it is not acceptable to hit anyone, monitor for effectiveness and adverse effects from the medication and report to MD. A care plan for [MEDICAL CONDITION] medication included the resident has dementia with short and long term memory problems and has negative behaviors. Behaviors included the resident will repeatedly strike her call light on the bedside table or at caretakers and has broken numerous lights. The goals included the following: reduce episodes of negative behavior; staff will meet her needs for daily living; resident will accept redirection; behaviors will not impede her care; and the resident will have no injury related to the administration of medications. The approaches included that staff… | 2020-09-01 |
| 1239 | 1239 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 759 | D | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical records reviews, staff interviews and polices and procedures, the facility failed to ensure that the medication error rate was not greater than 5%. The medication error rate was 6.9%. Findings include: -Resident #31 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A physician's progress note dated (MONTH) 11, (YEAR) included that resident #31 had [MEDICAL CONDITION] with status [REDACTED]. The resident also suffered from depression and had made a suicide attempt. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A medication administration observation was conducted on (MONTH) 4, (YEAR) at 8:15 a.m., with a LPN (Licensed Practical Nurse/staff #51). At this time, staff #51 was observed to administer [MEDICATION NAME] 150 mg (half of a 300 mg tablet) to resident #31, instead of [MEDICATION NAME] 50 mg as ordered. During an interview with staff #51 conducted on (MONTH) 4, (YEAR) at 9:32 a.m., staff #51 reviewed the physician's orders [REDACTED]. -Resident #60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A medication administration observation was conducted on 10/03/18 at 8:17 a.m. with a LPN (staff #34). Staff #34 retrieved the [MEDICATION NAME] inhaler from the medication cart. The instructions on the package included to wait one minute between each puff and to have the resident rinse their mouth after administration. During the medication pass observation, the nurse administered one puff to the resident, then waited eight seconds and administered the second puff. Following the observation, staff #34 reviewed the instructions on the inhaler and stated that she did know she was supposed to wait one minute between puffs and was unaware that she had only waited eight seconds between puffs. An interview was conducted on 10/03/18 at 9:45 a.m. with the Director of Nursing (staff #118), who stated that you are supposed to wait one minute… | 2020-09-01 |
| 1240 | 1240 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 761 | D | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that multiple narcotic medications and controlled substances were stored in a secure manner. Findings include: During random observations conducted on (MONTH) 3, (YEAR) between 9:00 a.m. and 12:00 a.m., the door of the Director of Nursing's (DON/staff #118) office was observed to be open, the lights were turned off and the office was unoccupied. The office was located adjacent to the nurses station, resident rooms, and was easily accessible from the resident corridor. An interview was conducted on (MONTH) 3, (YEAR) at 12:00 p.m., with an LPN (Licensed Practical Nurse/staff #121). Staff #121 stated that when narcotic medications and other controlled substances are discontinued, the medications and the sign out sheet for the medications are provided to the DON for disposal. During an observation conducted on (MONTH) 3, (YEAR) at 12:15 p.m., the door to the DON's office was observed to be open, the lights were turned off, and the office was unoccupied. An interview was conducted on (MONTH) 3, (YEAR) at 1:16 p.m. with a LPN (staff #34), who stated that when a controlled substance is discontinued or the physician's orders [REDACTED]. An interview was conducted on (MONTH) 3, (YEAR) at 1:27 p.m. , with the staff #118. During the interview, staff #118 said that the nurses bring her the narcotic medications and other controlled substances that are to be destroyed, and she locks them in a drawer in her office where they are stored until they are destroyed. Staff #118 agreed that sometimes her office door is open and that at any given time, there could be narcotics and other controlled substances in her office, because she only destroys them when there are enough in the drawer. Staff #118 stated that she was not aware that the narcotic medications and other controlled substances stored in her office were not being stored as double-locked, and th… | 2020-09-01 |
| 1241 | 1241 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 838 | E | 0 | 1 | 80M411 | Based on review of the Facility Assessment, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Findings include: Review of the Facility's Assessment revealed that there were multiple areas which were not addressed as follows: Regarding diseases/condition, physical and cognitive disabilities: Under musculoskeletal, the section did not identify residents with contractures or limited range of movement. Regarding staffing needs, training and competencies: The staff training did not include for basic restorative services, however, the care identified included that restorative nurse and contracture prevention/care are provided at the facility. The assessment also did not document a plan for increased or decreased staffing, as the census and resident's needs change. The training section did not include an evaluation of what policies and procedures may be required in the provision of care and that these meet current professional standards of practice, but only documented that all nurses are supervised by an experienced registered nurse. Regarding facility resources: The assessment did not include any contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies, or address their process for overseeing these services and how those services will meet resident needs and regulatory, operational, maintenance, and staff training requirements. The assessment did not include how those contractors will ensure services are provided both during normal operational hours and during emergencies. The assessment also did not include health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations, such as how the facility will securely transfer health information to a hospital, h… | 2020-09-01 |
| 1242 | 1242 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 842 | F | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that medical records were complete and/or accurate for multiple residents, and failed to ensure that medical record information was safeguarded against loss for multiple residents. Findings include: During the survey, 27 resident's medical records were reviewed and the following concerns were identified from (MONTH) (YEAR) to (MONTH) (YEAR): -missing documentation of treatments being provided for multiple residents -contradicting documentation for advanced directives on multiple residents -consents for the use of [MEDICAL CONDITION] medications were incomplete for several residents -incomplete Minimum Data Set assessments on two residents -incomplete activity assessments on several residents (and backdating activity assessments per an interview with the Activity Director) -incomplete skin assessments for one resident -missing documentation of providing daily monitoring for wounds and behaviors for residents -missing documentation on the Medication Administration Record [REDACTED] During an interview with the Administrator (staff #119) conducted on (MONTH) 4, (YEAR) at 2:49 p.m., she stated that it is expected that the nurse's and CNA's (Certified Nursing Assistant) document in the clinical record, as care is completed. She stated when there is missing documentation, it indicates that the care was not given. Regarding the retention of medical records: During the survey, the ADL documentation completed by the CNA's was requested by the survey team for multiple residents. However, multiple staff members stated that the system went down and the documentation for all of the residents in the facility was lost for at least the past six months. Per facility staff, the CNA's use an electronic documentation system to document activities of daily living (ADL) on each resident for each shift, which includes bed mobility, transfers, walking in the r… | 2020-09-01 |
| 1243 | 1243 | DESERT HIGHLANDS CARE CENTER | 35169 | 1081 KATHLEEN AVE | KINGMAN | AZ | 86401 | 2018-10-11 | 867 | F | 0 | 1 | 80M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to identify quality deficiencies and develop and implement appropriate plans of action to correct the quality deficiencies. Findings include: Regarding the systemic issue of retention of medical record documentation: During the survey, Activity of Daily Living (ADL) care documentation was requested on multiple residents. However, multiple staff members stated that the system went down and that the Certified Nursing Assistants (CNA's) ADL care documentation for all of the residents in the facility was lost for at least the past six months. According to facility staff, the CNA's use an electronic documentation system to document ADL care on each resident for each shift, which includes bed mobility, transfers, walking in the room, walking in the corridor, locomotion on the unit, locomotion off the unit, dressing, eating, toilet use, personal hygiene and bathing. An interview was conducted on 10/10/18 at 1:38 p.m., with the Administrator (staff #119) and the Director of Nursing (staff #118). The Administrator stated that seven months of CNA data were lost from (MONTH) (YEAR) to (MONTH) (YEAR). She said that she called the facility's Information Technology department and they didn't see any backup information for the CNA documentation, so the information was lost for all residents in the facility. Concerns were also identifed that ADL documentation was missing from (MONTH) and (MONTH) (YEAR), and for some residents in (MONTH) (YEAR) as well. Regarding the accuracy and completion of medical record documentation: During the survey, concerns were identified regarding accurate and/or missing documentation in multiple residents medical records as noted below: -missing documentation that treatments were provided -contradicting documentation with advanced directives for code status -consents for the use of [MEDICAL CONDITION] medicati… | 2020-09-01 |
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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 );