cms_AZ
Data source: Big Local News · About: big-local-datasette
32 rows where "inspection_date" is on date 2019-01-10
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Suggested facets: facility_name, facility_id, address, city, zip, deficiency_tag, scope_severity, complaint, eventid, 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 499 | 499 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 552 | D | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews and policies and procedures, the facility failed to ensure that one resident (#135) had been informed in advance of the risks and benefits of an antipsychotic medication. Findings include: Resident #135 was admitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed a form titled Admission Record dated (MONTH) 7, (YEAR), which included the resident was self-responsible. A form titled, Consent to Admit and Treat dated (MONTH) 7, (YEAR) included a statement that the signer of the form was the responsible party for medical decision making. The form was signed by resident #135. A physician's orders [REDACTED]. A written care plan initiated on (MONTH) 10, (YEAR) for the use of [MEDICAL CONDITION] medications related to behavioral management included an intervention for staff to educate the resident/family/caregivers about the risks, benefits and side effects and toxic symptoms of the medication. Further review of the clinical record revealed no evidence that the resident was informed of the risks, benefits and side effects of Risperdone. An interview was conducted on (MONTH) 10, 2019 at 9:17 a.m., with the Director of Nursing (DON/staff #125). The DON stated that when an antipsychotic drug is prescribed, the use of the medication is explained to the resident, and they have a form which includes the risks and benefits of the medications. The DON stated that they are to obtain informed consent. The DON said that after the risks and benefits are explained, the resident signs the form. An interview was conducted on (MONTH) 10, 2019 at 9:35 a.m. with a RN (Registered Nurse/staff #165). During the interview, the nurse stated that there are consent forms for antipsychotic medications. Staff #165 said if the resident is unable to sign the consent form, consent is obtained from the resident's responsible party. Staff #165 stated they are required to obtain … | 2020-09-01 |
| 500 | 500 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 578 | E | 0 | 1 | V3CM11 | **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 two residents (#164 and #121) were afforded the right to formulate advance directives. Findings include: -Resident #164 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. Review of the resident's clinical record revealed no evidence of any advance directives for resident #164. There was also no documentation that the resident declined formulating advance directives. Further review of the clinical record revealed there was no code status listed on the resident's face sheet or in the available space specific for code status in the electronic record. According to the current physician's orders [REDACTED]. In an interview with a Licensed Practical Nurse (LPN/staff #153) on (MONTH) 10, 2019 at 9:30 a.m., she stated if she needed to find out a resident's code status, she would look in the electronic record, as there is a place where the code status is easily viewable. Further, she stated the resident's code status is listed on their report sheet. She stated the code status should be updated, as soon as the resident is admitted . An interview with medical record staff (staff #184) was conducted on (MONTH) 10, 2019 at 9:34 a.m. At this time, she reviewed resident #164's scanned documents and was unable to find any advance directives. She stated it could be in a stack of documents that are waiting to be scanned, however, no advanced directives were located. She also stated it could be in the physician's binder waiting to be signed by the physician, however, no advanced directives were found in the binder. In an interview with the Director of Nursing (DON/staff #125) on (MONTH) 10, 2019 at 1:31 p.m., she stated an audit had j… | 2020-09-01 |
| 501 | 501 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 584 | E | 0 | 1 | V3CM11 | Based on observations, and family, resident and staff interviews, the facility failed to maintain an environment that was free of odors. Findings include: During a family interview conducted on (MONTH) 7, 2019 at 11:07 a.m., the family member of a resident stated that the hallways on the second floor always smell like urine. An interview with a resident who resided on the second floor was conducted on (MONTH) 7, 2019 at 11:49 a.m. The resident stated that he keeps his door to the bathroom shut, because of the sewage odor. During an interview conducted on (MONTH) 7, 2019 at 1:28 p.m. with another resident who resided on the second floor, a strong pervasive urine odor was detected in this resident's room and in the bathroom. During the survey from (MONTH) 7 through 10, 2019, pervasive urine odors were frequently smelled in the hallways on the second floor. An environmental tour was conducted on (MONTH) 10, 2019 at 12:30 p.m., with the maintenance director (staff #180) and the administrator (as of (MONTH) 12/staff #222). At this time, there was still a slight sewage odor in the first resident's bathroom on the second floor. An interview was conducted with the maintenance director (staff #180) on (MONTH) 10, 2019 at 12:40 p.m. Staff #180 stated that he would call a plumber to address the odor in the bathroom. An interview was conducted with staff #222 on (MONTH) 10, 2019 at 12:45 p.m. Staff #222 stated that she thought she smelled urine yesterday, when the resident was being changed. The facility did not have policy regarding the prevention of odors throughout the facility. | 2020-09-01 |
| 502 | 502 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 600 | E | 1 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record reviews, staff and resident interviews, facility documents and policies and procedures, the facility failed to ensure that one resident (#225) with dementia and behaviors was free from neglect, failed to ensure that one resident (#61) was free from abuse by resident (#275), failed to ensure that one resident (#117) was free from abuse by resident (#61), and that one resident (#21) was free from abuse by resident (#62). Findings include: -Resident #225 was admitted on (MONTH) 22, (YEAR) and readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a written care plan initiated on (MONTH) 11, (YEAR), with a revision date of (MONTH) 16, (YEAR), which identified that the resident was an elopement risk/wanderer, related to escapist behavior and history of attempts to leave the facility unattended. A goal included the resident would not leave the facility unattended. Interventions included identifying a pattern of wandering and intervening as appropriate, monitoring the resident's location every 30 minutes and documenting wandering behavior. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 25, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 9, which indicated the resident had moderate cognitive impairment. The MDS also included the resident was delusional, had physical and verbal behavioral symptoms directed at others, refused care, wandered daily and had dementia and [MEDICAL CONDITION]. A nurse practitioner assessment dated (MONTH) 2, (YEAR), revealed the resident had dementia, wandering, [MEDICAL CONDITION], anxiety, adjustment disorder and depression. The assessment included the resident was residing on the behavioral unit for safety and received psychiatric services. The assessment also included the resident desperately tries to escape if given the chance. She speaks Spanish mostly, but understands a lot of English. Under assessment… | 2020-09-01 |
| 503 | 503 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 607 | E | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility documents and policy review, the facility failed to include in their Abuse policy that all alleged violations of abuse and neglect, must be reported to the State Survey Agency within two hours after the allegation is made, as manifested by an allegation of neglect for one resident (#225). Findings include: Resident #225 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 5, (YEAR) at 10:05 a.m. revealed the resident was discovered missing at 8:15 a.m. The note included the resident was not discovered in her room and that a code yellow had been initiated. Review of the facility's investigative report dated (MONTH) 5, (YEAR) revealed that on the morning of (MONTH) 5, (YEAR), it was determined that the resident had not reported for breakfast, so missing person procedures were immediately implemented. The report included the resident was able to leave the facility obtain transportation, cross the border into Mexico, and after entering Mexico obtained transportation to a family home, arriving unharmed. Continued review of the investigative report revealed that although the resident was discovered missing on (MONTH) 5, (YEAR) at 8:30 a.m., the facility did not notify the State Survey Agency until 3:30 p.m. on (MONTH) 5. An interview was conducted with the Administrator (staff #20) on (MONTH) 8, 2019 at 2:46 p.m. The Administrator stated that the facility had two hours to report all allegations of abuse, including neglect to the State Agency. The Administrator also stated that he was unable to explain why the elopement of resident #225 was reported late to the State Agency. Review of the facility's policy and procedure titled, Reporting Abuse to State Agencies and other Entities/Individuals revealed that all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities as may… | 2020-09-01 |
| 504 | 504 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 609 | D | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility documents and policies and procedures, the facility failed to ensure that an allegation of neglect for one resident (#225) was reported to the State Survey Agency within two hours after the allegation. Findings include: Resident #225 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. A nursing note dated (MONTH) 5, (YEAR) at 10:05 a.m. revealed the resident was discovered missing at 8:15 a.m. The note included the resident was not discovered in her room and that a code yellow had been initiated. Review of the facility's investigative report dated (MONTH) 5, (YEAR) revealed that on the morning of (MONTH) 5, (YEAR), it was determined that the resident had not reported for breakfast, so missing person procedures were immediately implemented. The report included the resident was able to leave the facility obtain transportation, cross the border into Mexico, and after entering Mexico obtained transportation to a family home, arriving unharmed. The report also included that the resident had been residing on a behavioral health (secured) unit, and that exit seeking and wandering behaviors were being monitored. Continued review of the facility investigative report revealed that although the resident was discovered missing on (MONTH) 5, (YEAR) at 8:30 a.m., the facility did not notify the State Survey Agency until 3:30 p.m. on (MONTH) 5. An interview was conducted with the Administrator (staff #20) on (MONTH) 8, 2019 at 2:46 p.m. The Administrator stated that the facility had two hours to report all allegations of abuse, including neglect to the State Agency. The Administrator also stated that he was unable to explain why the elopement of resident #225 was reported late to the State Agency. A facility's policy and procedure titled Recognizing Signs and Symptoms of Abuse/Neglect included a definition of neglect as the failure to provide goods and services as necessary to avoid physi… | 2020-09-01 |
| 505 | 505 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 623 | D | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and review of policies and procedures, the facility failed to notify the State Long Term Care Ombudsman when one resident (#50) was transferred/discharged to the hospital on two separate occasions, and when one resident (#175) was discharged to home. Findings include: -Resident #50 was readmitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A progress note dated (MONTH) 26, (YEAR) revealed the resident was sent to the emergency room , due to difficulty breathing. A progress note dated (MONTH) 29, (YEAR) revealed the resident was readmitted to the facility. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 31, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A progress note dated (MONTH) 23, (YEAR) revealed that the resident was admitted to Banner South Hospital Intensive Care Unit. Another progress note dated (MONTH) 26, (YEAR) revealed that the resident was readmitted to the facility. However, there was no documentation that the State Long Term Care Ombudsman was sent a copy of the notice of discharges for each hospitalization . An interview was conducted with a licensed practical nurse (LPN/staff #150) on (MONTH) 8, 2019 at 1:08 p.m., who stated that when she gets a patient ready to be transferred, she does not notify the Ombudsman and said the case manager (#190) completes the paperwork when a patient is being discharged . An interview was conducted on (MONTH) 8, 2019 at 1:19 p.m. with case manager (staff #190), who stated that she completes the paperwork when a resident is being discharged and staff #193 notifies the Ombudsman about the discharge. Staff #193 was interviewed on (MONTH) 8, 2019 at 2:42 p.m. He stated that the facility had a meeting last fall to talk about a better way to make sure the Ombudsman is notified. He said that he called the Ombudsman and asked if h… | 2020-09-01 |
| 506 | 506 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 641 | D | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate regarding antibiotic use and refusal of care for one resident (#62). Findings include: Resident #62 was admitted on (MONTH) 06, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. -Bactrim 400-80 milligrams (mg) by mouth once a day by mouth for [MEDICATION NAME] for chronic UTI dated (MONTH) 16, (YEAR) -[MEDICATION NAME] HFA aerosol solution 17 micrograms (mcg) one puff orally every 6 hours for [MEDICAL CONDITIONS] dated (MONTH) 24, (YEAR) -[MEDICATION NAME] 25 mg by mouth once a day for hypertension dated (MONTH) 25, (YEAR) -[MEDICATION NAME] 75 mcg by mouth once a day for [MEDICAL CONDITION] dated (MONTH) 25, (YEAR). A review of the MAR for (MONTH) (YEAR) revealed that the resident was administered Bactrim from (MONTH) 16-31. The MAR indicated [REDACTED]. However, review of the quarterly MDS assessment dated (MONTH) 1, (YEAR), revealed the resident did not receive an antibiotic and displayed no refusal of care during the 7 day look-back period. The MDS assessment also included a Brief Interview for Mental Status score of 15 which indicated the resident had no cognitive impairment and that the resident displayed verbal behaviors directed towards others. An interview was conducted with a MDS Coordinator (staff #182) on 01/09/19 at 11:31 AM. Staff #182 stated that information obtained from the nurses' notes and the medication records are used to code a MDS assessment. She also stated that information is obtained from speaking with the residents and the staff. She acknowledged that the quarterly MDS assessment dated (MONTH) 1, (YEAR) was an error in documentation regarding refusal of care. During an interview conducted with the Director of Nursing (DON/staff #125) on 01/09/19 at 11:44 AM., the DON stated that her expectation is that the … | 2020-09-01 |
| 507 | 507 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 645 | E | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#61) was referred to the appropriate state-designated authority for Level II PASARR (pre-admission screening and resident review) evaluation and determination. Findings include: Resident #61 was admitted to the facility on (MONTH) 20, 2014 with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Level I PASARR dated (MONTH) 4, (YEAR) which revealed the resident had a primary [DIAGNOSES REDACTED]. Further review of the clinical record revealed no evidence that the facility referred the resident to the appropriate state-designated authority for a Level II PASARR. An interview was conducted with a social worker (staff #203) on (MONTH) 9, 2019 at 9:00 a.m. Staff #203 stated that if a resident had a primary [DIAGNOSES REDACTED]. Staff #203 stated that she was unsure if a referral for a Level II PASARR was completed for this resident. An interview was conducted with another social worker (staff #204) on (MONTH) 9, 2019 at 10:26 a.m. Staff #204 stated that the facility did an audit about a month ago and the resident qualified for a referral for a Level II PASARR. Staff #204 stated that the referral was not completed yet. Review of the facility's policy Admission Criteria revealed .Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review program (PASARR) to the extent possible . | 2020-09-01 |
| 508 | 508 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 657 | E | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy and procedure, the facility failed to ensure a care plan was revised for one resident (#74). Findings include: Resident #74 was admitted to the facility on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed the resident was cognitively intact and required extensive/total assist with activities of daily living (ADLS). Review of the care plan for mobility dated (MONTH) 24, (YEAR) revealed the resident had limited physical mobility related to current co-morbidities including [MEDICAL CONDITION] (MS). Interventions included applying splints to both arms at night and removing in the morning. Further review of the care plan revealed it was not revised to reflect the splints had been discontinued. An interview was conducted with the Assistant Director of Nursing (ADON/staff #21) on (MONTH) 9, 2019 at 3:46 PM. Staff #21 stated the resident's splints had been discontinued. She stated that she did not know why the care plan had not been updated. The ADON stated all departments are responsible for updating the care plan, including nursing. She said the nursing management meets every morning to discuss residents' care plans, change of condition, etc. An interview was conducted with the Director of Nursing (DON/staff #125) on (MONTH) 10, 2019 at 9:29 AM. The DON stated anything in the care plan related to nursing is updated daily. She said they have an interdisciplinary team (IDT) meeting every morning. She stated they are good at adding to the care plan but need to get better at discontinuing things. The DON said the splints should have been resolved in the care plan. Review of the facility's policy titled Care Plans - Comprehensive revealed assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. | 2020-09-01 |
| 509 | 509 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 689 | D | 0 | 1 | V3CM11 | **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 a public restroom accessible to residents was free from accident hazards. Findings include: During an observation conducted on (MONTH) 7, 2019 at 10:30 a.m., two unlocked restrooms were observed near the front entrance of the facility. When the door to restroom [ROOM NUMBER] was opened and released, the door rapidly slammed shut causing a potential accident hazard to residents who may use the restroom. Multiple residents passed by this area to go to the front lobby and to go outside of the facility. An interview was conducted with a receptionist (staff #191) on (MONTH) 8, 2019 at 9:25 a.m. Staff #191 stated that they asked the residents not to use the public restrooms but that some of them go in there anyway. Staff #191 stated that the residents probably use the public restrooms at night when no one is at the receptionist desk. Staff #191 further stated the public bathroom doors used to be locked. Additional observations conducted on (MONTH) 8, 9, and 10, 2019 revealed the area near the public restrooms and front lobby continued to be a high traffic area with residents going to the front lobby or out of the facility. An interview was conducted with another receptionist (staff #194) on (MONTH) 10, 2019 at 11:00 a.m. Staff #194 stated that the residents were asked to not use the public restrooms. Staff #194 further stated the doors used to be locked. An interview was conducted with the managing partner of the facility (staff #220) on (MONTH) 10, 2019 at 12:35 p.m. Staff #220 stated that the facility will be repairing the door today so that it does not slam shut. Review of the facility's policy Safety and Supervision of Residents revealed Our facility strives to make the environment as free from accident hazards as possible. The policy included resident safety and supervision and assistance to prevent accidents are facility-wide pri… | 2020-09-01 |
| 510 | 510 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 695 | D | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure one resident (#50) was provided respiratory care consistent with the physician's order. Findings include: Resident #50 was readmitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of the current summary of physician's orders revealed an order for [REDACTED]. Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 31, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also included the resident was receiving oxygen therapy. The current care plan revealed the resident had altered respiratory status related to [MEDICAL CONDITION] with [MEDICAL CONDITION]. The interventions included administering medication/puffers as ordered and monitoring for effectiveness and side effects and monitoring/documenting/reporting abnormal breathing patterns to the physician. During an interview conducted with the resident on (MONTH) 7, 2019 at 3:23 p.m., the oxygen concentrator was observed to be set at 2.5 liters, however, the resident did not have on the nasal cannula, as it was lying on the resident's tray. Observation of the tubing revealed no date when the tubing had been changed. On (MONTH) 9, 2019 at 12:28 p.m., the resident was observed sleeping in his wheelchair with the oxygen tubing on and the concentrator was set at 2.5 liters. The tubing was not observed to have a date to reflect when the tubing had been last changed. An interview was conducted with a certified nursing assistant (CNA/staff #58) on (MONTH) 10, 2019 at 9:14 a.m., who stated that the CNA's on the overnight shift change the tubing on the oxygen concentrators every Sunday, and tape the date on the tubing to show when the tubing was changed. She stated that if there is no date on the tubing or if the date indicates that it is overdue, she changes the tubing… | 2020-09-01 |
| 511 | 511 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 698 | E | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure physician orders [REDACTED].#151) regarding [MEDICAL TREATMENT]. Findings include: Resident #151 was admitted to the facility on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) included the resident had short-term and long-term memory problems and had severe impairment with daily decision making. The MDS assessment also included the resident was receiving [MEDICAL TREATMENT]. A nursing note dated (MONTH) 23, (YEAR) revealed the resident had a right sided vascular catheter. Review of the clinical record revealed the resident went out to [MEDICAL TREATMENT] appointments on several occasions in (MONTH) and (MONTH) (YEAR) and (MONTH) 2019. A care plan dated (MONTH) 21, (YEAR) included the resident needs [MEDICAL TREATMENT] related to end stage [MEDICAL CONDITION]. Interventions included checking and changing the dressing daily at access site and document. However, review of the clinical record revealed no evidence that there was a physician's orders [REDACTED]. In an interview with a licensed practical nurse (LPN/staff #165) on (MONTH) 10, 2019 at 10:31 a.m., he stated that for a resident receiving [MEDICAL TREATMENT], there should be an order for [REDACTED]. The nurse reviewed resident #151's electronic record and was unable to locate an order for [REDACTED].>During an interview conducted with the LPN (staff #153) caring for this resident on (MONTH) 10, 2019 at 10:38 a.m., she stated the resident was currently at the [MEDICAL TREATMENT] center. She stated she knows when the resident is scheduled for [MEDICAL TREATMENT] based on an appointment log that is reviewed every day and her report sheet that has the [MEDICAL TREATMENT] days and time. The LPN also stated that when the resident returns from [MEDICAL TREATMENT] an assessment is done which includes checking the site. She stat… | 2020-09-01 |
| 512 | 512 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 725 | E | 0 | 1 | V3CM11 | Based on resident and staff interviews, facility documentation and policies and procedures, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Findings include: Multiple resident interviews were conducted on (MONTH) 7, (YEAR) regarding facility staffing. Ten random residents stated that there was not enough staff and that they have to wait too long for staff assistance and for their call lights to be answered. An interview was conducted with a CNA (certified nursing assistant). The CNA stated that the A-1 unit for high acuity behavioral residents was usually staffed with 3 CNA's to care for 20-24 residents. The CNA stated that one CNA is supposed to be in the hall at all times to monitor to prevent resident to resident altercations, but that does not always happen because of call ins. An interview was conducted with another CNA, who stated that someone is always supposed to be monitoring the hallway on the A-1 unit, but that does not always happen and it's kind of irritating. The CNA stated we do the best we can, but if there is a call in there is no one to monitor the hallway and the residents get in to altercations. An interview was conducted with another CNA who stated that it is challenging to care for the residents when there are call ins. An interview was conducted with a fourth CNA, who stated that sometimes it is hard to care for the residents when there are call ins. An interview was conducted with another CNA, who stated that care and showers do not get done when there is not enough staff. The CNA further explained that care gets done but not like it should and showers get missed. An interview was conducted with another CNA, who stated that the facility attempts to staff adequately, but some days they are short. An interview was conducted with a seventh CNA, who stated that they used to have four CNA's for this hallway and now t… | 2020-09-01 |
| 513 | 513 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 758 | D | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#135) who was prescribed an antipsychotic medication upon admission, had indications for its use. Findings include: Resident #135 was admitted on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged (MONTH) 26, (YEAR). Review of hospital records prior to the resident's admission, revealed a H&P (History and Physical) report dated (MONTH) 5, (YEAR) that the resident had a significant history of Alzheimer's dementia and [MEDICAL CONDITION] and was cooperative with normal mood and cognition. The hospital H&P included a list of medications that the resident was receiving in the hospital. The list did not include the [MEDICATION NAME] (antipsychotic) or any other antipsychotic medication. Continued review of the hospital records revealed a discharge summary dated (MONTH) 7, (YEAR) that included an order for [REDACTED]. Review of the closed clinical record revealed a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. A discharge MDS (Minimum Data Set) assessment dated (MONTH) 26, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 11 which indicated the resident had moderately impaired cognition. The assessment included the resident felt tired, depressed, had difficulty sleeping, and verbal behaviors directed at others. The assessment also included the resident received antipsychotic medications. However, the assessment did not include the resident had a psychiatric mood disorder. Further review of the closed record did not reveal any additional documented evidence that the [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 10, 2019 at 9:17 a.m. with the Director of Nursing (DON/staff #125). The Director stated that a [DIAGNOSES REDACTED]. The DON stated that when a resident is admitted from the hospital, the medications that are prescribed m… | 2020-09-01 |
| 514 | 514 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 842 | D | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and policies and procedures, the facility failed to ensure that electronic and paper health records for one resident (#225) were readily accessible to the State Survey Team. Findings include: Resident #225 was admitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. Resident #225 was discharged on (MONTH) 5, (YEAR). During random reviews of the facility electronic records conducted on (MONTH) 7, 2019 it was revealed the electronic health records for resident #225 were not accessible in the data base provided by the facility. An interview was conducted with the administrator (staff #20) on (MONTH) 7, 2019 at 10:15 a.m. The administrator stated that the facility did not have access to electronic records for resident #225, and that access to those records had been removed by the previous owner of the facility when the facility was purchased by the current owner in (MONTH) (YEAR). The Administrator stated that he would notify the previous owner that access to the records was needed, and that the facility staff were aware that they were supposed to have access to all electronic health records for resident #225. An interview was conducted with a corporate staff member (staff #220) on (MONTH) 7, 2019 at 1:45 p.m. Staff #220 stated that he was aware of the requirement that access to medical records was to be maintained for 7 years. Staff #220 also stated that staff were in communication with the previous owners of the facility to obtain access to the health records for resident #225. An interview was conducted on (MONTH) 8, 2019 at 8:30 a.m. with medical records (staff #184). Staff #184 stated that the paper records and electronic health records for resident #225 were not accessible, because the records had been removed by the previous owner of the facility. Staff #184 stated that the previous owner was scanning records to the facility. She stated that the process of uploading the documents would take hours a… | 2020-09-01 |
| 515 | 515 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 867 | E | 0 | 1 | V3CM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on concerns identified during the survey, staff interview and policy review, the quality assessment and assurance (QAA) committee failed to identify quality concerns and implement appropriate plans of action to correct the quality deficiencies. Findings include: During the facility's annual recertification survey, multiple concerns were identified in the following areas: -Pervasive odors throughout the facility. -Resident to resident abuse involving 5 residents. -One resident eloped from the facility. -Implement facility policy regarding reporting an allegation of neglect. -Report an allegation of neglect within two hours. -A physician's orders [REDACTED]. -Failed to maintain adequate staffing. -Failed to provide access to electronic records timely. An interview was conducted with the administrator (staff #20) on (MONTH) 10, 2019 at 2:26 p.m. Staff #20 stated that when staff identify a quality concern they bring their concerns to the QAA committee. Staff #20 stated that if a performance improvement plan is developed the QAA committee monitors the progress. The administrator further acknowledged there were no action plans regarding the quality concerns identified during the survey and that the QAA process had not identified the above issues. Review of the facility's policy regarding Quality Assurance and Performance Improvement (QAPI) Committee revealed .The primary goals of the QAPI Committee are to .Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately . | 2020-09-01 |
| 516 | 516 | SAPPHIRE OF TUCSON NURSING AND REHAB, LLC | 35099 | 2900 EAST MILBER STREET | TUCSON | AZ | 85714 | 2019-01-10 | 919 | D | 0 | 1 | V3CM11 | Based on observations and staff interviews, the facility failed to ensure that two public restrooms, which were unlocked, were equipped to allow residents to call for staff assistance. Findings include: During an observation conducted on (MONTH) 7, 2019 at 10:30 a.m., two unlocked restrooms were observed near the front entrance of the facility. Neither restroom was equipped with a communication system to alert staff should a resident require assistance while in the restroom. Once inside of each restroom a deadbolt lock was observed on the doors. The deadbolt lock was unable to be unlocked from the outside of the door in the event of an emergency. Signs were posted on both of the restroom doors which stated Lobby restrooms are for visitors and staff only. Residents, please utilize resident restrooms. Thank you for your cooperation. Kind regards, Sapphire Management. Multiple residents passed by this area to go to the front lobby or to go outside of the facility. An interview was conducted with a receptionist (staff #191) on (MONTH) 8, 2019 at 9:25 a.m. Staff #191 stated that they ask the residents not to use the public restrooms but that some of the residents go in there anyway. Staff #191 stated that the residents probably use the public restrooms at night when no one is at the receptionist desk. Staff #191 further stated that the public bathroom doors used to be locked. Observations conducted on (MONTH) 8, 9, and 10, 2019 revealed the area near the public restrooms and front lobby continued to be a high traffic area with residents going to the front lobby or out of the facility. An interview was conducted with another receptionist (staff #194) on (MONTH) 10, 2019 at 11:00 a.m. Staff #194 stated that the residents were asked to not use the public restrooms. Staff #194 stated that the facility put the signs on the doors of the public restrooms due to the fact that residents could go in there and fall and they would not know that they were in there because there is no call light. Staff #194 further stated the doors… | 2020-09-01 |
| 1921 | 1921 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 600 | D | 1 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff and resident interviews, facility documentation, and a review of policy and procedures, the facility failed to ensure one resident (#148) was free from physical abuse by one resident (#97). Findings include: Resident #148 was admitted on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Review of the clinical record revealed a physician's orders [REDACTED]. -Resident #97 was admitted to the facility on (MONTH) 6, (YEAR) with [DIAGNOSES REDACTED]. Review of the care plan initiated on (MONTH) 7, (YEAR) revealed the resident had behavior problems of physical and verbal aggression and swings his arms uncontrollably and may hit others related to [DIAGNOSES REDACTED]. Interventions included administering medications as ordered and to anticipate and meet needs. Review of the admission MDS assessment dated (MONTH) 13, (YEAR) revealed the resident scored an 11 on the BIMS indicating the resident had moderate cognitive impairment. The assessment also included the resident displayed behavioral symptoms and at times is verbally and physically aggressive towards staff and peers. Review of an incident note dated (MONTH) 13, (YEAR) revealed at 4:30 p.m. in the men's day room resident #148 was at the table playing a board game with a certified nursing assistant (CNA/staff #87) when resident #97 passed by and slapped the posterior side of resident's 148 upper arm with his left opened hand. Per the documentation, the CNA (#87) separated both residents and called the nurse for help. A physician's orders [REDACTED].#97 on 5 minute checks every shift due to initiating a physical non-injury aggression incident. Review of the facility's investigation dated (MONTH) 14, (YEAR) revealed that on (MONTH) 13, (YEAR) at 4:30 p.m. an inc… | 2020-09-01 |
| 1922 | 1922 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 602 | D | 1 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure one resident (#110) was free from misappropriation of the resident's property. Findings include: Resident #110 was admitted on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment dated (MONTH) 27, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident had intact cognition. The current comprehensive care plan revealed the resident was alert and oriented and independent with decision making. A review of the NP (nurse practitioner) note dated (MONTH) 26, (YEAR) revealed the resident was alert and oriented x 3. Review of the facility's investigative report revealed that on (MONTH) 29, (YEAR) at around 2:00 p.m., an allegation of misappropriation of resident property was reported. Per the report, resident #110 was missing $300.00 from his checkbook. The report included the resident took the money out of his safe the night before and placed it in his checkbook and that his family was going to take him to lunch on (MONTH) 29, (YEAR). The report revealed the resident stated the $300.00 was given to him by his family the previous weekend. The report also included the family confirmed the resident was given $200.00 (which was a different amount from what the resident reported). During an interview conducted with the resident on (MONTH) 31, (YEAR) at 2:54 p.m., the resident stated that the $300.00 he had in his bedside stand drawer was stolen. He stated that he thinks a night CNA (certified nurse assistant) took the money and that he reported it to staff. Another interview was conducted with the resident on (MONTH) 3, 2019 at 11:12 a.m. The resident stated that he reported to the nurse that he lost his $300.00 which was in his wallet in the drawer by the side of his bed. He stated that he believed the morning CNA took the money after he… | 2020-09-01 |
| 1923 | 1923 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 607 | D | 0 | 1 | NRY211 | **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 implement their abuse policy for an allegation of misappropriation of property for one resident (#110), an allegation of abuse regarding two residents (#97 and #148), and an allegation of abuse for one resident (#52). Findings include: -Resident #110 was admitted on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment dated (MONTH) 27, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident had intact cognition. Review of the facility's investigative report dated (MONTH) 30, (YEAR), revealed that on (MONTH) 29, (YEAR) at around 2:00 p.m., an allegation of misappropriation of resident property was reported. Per the report, resident #110 was missing $300.00 from his checkbook. The report revealed the resident stated the $300.00 was given to him by his family the previous weekend. The report further revealed the family confirmed the resident was given $200.00 (which was a different amount from what the resident reported). The report also included the Director of Social Services (staff #235) was unable to locate the missing money. The report also included a Concern/Grievance Report that revealed the following: -Resident filed the concern/grievance regarding missing $300.00 on (MONTH) 29, (YEAR) at 2:00 p.m. -Investigation was conducted and completed by the Director of Social Services (staff #235) on (MONTH) 30, (YEAR) -The resident, staff, nurse, Unit Manager, and housekeeping were interviewed. However, the names of staff interviewed and details or results of the interviews were not documented except for a witness statement from a clinical manager. During an interview conducted with the Director of Social Services (staff #235) on (MONTH) 4, 2019 at 8:37 a.m., he stated that for allegations of missing or stolen items including money, he wil… | 2020-09-01 |
| 1924 | 1924 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 609 | D | 1 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure an allegation of abuse for one resident (#52) and an allegation of misappropriation of property for one resident (#110) were reported to the State Agency (SA) and Adult Protective Services (APS) within the required timeframe. Findings include: -Resident #110 was admitted on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. Review of the facility's investigative report revealed that on (MONTH) 29, (YEAR) at around 2:00 p.m., an allegation of misappropriation of resident property was reported. Per the report, resident #110 was missing $300.00 from his checkbook. The report also included the family confirmed the resident was given $200.00 (which was a different amount from what the resident reported). The report also included a Concern/Grievance Report that included the resident filed the concern/grievance regarding missing $300.00 on (MONTH) 29, (YEAR) at 2:00 p.m. However, further review of the facility's investigative report revealed documentation that the allegation of missing money was reported to the State Agency on (MONTH) 30, (YEAR) at 10:15 a.m. and to APS on (MONTH) 3, (YEAR) at 2:00 p.m. In an interview with a licensed practical nurse (LPN/staff #15) conducted on (MONTH) 2, 2019 at 1:26 p.m., she stated that if she received a report or allegation of missing or stolen money, she would report this immediately to the social worker who will be responsible for the investigation. An interview was conducted with another LPN (staff #3) on (MONTH) 2, 2019 at 1:29 p.m. Staff #3 stated that if she received reports or allegations of missing or stolen money, she together with another staff would attempt to locate the money and if it was not found, she would report the incident that same day to social services. She said social services will conduct an investigation and will be responsible for reporting the incident. During an in… | 2020-09-01 |
| 1925 | 1925 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 610 | D | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews, facility documentation, and policy, the facility failed to have evidence that an allegation of abuse regarding two residents (#97 and #148) and an allegation of abuse regarding one resident (#52) and an allegation of misappropriation of property for one resident (#110) was thoroughly investigated and failed to ensure the results of the investigation regarding an allegation of abuse involving two residents (#52 and #148) was reported to the State Agency within 5 working days. Findings include: -Resident #110 was admitted on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. Review of the facility's investigative report dated (MONTH) 30, (YEAR), revealed that on (MONTH) 29, (YEAR) at around 2:00 p.m., an allegation of misappropriation of resident property was reported. Per the report, resident #110 was missing $300.00 from his checkbook. The report revealed the resident stated the $300.00 was given to him by his family the previous weekend. The report further revealed the family confirmed the resident was given $200.00 (which was a different amount from what the resident reported). The report also included the Director of Social Services (staff #235) was unable to locate the missing money. The report also included a Concern/Grievance Report that revealed the following: -Resident filed the concern/grievance regarding missing $300.00 on (MONTH) 29, (YEAR) at 2:00 p.m. -Investigation was conducted and completed by the Director of Social Services (staff #235) on (MONTH) 30, (YEAR) -The resident, staff, nurse, Unit Manager, and housekeeping were interviewed. However, the names of staff interviewed and details or results of the interviews were not documented except for a witness statement from a clinical manager. The investigative report did not include if staff from all shift who may have had contact with the resident were interviewed. The report also did not included if other residents wer… | 2020-09-01 |
| 1926 | 1926 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 644 | E | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to incorporate PASRR (preadmission screening and resident review) level II recommendations into one resident (#139) assessment and care planning. Findings include: Resident #139 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the state PASRR level II screening psychiatric evaluation dated (MONTH) 16, (YEAR) revealed the resident had a qualifying serious mental illness [DIAGNOSES REDACTED]. The evaluation included the resident would benefit from psychiatric medication management and psychotherapy. However, review of the annual Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR) revealed the resident was not considered by the state level II PASRR process to have serious mental illness. The MDS assessment also included the resident did not receive psychological therapy. Review of the care plan initiated on (MONTH) 15, (YEAR) revealed focus issues regarding [MEDICAL CONDITION] that included behaviors, self-isolation, and poor impulse control with interventions that included psychiatric provider as needed and psychiatric/psychogeriatric consult as needed but did not include psychotherapy was provided. Further review of the clinical record revealed no physician's order for psychotherapy and no documentation that the resident was provided psychotherapy. An interview was conducted on (MONTH) 10, 2019 at 10:32 AM with a Registered Nurse (RN/staff #122). He stated that he assumed social services or the physician made the referrals for special services and that he was not sure if anyone was referred out for services. The RN stated that he thought there was a psychologist that worked at the facility, but that he worked with residents on a different unit and not with resident #139. He stated We meet our residents' needs here. During an interview conducted on (MONTH) 10, 2019 at 10:43 AM with the Director of Nursing (DON/staff #184), she stated that… | 2020-09-01 |
| 1927 | 1927 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 655 | D | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure a summary of the baseline care plan for one resident (#83) was provided to the resident and their representative. Findings include: Resident #83 was admitted on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. The admission nursing data assessment dated (MONTH) 26, (YEAR) revealed that the resident was alert, able to make needs known, and participated in the assessment. The admission summary note dated (MONTH) 26, (YEAR) revealed the resident was alert and oriented x 3 and able to make needs known and signed all her consent and document. The baseline care plan dated (MONTH) 26, (YEAR) revealed that the resident was alert and cognitively intact, able to verbally communicate, and vision and hearing were adequate. The baseline care plan also included the resident was independent with bed mobility, transfer, walking and toileting. However, further review of the baseline care plan revealed the section that the care plan was reviewed with the resident/representative and the date was blank. The admission social services evaluation dated (MONTH) 29, (YEAR) included the resident was her own responsible party. The admission MDS (Minimum Data Set) assessment dated (MONTH) 2, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 12 which indicated the resident had moderately impaired cognition. A physician progress notes [REDACTED]. Further review of the clinical record revealed no evidence the baseline care plan was reviewed with the resident and/or the resident's responsible party. An interview was conducted with a registered nurse (RN/staff #17) on (MONTH) 8, 2019 at 10:00 a.m. The RN stated that the resident is alert and oriented and requires supervision but is independent with ADLs (activities of daily living). She stated the baseline care plan is initiated by the admitting nurse and is completed within 24-48 hours of admission. The RN stated that sometime… | 2020-09-01 |
| 1928 | 1928 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 656 | D | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policies, the facility failed to ensure that a comprehensive person-centered care plan was developed for one resident (#148) regarding the use of a supra-pubic catheter and an ostomy. Findings include: Resident #148 was admitted on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. Review of the Admission Nursing Data Collection dated (MONTH) 11, (YEAR) revealed that the resident had an indwelling catheter. Review of the nursing skin/wound note dated (MONTH) 12, (YEAR) revealed that the resident had a [MEDICAL CONDITION] to the left lower quadrant and a supra pubic catheter. The baseline care plan dated (MONTH) 12, (YEAR) revealed the resident had a [MEDICAL CONDITION] and a suprapubic catheter that required care each shift. The annual Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The assessment included the resident had an indwelling catheter, a [MEDICAL CONDITION] bladder diagnosis, and an ostomy. The urinary incontinence and indwelling catheter Care Area Assessment (CAA) for the assessment included it would be addressed in the care plan with the overall objective of avoiding complications, maintaining current level of functioning, and minimizing risks. However, review of the comprehensive care plan did not reveal any care plan, goals, or approaches that addressed the care required for the supra pubic catheter or the ostomy. Review of the Treatment Administration Records (TAR) for (MONTH) and (MONTH) (YEAR) and (MONTH) 2019 revealed that the resident was receiving [MEDICAL CONDITION] care and routine supra pubic catheter care each shift. An interview was conducted with a Licensed Practical Nurse (LPN/staff #255) on (MONTH) 10, 2019 at 2:17 p.m. He stated that when a resident is admitted the nurse would include a… | 2020-09-01 |
| 1929 | 1929 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 658 | E | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure one resident (#148) received pain medications per the physician's orders [REDACTED]. Findings include: Resident #148 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 7-10. The admission Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR) revealed a score of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The assessment also included the resident was on a pain medication regimen. Review of the current care plan regarding pain medication revealed a goal that the resident would be free of any discomfort or adverse side effects from pain medication. Interventions included administering [MEDICATION NAME] medications as ordered by the physician. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. An interview was conducted on (MONTH) 10, 2019 at 1:15 p.m. with a registered nurse (RN/staff # 122). He stated pain medications with parameters have to be administered according to physician orders. He stated if the pain level is outside of the ordered pain medication parameters then the nurse would need to call the physician. An interview was conducted on (MONTH) 10, 2019 at 3:54 p.m. with the Director of Nursing (DON/staff #184). She stated the nursing staff are expected to follow the ordered pain medication parameters. She stated it is appropriate for the nurse to administer a low dose of medication if the resident is requesting the lower dose for their pain level. She stated if the resident insist on receiving a pain medication that is for a higher pain level than their current pain level, the nurse is to notify the physician and document on the clinical record. Review of the facility's policy titled Administering Medications revealed medi… | 2020-09-01 |
| 1930 | 1930 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 744 | E | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure one resident (#83) diagnosed with [REDACTED]. Findings include: Resident #83 was admitted on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. The Level II PASRR (Pre-Admission Screening and Resident Review) Evaluation dated (MONTH) 6, (YEAR) revealed a principal [DIAGNOSES REDACTED]. It also included the resident was alert, oriented to self and can handle simple daily activities. The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) Axis I [DIAGNOSES REDACTED]. The behavioral hospital discharge/aftercare instructions dated (MONTH) 25, (YEAR) included the principal [DIAGNOSES REDACTED]. The instructions included dementia with behaviors was addressed during treatment and that things that scared the resident was a trigger for the unwanted behaviors (specific behaviors not listed). The following interventions were effective in reducing the behaviors: music, reading, pacing/walking and talking with peers. Per the documentation, the resident's behaviors had improved at discharge. The behavioral hospital discharge medication list dated (MONTH) 26, (YEAR) included [MEDICATION NAME] (antipsychotic) 0.25 mg (milligrams) by mouth at bedtime for [MEDICAL CONDITION]. A physician's orders [REDACTED]. The consent for Treatment with [MEDICAL CONDITION] Medication dated (MONTH) 26, (YEAR) revealed administration of the antipsychotic medication [MEDICATION NAME] was recommended for the [DIAGNOSES REDACTED]. The care plan dated (MONTH) 26, (YEAR) regarding the use of the [MEDICAL CONDITION] medication [MEDICATION NAME] (brand name for [MEDICATION NAME]) related to [MEDICAL CONDITION] as evidenced by yelling included a goal that the resident will be/remain free of [MEDICAL CONDITION] drug related complications. Interventions included administering the [MEDICAL CONDITION] medication as ordered by the physician, consulting with pharmacy for the phys… | 2020-09-01 |
| 1931 | 1931 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 756 | E | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure one resident's (#83) clinical record contained determination documentation by the physician regarding a gradual dose reduction and/or the rationale for the continued use of an anti-psychotic medication. Findings include: Resident #83 was admitted on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated (MONTH) 27, (YEAR) revealed a note was written to the physician that CMS (Centers for Medicare & Medicaid Services) guidelines states a facility must re-evaluate the use of the antipsychotic medication at the time of admission and/or within 2 weeks of admission and consider whether or not the medication is appropriate and if the medication can be tapered or discontinued. The review included the pharmacist instructed the physician to please re-evaluate the need of [MEDICATION NAME] for possible taper of dose or discontinuation and document rationale in the clinical record. The review also included a handwritten note Dose reduction evaluation was completed on (MONTH) 16, (YEAR). 0 dose reduction. However, this note was not signed by the staff or the physician. Review of the Psychoactive Gradual Dose Reduction review dated (MONTH) 13, (YEAR) to the physician included the resident was receiving [MEDICATION NAME] 0.25 mg by mouth at bedtime. The review also included the facility assessment of the medication benefit included [MEDICAL CONDITION], depression, and social isolation. The form was signed by the physician on (MONTH) 16, (YEAR). However, the section for the physician's determination regarding dose reduction or the clinical rationale for the continued use of the antipsychotic was blank. The Consultant Pharmacist's Medication Regimen Reviews dated (MONTH) 3, (YEAR) and (MONTH) 4, (YEAR) revealed no recommendations regarding the … | 2020-09-01 |
| 1932 | 1932 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 757 | E | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#148) was free of unnecessary drugs, by failed to ensure pain medications were administered as ordered by the physician. Findings include: Resident #148 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 7-10. The admission Minimum Data Set (MDS) assessment dated (MONTH) 18, (YEAR) revealed a score of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The assessment also included the resident was on a pain medication regimen. Review of the current care plan regarding pain medication revealed a goal that the resident would be free of any discomfort or adverse side effects from pain medication. Interventions included administering [MEDICATION NAME] medications as ordered by the physician. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. An interview was conducted on (MONTH) 10, 2019 at 1:15 p.m. with a registered nurse (RN/staff # 122). He stated pain medications with parameters have to be followed according to physician orders. He stated if the pain level is outside of the ordered pain medication parameters then the nurse would need to call the physician. An interview was conducted on (MONTH) 10, 2019 at 3:54 p.m. with the Director of Nursing (DON/staff #184). She stated nursing staff are expected to follow the ordered pain medication parameters. She stated it is appropriate for the nurse to administer a low dose of medication if the resident is requesting the lower dose for their pain level. She stated if the resident insist on receiving a pain medication that is for a higher pain level than their current pain level, the nurse is to notify the p… | 2020-09-01 |
| 1933 | 1933 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 758 | E | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure one resident (#83) was free from an unnecessary [MEDICAL CONDITION] medication and failed to ensure as needed (prn) antipsychotic medications orders were limited to 14 days and/or included the duration for the prn order for one resident (#39). Findings include: -Resident #83 was admitted on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the consent for Treatment with [MEDICAL CONDITION] Medication dated (MONTH) 26, (YEAR) revealed administration of the antipsychotic medication [MEDICATION NAME] was recommended for the [DIAGNOSES REDACTED]. The care plan dated (MONTH) 26, (YEAR) regarding the use of the [MEDICAL CONDITION] medication [MEDICATION NAME] related to [MEDICAL CONDITION] as evidenced by yelling included a goal that the resident will be/remain free of [MEDICAL CONDITION] drug related complications. Interventions included administering the [MEDICAL CONDITION] medication as ordered by the physician, consulting with pharmacy for the physician to consider a dose reduction, discussing with the physician the ongoing need for use of the medication, monitoring for side effects and effectiveness every shift; and reviewing behaviors and interventions and alternate therapies attempted and their effectiveness. The care plan also included the following Black Box warning Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. The physician's orders [REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated (MONTH) 27, (YEAR) revealed a note was written to the physician that CMS (Centers for Medicare & Medicaid Services) guidelines states a facility must re-evaluate the use of the antipsychotic medication at the time of admissi… | 2020-09-01 |
| 1934 | 1934 | IMMANUEL CAMPUS OF CARE | 35250 | 11301 NORTH 99TH AVENUE | PEORIA | AZ | 85345 | 2019-01-10 | 761 | E | 0 | 1 | NRY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to ensure expired items in the medication rooms and the medication carts were not available for use. Findings include: During a medication room observation conducted on (MONTH) 2, 2019 at 11:30 a.m. with a licensed practical nurse (LPN/staff #255) on the Garden Cove unit, one individually packed [MEDICATION NAME] non-adhesive wound dressing in a cabinet was observed with an expiration date of (MONTH) (YEAR). An interview was conducted with staff #255 immediately following the observation. He stated that the wound dressing was prescribed for a resident that has been discharged . The LPN stated the night nurses check the medication rooms daily and the central supply staff checks the rooms every Sunday for expired medications or items. He further stated that expired items or medications are discarded and not used. A medication room observation was conducted on (MONTH) 2, 2019 at 12:38 p.m. with a LPN (staff #96) on the[NAME]Heights unit. One light blue top blood collection tube was observed with an expiration date of (MONTH) 31, (YEAR) mixed with other unexpired blood collection tubes in a cabinet. During an interview conducted with staff #96 immediately following the observation, she stated that the night shift nurses are responsible for checking the medication rooms for expired items including the blood collection tubes. An observation was conducted of a medication cart on the Sunrise View unit with a LPN (staff #88) on (MONTH) 2, 2019 at 12:46 p.m. Two individually packets of Prosource protein powder (supplement) were observed with an expiration date of (MONTH) 19, (YEAR). Staff #88 stated that the packets were expired and that she does not administer the packets. She removed the packets from her cart and stated that she did not know who placed the packets in her cart. The LPN stated that she checks for expired items every time she re-stocks the cart and prior to … | 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 );