cms_AZ
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7,860 rows
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Suggested facets: scope_severity, standard, 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2018-08-24 | 623 | D | 0 | 1 | D0BP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure that the State Long Term Care Ombudsman was sent a copy of the transfer/discharge of one resident (#3). Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a nurse's notes dated 5/7/2018, revealed the resident was discharged to an acute hospital for increased shortness of breath, fatigue, weakness, wheezing, and moist cough. Review of a nurse's note dated 5/9/18, revealed the resident was re-admitted on [DATE]. A nurse's note dated 6/7/2018, revealed the resident was sent out via ambulance to a hospital for worsening respiratory condition. A nurse's note dated 6/11/2018, revealed the resident was readmitted to the facility 6/11/2018. Further review of the clinical record revealed no documentation that a copy of the transfer notices was sent to the Office of the State Long Term Care Ombudsman. During an interview conducted with the Administrator (staff #59) on 08/23/18 at 10:31 AM, the administrator stated that he is aware of the requirement to notify the Ombudsman of transfers/discharges but that they have not initiated a process to notify the ombudsman. | 2020-09-01 |
| 2 | 2 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2018-08-24 | 658 | D | 0 | 1 | D0BP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, staff and resident interviews, and policy, the facility failed to ensure the administration of an intravenous (IV) medication for one resident (#1) was administered according to professional standards and failed to ensure one resident's (#7) medication order was verified for route. Findings include: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During a medication administration observation conducted on (MONTH) 21, (YEAR) at 9:10 AM , the Licensed Practical Nurse (LPN/staff #41) was observed administering [MEDICATION NAME] via the PICC. However, the LPN was not observed to check the PICC line for a blood return before administering the antibiotic. An interview was conducted with staff #41 on (MONTH) 21, (YEAR) at 9:16 AM. Staff #41 stated that she usually checks the PICC line for a blood return before administering the antibiotic but that she did not check for a blood return this time. During an interview conducted with the Director of Nursing (DON/staff #49) on (MONTH) 23, (YEAR) at 10:37 AM, the DON stated that it is her expectation that nurses properly check the PICC line for placement before flushing and administering medications. The facility's policy Flushing Midline and Central Line IV Catheters did not include checking the line for a blood return. -Resident #7 was admitted on (MONTH) 24, (YEAR) with a re-admission on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a physician's orders [REDACTED]. On (MONTH) 10, (YEAR), the order was changed to [MEDICATION NAME] by mouth. A review of the resident's MDS (Minimum Data Set) assessments from (MONTH) 10, (YEAR) to (MONTH) 8, (YEAR), revealed the resident had a tube feed. A review of the resident's MARs (Medication Administration Records) from (MONTH) (YEAR) through (MONTH) 20, (YEAR), revealed the resident's [MEDICATION NAME] was admi… | 2020-09-01 |
| 3 | 3 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2018-08-24 | 693 | D | 0 | 1 | D0BP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#7) with a Percutaneous Endoscopic Gastrostomy (PEG) tube received appropriate services when administering medications. Findings include: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The current care plan regarding tube feeding revealed an intervention to check for tube placement and gastric contents/residual volume per facility protocol. During a medication administration observation conducted on (MONTH) 21, (YEAR) at 07:56 AM, a Registered Nurse (RN/staff #6) was observed administering [MEDICATION NAME] and [MEDICATION NAME] via the resident's PEG tube. However, the RN was not observed to check the PEG tube for placement prior to administering the medications. An interview was conducted with staff #6 on (MONTH) 21, (YEAR) at 9:19 a.m. Staff #6 stated that the PEG tube placement should be checked by using a stethoscope to listen for air in the stomach before administering medications. She also stated that she did not check the PEG tube placement before administering [MEDICATION NAME] and [MEDICATION NAME]. During an interview conducted with the Director of Nursing (staff #49) on (MONTH) 23, (YEAR) at 10:37 AM, she stated that the expectation is that the nurse would check the PEG tube placement before administering medications. Review of the facility's policy regarding the administration of medications via PEG tube revealed that gastrostomy tubes should be auscultated by administering approximately 10 cc (cubic centimeters) of air into the tube and listening for a whooshing sound to check placement of the tube in the stomach before administering medications. | 2020-09-01 |
| 4 | 4 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2018-08-24 | 757 | D | 0 | 1 | D0BP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy, the facility failed to ensure one resident's (#295) physician's order for an antibiotic had an appropriate [DIAGNOSES REDACTED].#295). Findings include: Resident #295 was admitted (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders revealed an order dated (MONTH) 4, (YEAR), for [MEDICATION NAME] solution (antibiotic) 0.3% one drop in both eyes two times a day for a [DIAGNOSES REDACTED]. Review of the current care plan revealed a vision problem related to [MEDICAL CONDITION] with an approach to administer [MEDICATION NAME] per orders. Review of the Medication Administration Record [REDACTED]. Review of an order listing report dated (MONTH) 20, (YEAR), revealed the [MEDICATION NAME] order for resident #295 was circled and a written note ? Diagnosis (Dx) was added. During an interview conducted with the Assistant Director of Nursing/infection preventionist (ADON/staff #15) on (MONTH) 21, (YEAR) at 12:29 p.m., she stated that every morning she prints a report containing antibiotic orders for the previous 24 hours. She stated that a stop date is required on all antibiotics except those that are being administered [MEDICATION NAME]. She also stated that she would make sure that the antibiotic had the correct diagnosis. An interview was conducted with the Director of Nursing (DON/staff #49) on (MONTH) 23, (YEAR) at 8:24 a.m. The DON stated that she would expect the nursing staff to follow the facility's policy and protocol regarding antibiotic use. She stated that she would have expected the infection preventionist to have identified the resident had an antibiotic order dated (MONTH) 4, (YEAR) before (MONTH) 20, (YEAR). The DON also stated that the order should have been clarified. Another interview was conducted with the ADON/infection preventionist on (MONTH) 23, (YEAR) at 9:01 a.m. She stated that she should have checked for the [DIAGNOSES REDACTED]. She fur… | 2020-09-01 |
| 5 | 5 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2018-08-24 | 814 | E | 0 | 1 | D0BP11 | Based on observations, staff interviews, and policy and procedure, the facility failed to ensure that refuse/garbage was disposed of properly. Findings include: An observation of the facility's main kitchen conducted at 8:10 a.m. on 8/20/18 revealed that when first entering the kitchen, a refuse/garbage-like odor was noted. The outside facility's refuse/garbage receptacles were observed next to the main kitchen that included a large refuse/garbage compacter and a dumpster. The odor was stronger near the compacter. There was liquid and some sort of sludge substance build up on the ground around the compacter. Also on the ground around the compacter was debris including a yogurt container and other packaging. There were two bags of refuse/garbage on the ground; one was leaking an unknown substance. The dumpster that was next to the compacter had bags of refuse/garbage in it and the lids were open. An observation of the skilled nursing portion of the facility conducted at 8:30 a.m. on 8/20/18 revealed a dumpster with an open lid. During an interview conducted with the clinical nutrition manager (staff #113) at 8:35 a.m. on 8/21/18, she stated that the food used at the skilled nursing center is prepared at the main kitchen and then sent over to the center. She stated the compacter is used for all refuse/garbage at the main kitchen and that the skilled nursing center is the only one that uses the smaller dumpster. An observation of the facility's main kitchen conducted at 10:40 a.m. on 8/21/18, revealed the dumpster next to the compacter had refuse/garbage in it and the lids were open. The dumpster was so close to the compacter, that the lids could not be closed without moving the entire dumpster. The area around the compacter had been cleaned, but some build up remained. The odor was somewhat diminished, but was still present in both the areas of the compacter and the kitchen. An observation of the skilled nursing facility's dumpster conducted at 11:00 a.m. on 8/21/18, revealed the dumpster was full of refuse/garbage… | 2020-09-01 |
| 6 | 6 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2019-10-17 | 578 | D | 0 | 1 | EJUZ11 | **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 1 of 15 sampled residents (#35) code status was consistent in the clinical record. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #35 was admitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Review of a nursing health status note dated (MONTH) 28, 2019 revealed the power of attorney (POA) for the resident would be signing the admission paperwork the next day. The note included the resident was willing to sign the paperwork but was unable to. A physician's orders [REDACTED]. Review of the care plan regarding advance directive initiated (MONTH) 28, 2019 revealed the resident and the resident family stated preference is that in the event cardiac function stops initiate CPR. The goal was that the resident preference will be honored in the event of a cardiac emergency. An intervention included that in the absence of breathing and pulse to call 911 and begin CPR. The admission Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. However, a Statement of Treatment Preferences signed (MONTH) 8, 2019 by the POA and the facility representative revealed a request that while a resident at the facility the resident will be designated a do not resuscitate (DNR). Per the form, it is understood this means no cardiopulmonary resuscitation will be employed in the plan of treatment, if necessary. A Pre-Hospital Medical Care Directive dated and signed (MONTH) 8, 2019 by the POA, Licensed Health Care Provider, and a witness revealed that in the event of cardiac or respiratory arrest, the resident refuses any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, ar… | 2020-09-01 |
| 7 | 7 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2019-10-17 | 641 | D | 0 | 1 | EJUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment for one resident (#13) was accurate regarding restraints. The deficient practice could result in inaccuracies within the resident's clinical record. The census was 53 residents. Findings include: Resident #13 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A side rail usage assessment dated (MONTH) 15, 2019 revealed the resident required the assistance of one person to enter or exit the bed and was able to move and change positions in bed without assistance. The assessment included the resident preferred to have the rails in place and was able to enter and exit the bed on her own with the rails in use. A physician's orders [REDACTED]. Review of the care plan initiated (MONTH) 7, 2019 for quarter side rails as a therapeutic device to support mobility and independence revealed the goal was to enhance functional independence and promote skin integrity through the use of the right quarter rail for positioning and turning while in bed. Interventions included the resident uses the right side rail to assist with transfers. However, the quarterly MDS assessment dated (MONTH) 9, 2019 revealed resident #13 was coded as having bed rails used daily as a physical restraint. During an observation conducted of resident #13's room on (MONTH) 15, 2019 at 8:51 a.m., quarter rails was observed attached to each side of the resident's bed. An interview was conducted with resident #13 on (MONTH) 15 at 1:40 p.m. The resident stated she likes having the bed rails and that she uses them to help her get in and out of bed. She stated she does not use them all of the time, and the rails do not prevent her from getting out of bed. Resident #13 stated she is able to transfer from her wheelchair to the bed without assistance, and she is able to wa… | 2020-09-01 |
| 8 | 8 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2019-10-17 | 657 | D | 0 | 1 | EJUZ11 | **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 the nutrition care plan was revised for one resident (#19). The deficient practice could result in inaccuracies regarding resident care. Findings include: Resident #19 was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the nutrition care plan initiated 12/12/2016 revealed a goal that the resident will maintain adequate nutritional status. Interventions included providing and serving diet as ordered, providing set-up and assistance with meals in the dining room as needed/accepted. Review of the summary of physician orders [REDACTED]. However, further review of the care plan did not reveal the care plan was revised to include the order for the resident to receive 1:1 assistance with her meals. An interview was conducted with a Certified Nursing Assistant (CNA/staff #20) on 10/16/19 at 10:39 AM. She stated the resident makes up her own mind on where and how she wants to eat her meals. She stated the resident will either eat in the dining room or in her room. The CNA stated the resident will not eat sometimes unless staff leaves the room. During an interview conducted with a Licensed Practical Nurse (LPN/staff #61) on 10/16/19 at 12:44 PM., she stated staff follows the care plan for the residents' nutritional needs. The LPN stated that staff will pop in to see the resident every 15-20 minutes to ensure she is eating. During an interview conducted with the Director of Nursing (DON/staff #4) on 10/16/19 at 12:54 PM., the DON stated that the care plan should include the physician order [REDACTED]. She stated the care plans are updated by the nursing supervisor and nursing staff as new orders are written. The DON stated care plans are reviewed weekly and corrected as needed for a change in the resident's condition or if new orders are obtained. She stated she was not aware there was an order for [REDACTED]. An interview was conducted with … | 2020-09-01 |
| 9 | 9 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2019-10-17 | 658 | E | 0 | 1 | EJUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and policy review, the facility failed to ensure services provided met professional standards of quality by failing to follow physician orders [REDACTED].#19). The deficient practice could result in adverse clinical outcomes. Findings include: Resident #19 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the current care plan revised 9/4/18 revealed the resident had a potential nutritional problem related to decreased cognition as evidenced by variable meal intake around 50% and the need for assistance/coaching. The goal was for the resident to maintain adequate nutritional status. Interventions included providing set-up and assistance with meals in the dining room as needed/accepted and monitoring, documenting, and notifying the physician as needed for refusals to eat and concerns during meals. Review of the percentage of meals eaten revealed the following for (MONTH) and (MONTH) 2019: For July, 36 meals the resident consumed was 50% or less. For August, 39 meals the resident consumed was 50% or less. The quarterly admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident cognitive skills were moderately impaired for daily decision making and the resident required supervision for eating. A quarterly nutrition review dated 8/30/2019 revealed the resident had decreased her consumption of solid food to 26-50% but was not a risk for unintended weight loss. Review of the summary of physician orders [REDACTED]. The percentage of meals eaten for (MONTH) and (MONTH) 2019 revealed the following: For September, 32 meals the resident consumed was 50% or less. For (MONTH) 1-16, 20 meals the resident consumed was 50% or less. Further review of the clinical record revealed no documentation that 1:1 assistance was provided to the resident as ordered or that the care plan included this order. An observation was conducted of the resident on 10/15/19 at 09:38 AM… | 2020-09-01 |
| 10 | 10 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2019-10-17 | 695 | D | 0 | 1 | EJUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure oxygen tubing for one sampled resident (#8) was changed as ordered and stored consistent with professional standards of practice. The deficient practice could result in respiratory complications and infection. Findings include: Resident #8 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) for (MONTH) 2019 revealed the oxygen tubing was changed on (MONTH) 6 and again on (MONTH) 13. During an observation conducted of the resident's room on (MONTH) 15, 2019 at 9:56 a.m., the resident was not observed using oxygen. The oxygen concentrator was on and in the bathroom shower. The tubing was connected to the concentrator and part of the tubing was lying on the floor of the shower. Another part of the tubing was looped around the grab bars next to the toilet. The tubing extended out of the bathroom, into the resident's room and was wrapped around the table next to the resident who was sitting in a chair. The tubing on the concentrator had a label with the date (MONTH) 12 on it. The nasal cannula had a separate label that had the date (MONTH) 5 on it. An interview was conducted with the resident immediately following this observation. The resident stated the oxygen concentrator was moved into the shower that morning to make room for staff to clean up an accident and that no one noticed the concentrator needed to be moved back into her room. Resident #8 stated that she does not know when the staff changes the oxygen tubing. Another observation was conducted of the resident's room was on (MONTH) 16, 2019 at 1:25 p.m. The oxygen concentrator was observed in the bathroom, but was no longer in the shower. Part of the tubing from the concentrator was wrapped around the grab bars next to the resident's toilet, and part of it was comi… | 2020-09-01 |
| 11 | 11 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2019-01-25 | 600 | D | 1 | 1 | YXH311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff and resident interviews, facility documentation, and a review of the facility's policy and procedures, the facility failed to ensure one resident (#94) was free from abuse from resident (#30) and that resident (#109) was free from abuse from resident (#33). Findings include: -Resident #94 was admitted to the facility on (MONTH) 20, 2013 and readmitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed the resident scored a 6 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. The assessment included the resident exhibited verbal behavioral symptoms such as threatening and screaming directed toward others A nurse practitioner note dated (MONTH) 7, (YEAR) revealed the resident was awake, alert, and oriented to self with memory loss and confusion and was able to independently propels herself in the wheelchair. A nursing note dated (MONTH) 9, (YEAR) revealed the resident was observed with scratches to her right cheek, back of neck, and right upper arm. A behavioral health team note dated (MONTH) 11, (YEAR) revealed on (MONTH) 9, (YEAR) the resident (#94) was witnessed to have scratches on her right cheek, back of her neck, and the right upper arm. Per the documentation, when the resident was asked about the scratches on her cheek, the resident stated that resident #30 caused the scratches. The documentation included the resident was asked why resident #30 scratched her and that she stated I don't know she (resident #30) just hates me and that they were talking when resident #30 struck her. The documentation included the resident was unable to elaborate more and stared blankly. -Resident #30 was admitted to the facility on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 27, (YEAR) revealed the resident scored a 15 … | 2020-09-01 |
| 12 | 12 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2019-01-25 | 607 | D | 1 | 1 | YXH311 | **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 implement their abuse policy regarding reporting an allegation of abuse involving two residents (#94 and #30). Findings include: -Resident #94 was admitted to the facility on (MONTH) 20, 2013 and readmitted on e (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed the resident scored a 6 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. -Resident #30 was admitted to the facility on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Review of facility documentation dated (MONTH) 13, (YEAR) revealed that on (MONTH) 9, (YEAR) at 12 p.m. resident #94 and resident #30 were outside on the patio when a staff member (#14) observed resident #30's hands on resident #94's shoulders. Per the documentation, staff intervened and scratches were noted on resident #94's right shoulder, right cheek, and right biceps area. The documentation included that this incident was reported to the State Agency on (MONTH) 9, (YEAR) at 8:30 p.m. An interview was conducted on (MONTH) 24, 2019 at 7:54 a.m. with a registered nurse (RN/staff #105). He stated a resident to resident altercation is a form of abuse. The RN stated that for a resident to resident altercation the abuse is reported right away to all managers, Adult Protective Services, the State Agency, and the police within 2 hours. During an interview conducted on (MONTH) 25, 2019 at 9:09 a.m. with the Social Services Director (staff #26), she stated an allegation of abuse is to be reported within two hours to the State Agency. An interview was conducted o… | 2020-09-01 |
| 13 | 13 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2019-01-25 | 609 | D | 1 | 1 | YXH311 | **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 involving two residents (#94 and #30) was reported to the State Agency within two hours. Findings include: -Resident #94 was admitted to the facility on (MONTH) 20, 2013 and readmitted on e (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed the resident scored a 6 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. -Resident #30 was admitted to the facility on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident is cognitively intact. Review of facility documentation dated (MONTH) 13, (YEAR) revealed on (MONTH) 9, (YEAR) at 12 p.m. resident #94 and resident #30 were outside on the patio when a staff member (#14) observed resident #30's hands on resident #94's shoulders. Per the documentation, staff intervened and scratches were noted on resident #94's right shoulder, right cheek, and right biceps area. The documentation included that this incident was reported to the State Agency on (MONTH) 9, (YEAR) at 8:30 p.m. An interview was conducted on (MONTH) 24, 2019 at 7:54 a.m. with a registered nurse (RN/staff #105). He stated a resident to resident altercation is a form of abuse. The RN stated that for a resident to resident altercation the abuse is reported right away to all managers, Adult Protective Services, the State Agency, and the police within 2 hours. During an interview conducted on (MONTH) 25, 2019 at 9:09 a.m. with the Social Services Director (staff #26), she stated an allegation of abuse is to be reported within two hours to the State Agency. An interview was conducted… | 2020-09-01 |
| 14 | 14 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2019-01-25 | 655 | D | 0 | 1 | YXH311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, the facility failed to ensure a summary of the baseline care plan was provided to one resident (#63). Findings include: Resident #63 was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed a form titled Baseline Care Plan Summary, this form included the resident's goals during his admission, medication orders, and diet orders. This form included a space for the resident to sign. However, there was no resident signature documented. Further review of the clinical record revealed no evidence the resident was provided with a summary of his baseline care plan. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. During an interview conducted on (MONTH) 22, 2019 at 12:28 p.m. with the resident, he stated that the staff do not include him in his care. An interview was conducted on (MONTH) 25, 2019 at 10:04 a.m. with a unit coordinator/ registered nurse (RN/ staff #40). She stated baseline care plans are developed within two days after admission and include resident diagnoses, activities of daily living needs, and dietary status. She stated baseline care plans and goals are reviewed with the resident and a copy is offered to the resident. The RN stated that the resident will sign on the baseline care plan summary that a copy of the baseline care plan was provided to them. After reviewing the clinical record, she stated the baseline care plan summary for resident #63 was not signed but that she reviewed the care plan with the resident. An interview was conducted on (MONTH) 25, 2019 at 10:58 a.m. with the Director of Nursing (DON/ staff #99). He stated baseline care plans are developed within 48 hours after admission. He stated the baseline care plan includes medica… | 2020-09-01 |
| 15 | 15 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2016-09-14 | 253 | E | 0 | 1 | MTU811 | Based on observations, resident and staff interviews and facility documentation, the facility failed to provide housekeeping and maintenance services necessary to maintain a comfortable interior for residents, and failed to ensure odor levels were acceptable throughout the facility. Findings include: -An environmental tour was conducted on (MONTH) 14, (YEAR) at 1:00 p.m., with the housekeeping director (staff #23) and the maintenance director (staff #44). Prior to the tour, staff #23 stated that the staffing coordinator does the walk through rounds daily on each of the facility's five units, so that every resident room is inspected weekly for safety issues and broken items. Staff #23 further stated that if repairs need to be made, a work order is completed and given to the maintenance director. At this same time, staff #44 stated that when he receives a work order, he tries to repair the area the same day. The following concerns were observed during the environmental tour: -Room A12: There was an area on the wall near the bathroom door where the wallpaper was peeling. The area was approximately 16 inches long. Also, near the toilet there was an area of cove base which was approximately 18 inch long, which was loose. An interview was conducted with staff #44 who stated that he received a work order last month regarding the wallpaper and that he will have to tear all of the wallpaper off the wall, as he can't glue it back on. He stated that he was not aware of the loose cove base in the bathroom. Review of facility documentation revealed that a Maintenance Work Order for the wallpaper was completed on (MONTH) 29, (YEAR). -Room A8: Under the entire width of the window on the wall, the paint was scraped/gouged. An interview was conducted with staff #44 who stated that it was difficult to repair and paint resident rooms, when the residents are in the rooms. The documentation from the Morning Walk Through Rounds dated (MONTH) 23 and 30, (YEAR) included to paint the window wall. -Room A3: The wallpaper around the nightl… | 2020-09-01 |
| 16 | 16 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2016-09-14 | 371 | D | 0 | 1 | MTU811 | Based on observations, staff interviews and policy and procedures, the facility failed to ensure one staff member (#82) wore a hair net in the kitchen and failed to ensure foods were dated when opened. Findings include: -On (MONTH) 12, (YEAR) at 10:00 a.m., an initial kitchen tour was completed with the dietary manager (staff #82). At this time, the dietary manager was observed not wearing a hairnet. Also during the initial kitchen tour, there was frozen pork in the freezer which was wrapped in plastic. The pork was not dated when opened. There was also a box of pork patties in the freezer which was opened, but not dated. The meat was not wrapped and was exposed to the air. An interview was conducted with staff #82 on (MONTH) 14, (YEAR) at 8:30 a.m. She stated that she knew she was suppose to wear a hairnet in the kitchen. She stated that she knew the opened items should have been dated when opened. An interview was conducted on (MONTH) 14, (YEAR), with the nutrition consultant (staff #146). She stated foods should be dated when opened and prior to being put back in the freezer. At this time, the freezer was inspected and there was a zip lock bag with frozen chicken, and it was not dated when opened. There was also a box of churros which was opened and not dated. The churros were not wrapped and were exposed to the air. Staff #146 stated that those items should have been dated after being opened. Staff #146 also stated that a hair net should be worn at all times in the kitchen. Review of the facility policy titled, Personal Hygiene Training revealed that a hair restraint should be worn when around exposed foods, in the kitchen or food service areas including the dining areas. A policy regarding Food Storage included that all foods will be checked to assure that foods will be consumed by their use by dates or discarded and that Food should be labeled and dated. | 2020-09-01 |
| 17 | 17 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2016-09-14 | 441 | D | 0 | 1 | MTU811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, staff interviews and review of policy and procedures, the facility failed to ensure that proper hand washing techniques were implemented during pressure ulcer treatments for two residents (#34 and #145). Findings include: -Resident #34 was readmitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed that on (MONTH) 14, (YEAR), one stage 4 pressure ulcer was still present on the resident's right hip. The (MONTH) (YEAR) recapitulation of physician's orders [REDACTED]. A pressure ulcer treatment observation was conducted on (MONTH) 14, (YEAR) at 9:30 a.m. At this time, the LPN (Licensed Practical Nurse/staff #127) was observed to wash her hands, donn gloves and cleansed the stage 4 pressure ulcer on the resident's right hip. Staff #127 was then observed to remove her gloves and donn another pair of gloves. Staff #127 then applied zinc oxide to the skin surrounding the pressure ulcer and proceeded to pack the pressure ulcer with the alginate and apply the border dressing. However, staff #127 was not observed to disinfect or wash her hands after cleansing the pressure ulcer and removing her gloves, after the application of the zinc oxide to the surrounding skin and prior to packing the pressure ulcer. An interview was conducted on (MONTH) 14, (YEAR) at 11:30 a.m., with staff #127. She stated that her usual practice was to only wash her hands at the beginning and the end of treatment. An interview with the Director of Nursing (DON/staff #109) was conducted immediately following this interview. Staff #109 stated that the LPN should have washed her hands after she cleansed the pressure ulcer and removed her gloves, after she applied the zinc oxide and prior to the application of the alginate and dressing. Staff #109 stated that the purpose of handwashing is for infection control and to not spread any bacteria that may be present. -Resident #145 was admitted to th… | 2020-09-01 |
| 18 | 18 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2016-09-14 | 469 | D | 0 | 1 | MTU811 | Based on observation and staff interviews, the facility failed to ensure that flies were not present in the residents' dining room. Findings include: An observation of the lunch meal was conducted on (MONTH) 12, (YEAR) at 11:45 a.m., on the La Oneita nursing unit. During this observation, two fly/bug lights were observed on the wall in the dining room and an air blower was positioned above the outside door leading into the dining room. A weak air current was felt at the top of the door frame. Further observations revealed there were multiple flies on residents, on the dining tables, on the residents' food, on the cups/glasses and on the milk cartons. Residents and staff were also observed swatting at the flies. A resident interview was conducted on (MONTH) 14, (YEAR) at 8:30 a.m. During this interview the resident agreed that there were flies in the dining room and stated, You just get use to it. An interview was conducted on (MONTH) 14, (YEAR) at 8:30 a.m., with a LPN (Licensed Practical Nurse/staff #113). Staff #113 stated that although the staff keep the outside door closed and have the fly/bug lights and the air blower, flies are still present in the dining room. Another interview was conducted on (MONTH) 14, (YEAR) at 8:45 a.m., with maintenance staff (staff #4). Staff #4 stated that the two fly/bug lights in the residents' dining room trap the flies on a sticky paper inside and the paper is changed about every two weeks. He stated that he just had his worker change the sticky paper. At this time, the two used sticky papers were observed sticking out of the open trash can in the dining room. Both sticky papers were covered with dead flies. Staff #4 stated that maybe he should start to change the sticky paper every week, since he was informed by the pest control provider that once the sticky paper had too many flies on it, additional flies will not land on it. Staff #4 also stated that he did not keep a maintenance schedule on the fly/bug lights and therefore, was unable to provide any documentation when the … | 2020-09-01 |
| 19 | 19 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2017-10-05 | 225 | D | 0 | 1 | 2ZZS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility investigation report review, orientation sheet review, staff interviews, and policy, the facility failed to ensure that a registry certified nursing assistant reported an allegation of verbal abuse in a timely manner. Findings include: Resident #7 was readmitted on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the Minimum Data Set quarterly assessment dated (MONTH) 24, (YEAR) revealed that the resident was moderately impaired and was totally dependent on staff for activities of daily living. Review of the clinical record revealed a nurse's notes dated (MONTH) 3, (YEAR) regarding an allegation of a staff verbally insulting resident #7. Review of the facility's investigation report revealed an allegation of abuse that occurred (MONTH) 28, (YEAR) on the 3 p.m. to 11 p.m. shift was reported (MONTH) 2, (YEAR) by a registry certified nursing assistant (staff #146). The allegation was that a certified nursing assistant (staff #147) was verbally abusive to resident #7. Staff #147 was yelling and cursing at resident #7. During an interview conducted with a licensed practical nurse (staff #129) (MONTH) 4, (YEAR) at 8:45 a.m., staff #129 stated the staff are to immediately report any incidents to the charge nurse or directly to the Director of Nursing. She also stated that agency staff are to review a book on the unit which contains facility policy. She further stated that when their orientation to the facility is completed they sign a document. An interview was conducted (MONTH) 4, (YEAR) at 9:27 a.m. with the staffing coordinator (staff #141). She stated that all agency staff must complete orientation during their first shift at the facility. She further stated once the orientation is completed, the agency staff signs the orientation sheet which it is kept on file in the staffing office. Review of the orientation sheet revealed the agency certified nursing assistant (staff #146) completed and signed … | 2020-09-01 |
| 20 | 20 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2017-10-05 | 278 | E | 0 | 1 | 2ZZS11 | **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 the MDS (Minimum Data Set) assessments were accurate for three residents (#1, #102, and #106). Findings include: -Resident #102 was admitted (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Preadmission Screening Resident Review (PASRR) level 2 evaluation dated (MONTH) 16, (YEAR) that included the resident had a serious mental illness and required nursing facility level care. However, an admission MDS assessment dated (MONTH) 26, (YEAR), revealed the resident was not considered by the level 2 PASRR process to have a serious mental illness. During an interview with the Social Services Director (staff #57) conducted on (MONTH) 4, (YEAR) at 1:16 p.m., staff #57 stated that a copy of the PASRR level 2 evaluation is placed it in the resident's clinical record. An interview was conducted with the MDS Coordinator (staff #130) on (MONTH) 5, (YEAR) at 2:05 p.m. Staff #130 stated that she reviews information in the resident's clinical record to complete the PASRR section of the MDS. The RAI manual instructs under PASRR level 2 conditions to code for serious mental illness if the resident has been diagnosed with [REDACTED]. -Resident #1 was readmitted (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR) revealed the resident had no natural teeth or tooth fragments. Further review revealed the dental Care Area Assessment (CAA) that included the resident was edentulous and on a mechanically altered diet. An observation of the resident was conducted (MONTH) 2, (YEAR) at 1:26 p.m. It was observed that the resident's teeth were in poor condition and that she had many missing teeth, but she had some teeth present. An interview was conducted on (MONTH) 5, (YEAR) at 11:47 a.m. with the MDS Licensed Practical Nurse (LPN… | 2020-09-01 |
| 21 | 21 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2017-10-05 | 281 | E | 0 | 1 | 2ZZS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, interviews, and policy and procedures, the facility failed to ensure that one resident (#121) was provided a medication through a PEG (percutaneous endoscopic Gastrostomy) tube in a safe manner and failed to ensure narcotic medications were signed as administered immediately after administering the medications. Findings include: Resident #121 was readmitted (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. A Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR), revealed the resident was unable to answer questions, the resident had a PEG tube, and the resident was on a mechanically altered diet. A medication administration observation was conducted on (MONTH) 2, (YEAR) at 11:20 a.m. with a licensed practical nurse (staff #70). During the observation, the nurse flushed the PEG tube with 80 cc. of water using a 60 cc syringe prior to administering a medication, mixed a crushed pill with 30 cc of water and pushed it into the tube, and pushed another 80 cc of water into the tube after administering the medication. However, the nurse depressed the plunger on the syringe to push the water and medication into the resident's PEG tube, rather than removing the plunger on the syringe, pouring the water and medication into the syringe, and allowing gravity to allow the water and medication to flow into the PEG tube. During an interview with staff #70 conducted on (MONTH) 2, (YEAR) at 11:25 a.m., the nurse stated that she did not know if she was supposed to use the plunger on the 60 cc syringe to push the flushes and the medication into the PEG tube, or remove the plunger on the syringe and allow gravity to pull the flushes and the medication into the PEG tube. The nurse stated that she had been provided training regarding how to administer medications into a PEG tube, and that she would review the facility's policy. During an intervie… | 2020-09-01 |
| 22 | 22 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2017-10-05 | 323 | D | 0 | 1 | 2ZZS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#33) was free from an accident hazard by not following physician orders. Findings include: Resident #33 was admitted (MONTH) 21, 2008 with [DIAGNOSES REDACTED]. Two physician's orders [REDACTED]. A care plan updated on (MONTH) 30, (YEAR), regarding the resident's risk for injury included the resident had actual and a potential for injury related to sensory deficits, lack of awareness, and limited mobility. Interventions for the care plan included removing hazards from the environment and bed bolsters for the resident to have for safety, comfort, and positioning. An MDS (Minimum Data set) assessment dated (MONTH) 2, (YEAR), revealed the resident's cognitive skills for daily decision making were severely impaired. An observation of the resident was conducted (MONTH) 3, (YEAR) at 8:46 a.m. The resident was lying in bed with one side of the bed against the wall. On the opposite side of the bed, the mattress was observed to have a pillow and a blue wedge underneath it to tilt the mattress toward the wall. The whole length of the mattress was propped up with these items. The resident was non-interviewable at this time. An additional observation was conducted (MONTH) 3, (YEAR) at 11:16 a.m. The resident was observed lying in bed with the observed same items wedged underneath the mattress. An observation of the resident was conducted (MONTH) 4, (YEAR) at 12:17 p.m. The resident was lying in bed with the same items wedged underneath the mattress of the bed. The resident was sleeping at this time. In an interview conducted on (MONTH) 5, (YEAR) at 12:23 p.m. with the unit coordinator (staff #78), she stated the resident had an order for [REDACTED]. An observation was made of the resident with staff #78. The resident was lying in bed with the pillow and wedge under the mattress as in previous observations. Staff #78 stated that … | 2020-09-01 |
| 23 | 23 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2017-10-05 | 441 | E | 0 | 1 | 2ZZS11 | Based on staff interviews, the facility failed to implement a water management program that included environmental testing for pathogens including the bacterium Legionella. Findings include: During an interview with the Director of Nursing (staff #107) conducted on (MONTH) 4, (YEAR), at 10:40 a.m., staff #107 stated that the facility's water softener and cooling systems were maintained by outside vendors. However, the facility did not have a policy or a program to test the facility's water for pathogens including the Legionella bacterium. During an interview conducted on (MONTH) 4, (YEAR) at 10:45 a.m. with the Administrator (staff #9), the administrator stated that the facility did not have a policy or program for testing the facility's water supply for waterborne pathogens including Legionella. | 2020-09-01 |
| 24 | 24 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2019-03-08 | 580 | D | 0 | 1 | QDGY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to notify one resident's (#281) physician of a low blood sugar value. The total sample size was 17. The deficient practice has the potential for adverse effects on residents with sliding scale insulin orders. Findings include: Resident #281 was admitted (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED]= 0 units and call MD (physician); 71-150 = 0 units; 151-200 = 3 units; 201-250 = 5 units; 251-300 = 7 units; 201-350 = 10 units; 351-400 = 12 units; greater than 401 = 14 units and notify MD. Review of the Medication Administration Record [REDACTED]. Further review of the clinical record did not reveal any documentation that the physician was notified of the low blood sugar. An interview was conducted with the Director of Nursing (DON/staff #56) on (MONTH) 6, 2019 at 7:48 a.m. Staff #56 stated staff should follow the physician's orders [REDACTED]. The DON further stated that no documentation was found the physician was notified when the resident blood sugar level dropped to 63. The facility's policy regarding change of condition revealed all changes in a resident's condition will be communicated to the physician. | 2020-09-01 |
| 25 | 25 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2019-03-08 | 637 | D | 0 | 1 | QDGY11 | **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 Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment was completed for one resident (#36), who was discharged from hospice services. The sample size was 17. This deficient practice could affect the resident's continuity of care. Findings include: Resident #36 was admitted on (MONTH) 13, 2012, with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. The SCSA MDS assessment dated (MONTH) 13, (YEAR), revealed the resident was receiving hospice services. Additional review of the clinical record revealed a physician's orders [REDACTED]. However, continued review of the clinical record did not reveal a SCSA MDS assessment was completed. On (MONTH) 7, 2019 at 10:25 AM, an interview was conducted with the MDS coordinator (staff #22). She stated that when a resident is discharged from hospice services, a SCSA MDS assessment needs to be completed. She also stated that she did not know this resident had been discharged from hospice services because she was not notified. Later that morning at 11:38 AM, staff #22 stated that a SCSA MDS assessment should have been completed for resident #36 in (MONTH) 2019. She said she missed it. The RAI manual instructs a SCSA MDS assessment is required when hospice services are discontinued and that the Assessment Reference Date must be within 14 days. | 2020-09-01 |
| 26 | 26 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2019-03-08 | 641 | D | 0 | 1 | QDGY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two residents (#382 and #81). The sample size was 31. This deficient practice could affect residents' continuity of care. Findings include: -Resident #382 was admitted on (MONTH) 21, 2019, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The orders also included blood sugar accuchecks before meals and at bedtime. Review of the Medication Administration Record [REDACTED]. A Nursing Progress Note dated (MONTH) 22, 2019, revealed the resident threw her medications when the medications were placed in her hand per her request. Review of the MAR indicated [REDACTED]. The admission MDS assessment dated (MONTH) 28, 2019 revealed a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The assessment also included the resident had no behaviors during the seven day look-back period which included no verbal or other behaviors directed towards others, and no rejection of care. An interview conducted on (MONTH) 7, 2019 at 12:55 p.m. with the Certified Nursing Assistant (CNA/staff #57) who had completed the section of the MDS assessment for behavior. She stated that she was aware the resident had refused medications and treatments and had slapped and scratched the nurse. The CNA stated that she did not include the behaviors on the MDS assessment because she understood why the resident had those behaviors. She stated that it was a communication problem. An interview was conducted on (MONTH) 8, 2019 at 9:43 a.m. with the Licensed Practical Nurse (LPN/staff #22) MDS Coordinator and the MDS resource Registered Nurse (RN/staff #128). Staff #22 stated that she did not review the behavior section of the MDS assessment. Staff #22 further stated that if she was completing the behavior section for this resident, she would… | 2020-09-01 |
| 27 | 27 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2019-03-08 | 656 | D | 0 | 1 | QDGY11 | **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 a care plan for [MEDICAL CONDITION] risk was developed for one resident (#32). This deficient practice has the potential to cause delays in assessments and care. The sample size was 2. The universe was 17. Findings include: Resident #32 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a care plan dated (MONTH) 17, (YEAR), which included goals and interventions related to a [DIAGNOSES REDACTED]. The resident was discharged from the facility with a return anticipated on (MONTH) 13, (YEAR). The resident was readmitted on (MONTH) 25, (YEAR). A new care plan was initiated for the resident on (MONTH) 25, (YEAR). However, the care plan did not include the resident's [DIAGNOSES REDACTED]. Review of the PPS (Prospective Payment System) 5 day MDS assessment dated (MONTH) 2, (YEAR), revealed the resident continued to have a [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 6, 2019 at 8:36 a.m. with the Director of Nursing (DON/staff #56). She stated that facility's protocol directs staff to discontinue a resident's orders and care plan if the resident is discharged from the facility for more than 24 hours. The DON stated that new orders and a new care plan would be initiated upon the resident's re-admission to the facility. A follow-up interview was conducted with the DON on (MONTH) 6, 2019 at 9:28 a.m. She stated that her expectation is that the comprehensive care plan include the resident's risk for [MEDICAL CONDITION]. The DON also stated there was a lapse in communication, and that the resident's risk for [MEDICAL CONDITION] was not included in the care plan when the resident was readmitted . Review of the facility's policy for care planning revealed the following: -The interdisciplinary team shall develop a comprehensive care plan for each resident. -The resident's care… | 2020-09-01 |
| 28 | 28 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2019-03-08 | 657 | D | 0 | 1 | QDGY11 | **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 of three sampled resident's (#36) comprehensive care plan was revised to reflect the change in hospice services. This deficient practice could result in a delay of care. Findings include: Resident #36 was admitted on (MONTH) 13, 2012, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the care plan dated (MONTH) 8, (YEAR) regarding hospice services revealed interventions to consult with the resident's physician and social services to have hospice care for the resident in the facility and working with nursing staff to provide maximum comfort for the resident. A physician's orders [REDACTED]. A social service progress note dated (MONTH) 23, 2019, revealed the IDT (interdisciplinary team) had met for a care conference. The note included a discussion of the resident's change in Hospice services. The note did not include a discussion about revising the care plan. However, review of the resident's current care plan did not reveal the care plan had been revised to reflect the resident's discharge from hospice. An interview was conducted on (MONTH) 6, 2019 at 10:39 AM with the Director of Nursing (DON/staff #56). She said that facility's protocol and her expectation would include revising the resident's care plan to reflect the change in hospice services. The DON also said their policy states any member of the IDT could make that revision. On (MONTH) 7, 2019 at 09:40 AM, an interview was conducted with a licensed practical nurse (LPN/staff #62). The LPN stated that if a resident is admitted or discharged from hospice services, it would trigger a change of condition due to a change of services. She stated that the MDS (minimum data set) coordinator would revise the care plan. Review of the facility's policy for care planning revealed the resident's plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and… | 2020-09-01 |
| 29 | 29 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2019-03-08 | 684 | D | 1 | 1 | QDGY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, clinical record review and staff interview, the facility failed to ensure one resident (#281) had blood glucose monitoring done as ordered by the physician. The deficient practice could result in treatment not being provided, as a result of high/low blood sugars. The total sample size was 17. Findings include: Resident #281 was admitted on (MONTH) 23, (YEAR) at approximately 3:00 p.m. [DIAGNOSES REDACTED]. A review of the clinical record revealed admission orders [REDACTED] blood sugar 0-70 = 0 units and call MD (physician); 71-150 = 0 units; 151-200 = 3 units; 201-250 = 5 units; 251-300 = 7 units; 201-350 = 10 units; 351-400 = 12 units; greater than 401 = 14 units and notify MD. A review of the MAR (Medication Administration Record) for (MONTH) (YEAR), revealed the resident's blood sugar monitoring was to be done at 7:30 a.m., 11:30 a.m., 4:30 p.m. and 8:00 p.m. Further review of the MAR indicated [REDACTED] During an interview with the Director of Nursing (DON/staff #56) on (MONTH) 6, 2019 at 8:58 a.m., staff #56 stated that the nurse should have documented the resident's glucose levels. Staff #56 stated the facility did not have a policy regarding blood glucose monitoring and documentation and that the nurses are to follow the order on the MAR. | 2020-09-01 |
| 30 | 30 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2019-03-08 | 757 | E | 0 | 1 | QDGY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, the facility failed to ensure one of five sampled residents (#36) was free of unnecessary drugs, by failing to administer a narcotic pain medication as ordered by the physician. The potential outcome includes receiving a medication which may be unnecessary. Findings include: Resident #36 was admitted on (MONTH) 13, 2012, with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. A pain care plan area dated (MONTH) 16, (YEAR) included that opioids were prescribed for chronic pain. Interventions included administering medication as ordered, monitoring for side-effects, monitoring for medication efficacy and educating the resident on alternatives. The Medication Administration Record [REDACTED]. Per the MAR, [MEDICATION NAME] 5 mg was administered six times outside of the physician ordered parameters as follows: twice on (MONTH) 17 for pain levels of 3 and 4; on (MONTH) 21 for a pain level of 3; on (MONTH) 23 for a pain level of 4; and on (MONTH) 25 and 28, for a pain level of 4. A physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 13, 2019, revealed the resident had severe cognitive impairment. Review of the MAR for (MONTH) 2019 revealed [MEDICATION NAME] 5 mg was administered 6 times outside of the physician ordered parameters as follows: on (MONTH) 4 for a pain level of 4; on (MONTH) 5 for a pain level of 3; on (MONTH) 6 for a pain level of 3; twice on (MONTH) 9 for pain levels of 4; and on (MONTH) 24 for a pain level of 4. Review of the MAR for (MONTH) 2019 revealed that [MEDICATION NAME] 5 mg was administered once outside of the physician ordered parameters on (MONTH) 20, for a pain level of 4. An observation of resident #36 was conducted on (MONTH) 6, 2019 at 12:05 p.m., in the dining room. The resident was asleep at the table and was not eating her lunch. A Certified Nursing Assistant (CNA) woke the resident up and aske… | 2020-09-01 |
| 31 | 31 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2016-11-02 | 250 | E | 0 | 1 | VT7X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to provide medically-related social services for one resident (#124). Findings include: Resident #124 was readmitted on (MONTH) 19, 2014, with [DIAGNOSES REDACTED]. A review of the clinical record revealed that the resident's BIMS (Brief Interview for Mental Status) score was a 3, which indicated severe cognitive impairment. A dental consultation dated (MONTH) 7, (YEAR), included a recommendation for multiple teeth extractions, as well as instructions for the resident or the resident's medical power of attorney. These included the following: 1. Need Primary Care Physician or Nurse Practitioner signature's for treatment. 2. Responsible party to sign, date, initial, and have witnessed the consent for extractions. 3. Pre medication orders, including a sedative. 5. Specific financial arrangements to be made. However, a review of the clinical record, inclusive of the social services documentation, revealed no documented evidence that anyone was designated or responsible to make informed decisions for this resident. An interview was conducted on (MONTH) 2, (YEAR), with the social service staff (staff #91), who stated that a responsible party had not been obtained to make decisions for this resident. Another interview was conducted on (MONTH) 2, (YEAR) at 1:57 p.m., with staff #99 (corporate resource staff), who stated that the facility did not have a policy to address guardianships or pubic fiduciaries. | 2020-09-01 |
| 32 | 32 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2016-11-02 | 412 | D | 0 | 1 | VT7X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility policy, the facility failed to ensure one resident (#124) was assisted with dental services. Findings include: Resident #124 was readmitted on (MONTH) 19, 2014, with [DIAGNOSES REDACTED]. A review of the clinical record revealed a physician's orders [REDACTED]. However, a dental consultation report was unable to be located in the clinical record. The resident was not interviewable, with a BIMS (Brief Interview for Mental Status) score of 3, which indicated severe cognitive impairment. An interview was conducted on (MONTH) 2, (YEAR) at 8:30 a.m., with a LPN (Licensed Practical Nurse-staff #44), who stated that she recalled that the resident had received a dental consultation and that recommendations had been made to have several teeth extractions but was unable to recall when the dental consultation was provided. Staff #44 stated that the social services staff would have been responsible to arrange for the dental consultation and to follow up on any recommendations that were made. An interview was conducted on (MONTH) 2, (YEAR) at 8:45 a.m., with Social Service staff (staff #91). She confirmed that it was her responsibility to arrange for the dental consultation and follow up regarding any recommendations. Following a review of the clinical record, inclusive of social services documentation, staff #91 stated that she was unable to locate any documentation regarding this dental consultation. Staff #91 stated she would now need to call the dental office to obtain a copy of the consultation and recommendations. On (MONTH) 2, (YEAR), the facility provided a copy of the dental consultation, which was dated (MONTH) 7, (YEAR). The consultation included that the resident required multiple tooth extractions. Another interview was conducted on (MONTH) 2, (YEAR) at 10:30 a.m., with the DON (Director of Nursing-staff #100), who stated that the social services staff should have followed up with the … | 2020-09-01 |
| 33 | 33 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 583 | D | 0 | 1 | 6GPJ11 | Based on observation, staff interviews and policy review, the facility failed to ensure that confidential resident information was secured. Findings include: An observation was conducted on (MONTH) 4, (YEAR) at 11:47 a.m., in the hallway near the station 2 nurse's station. At this time, a computer type device was observed to be mounted on the wall. The computer screen was on and was visible to anyone walking down the hallway. The computer screen displayed a resident's name, picture, room number and vital signs. An interview was conducted with a certified nursing assistant (CNA #98) on (MONTH) 4, (YEAR) at 11:58 a.m. Staff #98 stated that she got distracted and forgot to close the computer screen. An interview was conducted with the Director of Nursing (DON/staff #66), who stated that it is against policy to leave the computer screens unattended and open, displaying resident information. Review of a facility policy titled Notice Of Privacy Practices included, We are legally required to protect the privacy of your health information. We call this information Protected Health Information or PHI for short, and it includes information that can be used to identify you .your past, present, or future health or condition, the provision of health care to you .We must provide you with this notice about our privacy practices that explain how, when, and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI that is necessary to accomplish the purpose of the use or disclosure. | 2020-09-01 |
| 34 | 34 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 641 | D | 0 | 1 | 6GPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments for two resident's (#66 and #68) accurately reflected their status. Findings include: -Resident #66 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated (MONTH) 1, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. However, a physician's progress note dated (MONTH) 11, (YEAR) included the resident remains in chronic vegetative state, non-communicative. A resident interview was attempted on (MONTH) 28, (YEAR) at 1:00 p.m. The resident appeared to be in a vegetative state and was unable to answer questions. A family member was at the bedside and confirmed that the resident was unable to understand questions or communicate in any manner. An interview was conducted on (MONTH) 5, (YEAR) at 9:26 a.m., with two MDS nurses (staff #116 and staff #117). They stated that they did not know why the MDS was coded in this manner, as it was a mistake and that the nurse who did the coding was no longer employed there. -Resident #68 was readmitted to the facility on (MONTH) 7, (YEAR) and discharged on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. The orders also included for [MEDICATION NAME] (antianxiety medication) 1 milligram by mouth two times a day as needed for anxiety. Review of the Medication Assessment Record (MAR) for (MONTH) (YEAR) revealed the resident received Ertapenem Sodium Solution from (MONTH) 8 through 18. Further review revealed that the resident received [MEDICATION NAME] on (MONTH) 11, 12, 13 and 14. However, review of the MDS assessment dated (MONTH) 14, (YEAR), revealed documentation in Section N, that antibiotics had not been administered to the resident. The MDS also includ… | 2020-09-01 |
| 35 | 35 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 655 | D | 1 | 1 | 6GPJ11 | **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 that a baseline care plan regarding respiratory needs was developed for one resident (#301). Findings include: Resident #301 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. The admission physician orders [REDACTED]. The orders also included for [MEDICATION NAME]-[MEDICATION NAME] solution ([MEDICATION NAME][MEDICATION NAME]) 3 milliliters via nebulizer every 4 hours as necessary for shortness of breath or wheezing. According to the Medication Administration Record [REDACTED]. Review of the clinical record including the resident's baseline care plans revealed no evidence that a baseline care plan had been developed within 48 hours to address the resident's respiratory needs related to [MEDICAL CONDITION], and the need for oxygen and nebulizer treatments. An interview was conducted with a Licensed Practical Nurse (LPN/staff #63) on (MONTH) 23, (YEAR) at 12:43 p.m. She stated the admitting nurse is responsible to make sure the baseline care plans are done right away and should include the resident's major problems. An interview was conducted with the Director of Nursing (DON/staff #66) on (MONTH) 30, (YEAR) at 12:50 p.m. She stated that baseline care plans should be developed for all new admissions, within 48 hours. Staff #66 acknowledged that no baseline care plan had been developed to address the resident's respiratory needs. A facility policy regarding care planning included that resident care plans will be initiated within 48 hours of admission. | 2020-09-01 |
| 36 | 36 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 657 | D | 0 | 1 | 6GPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews and policy review, the facility failed to ensure one resident (#55) was able to participate in the care planning process. Findings include: Resident #55 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a care plan meeting invitation for the resident dated (MONTH) 1, (YEAR), which informed the resident that a care plan conference was scheduled for (MONTH) 9, (YEAR). An admission MDS (Minimum Data Set) assessment dated (MONTH) 2, (YEAR), included the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. A progress note written by the Social Service Supervisor (staff #92) dated (MONTH) 2, (YEAR), included documentation that the resident was invited to her care plan meeting. In an interview with resident #55 on (MONTH) 29, (YEAR) at 8:57 a.m., the resident stated that she was supposed to have a care plan conference, but it did not happen. She stated they told her that she was going to have one at another time, but that did not happen either. An interview with staff #92 was conducted on (MONTH) 1, (YEAR) at 11:30 a.m. She stated that resident's who are in the facility for skilled care have a care plan meeting scheduled 14 to 21 days, after their admission. She stated the residents receive an invitation, and then they are to let her know if they would like to attend or not. Staff #92 stated that care plan meetings are held on Thursdays, and the residents can choose a time that works for them. Another interview was conducted with staff #92 on (MONTH) 4, (YEAR) at 11:47 a.m. She stated that resident #55 wanted to attend, however, did not show up at the scheduled time and location for the meeting, so the meeting was held without the resident. She stated that later in the day of the scheduled conference, resident #55 reported that she had been waiting at t… | 2020-09-01 |
| 37 | 37 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 684 | D | 0 | 1 | 6GPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure the necessary treatment and services were provided for one resident (#147), as ordered by the physician. Findings include: Resident #147 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. The Initial Admission Record dated (MONTH) 20, (YEAR) included the resident was alert and oriented to time, place and person. Skin integrity findings included the resident had a surgical wound to the left outer ankle. According to the skin integrity care plan dated (MONTH) 21, (YEAR), the resident had actual skin impairment. A goal included that the surgical wounds to the left lower extremity (LLE) would heal. However, the locations of the wounds to the left lower extremity were not identified. An intervention included following the facility protocol for treatment of [REDACTED]. A physician's orders [REDACTED]. A Weekly Skilled Review note dated (MONTH) 28, (YEAR) included the resident received wound care twice a day to the lateral side of the LLE. Review of the Wound Administration Record from (MONTH) 22 through 30, (YEAR) revealed the order to cleanse the left outer leg with wound cleanser, apply Dakin soaked gauze, apply an ABD pad and wrap with Kerlix, twice daily. However, the documentation showed that the treatment was only provided once daily, instead of twice daily as ordered. An interview with the resident was conducted on (MONTH) 4, (YEAR) at 1:39 p.m. She stated that she receives wound treatment to her left lower leg once daily. An interview with a wound nurse (staff #44) was conducted on (MONTH) 4, (YEAR) at 1:42 p.m. She stated the wound care was ordered once daily to the left lower leg. An interview with another wound nurse (staff #48) was conducted on (MONTH) 5, (YEAR) at 8:56 a.m. She stated that the resident receives daily wound treatments to the left outer leg. At this time, the wound treatment … | 2020-09-01 |
| 38 | 38 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 686 | D | 0 | 1 | 6GPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, review of the National Pressure Ulcer Advisory Panel's (NPUAP) Pressure Injury Stages guidelines and policy review, the facility failed to ensure a pressure ulcer was accurately staged, thoroughly assessed and consistently monitored for one resident (#147). Findings include: Resident #147 was admitted on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. The Initial Admission Record dated (MONTH) 20, (YEAR) included the resident was alert and oriented to time, place and person. Skin integrity findings included the resident had a surgical wound to left outer ankle. There was no documentation that the resident had any pressure ulcers upon admission. However, a nutrition care plan dated (MONTH) 20, (YEAR) included the resident required increased calories and protein needs related to wound healing, due to a pressure injury. The stage and location of the pressure injury was not identified. Review of the Weekly Skin Evaluation dated (MONTH) 21, (YEAR) revealed the resident had a stage II pressure ulcer to the left inner lower leg, which measured 3.5 centimeters (cm) x 1.0 cm, and the wound bed was described as having yellow slough. However, a stage II pressure ulcer in this document was defined as partial thickness loss of dermis, presenting as shallow open ulcer with a red pink wound bed without slough. A stage III pressure ulcer was defined as full thickness tissue loss and slough may be present. Further review of the evaluation revealed there was no documentation if the wound had any drainage, odor, the condition of the surrounding skin or progress of the wound. The skin integrity care plan dated (MONTH) 21, (YEAR) included the resident had actual skin impairment. However, the care plan did not include the identification of the pressure ulcer to the left inner lower leg. Interventions included following facility protocol for treatment of [REDACTED]. A physician's orders [RE… | 2020-09-01 |
| 39 | 39 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 761 | D | 0 | 1 | 6GPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility documentation, staff and resident interviews, and policy and procedures, the facility failed to ensure that medications for two residents (#54 and #144) were secured in a locked storage area and were only accessible to authorized personnel. Findings include: -Resident #54 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR) revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. An observation was conducted in the resident's room on (MONTH) 29, (YEAR) at 9:08 a.m. A vial of [MEDICATION NAME] Nebulizing Solution was observed on the bedside table. The resident stated that the medication was left by a nurse (LPN/staff #46) the night before. At this time, a Licensed Practical Nurse (LPN/staff #63) entered the resident's room and the resident notified her of the presence of the medication. The nurse then removed the medication from the bedside table and placed it in her pocket and left the room. Following this, an interview was conducted with staff #63. She stated that it was the first time she had been in the resident's room that day and that the medication was [MEDICATION NAME]. An interview was conducted with the Director of Nursing (DON/staff #66) on (MONTH) 5, (YEAR) at 9:08 a.m. She stated that staff are never to leave medications at the bedside. She stated that staff are expected to observe residents taking the medication before leaving the room. She stated the nurses have received training on medication storage and that training and reminders are ongoing. An interview was conducted with LPN (staff #46) on (MONTH) 5, (YEAR) at 2:38 p.m. She stated that she forgot and left the [MEDICATION NAME] at the bedside. She stated the policy and expectation in th… | 2020-09-01 |
| 40 | 40 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 812 | D | 0 | 1 | 6GPJ11 | Based on observations, staff interview and policy review, the facility failed to ensure eating utensils were dry and ready to use, prior to being placed on resident's food trays. Findings include: An observation was conducted of the tray line on (MONTH) 30, (YEAR) at 12:05 p.m. Staff were observed placing wet eating utensils on the resident's food trays, just prior to the food trays being placed in the food cart for delivery to the unit. At this time, a dietary staff member directed the staff to make sure the utensils were not wet, and some of the wet utensils were removed off of the trays. However, further observations revealed that staff continued to place wet utensils on the food trays. An interview was conducted with a dietary staff member (staff #57) on (MONTH) 30, (YEAR) at 1:00 p.m. Staff #57 stated that he was responsible for ensuring that the utensils placed on the resident's trays were clean and dry. Staff #57 stated that the utensils had just come from the dishwasher and he missed some. Review of a policy regarding clean and dry dishware and utensils revealed documentation that all flatware, serving dishes, and cookware will be washed, rinsed, and sanitized after each use. The policy included that dishes and utensils were to air dry on the dish rack and were not to be dried with towels, and that when removing dishes, staff were to inspect them for cleanliness and dryness. | 2020-09-01 |
| 41 | 41 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 578 | D | 0 | 1 | ZWO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to have documentation of advanced directives for one resident (#10) and obtain physician orders once obtained, and failed to obtain physician orders in accordance with the advance directive for one resident (#171). Findings include: -Resident #10 was admitted to the facility on (MONTH) 30, (YEAR) and readmitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 3, which indicated severe cognitive impairment. Review of the clinical record on (MONTH) 5, 2019 revealed no documentation regarding advance directives for resident #10. There were also no physician orders for any advance directives. An interview was conducted with two licensed practical nurses (LPN/staff #52/staff #53) on (MONTH) 6, 2019 at 2:50 p.m. The nurses stated that they were unable to locate advance directive information for resident #10. Staff #52 stated that the nurses usually get a new order when a resident returns from the hospital, because the directive could change at anytime. Staff #52 stated that she would need to have the responsible party for the resident sign the form and that she would contact the responsible party right away. Review of the clinical record on (MONTH) 7, 2019 revealed advance directives had been obtained for resident #10. The advance directives were obtained from the resident's responsible party by telephone on (MONTH) 6, 2019 and included for a Do Not Resuscitate (DNR) status. Further review of the physician orders on (MONTH) 7, 2019 revealed there was no physician order for [REDACTED].>-Resident #171 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed an Advanced Directive form indicating the resident was a DNR status, which was signed by… | 2020-09-01 |
| 42 | 42 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 640 | D | 0 | 1 | ZWO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a Minimum Data Set (MDS) assessment was transmitted, within 14 days after completion for one resident (#2). Findings include: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a discharge MDS assessment was completed and dated 8/6/18. Review of the MDS transmittal report revealed that the discharge MDS assessment dated [DATE] had not been transmitted. An interview was conducted on 1/08/2019 at 11:23 a.m., with the MDS Coordinator (staff #116). Staff #116 stated the MDS assessments are completed by reviewing each chart, checking history and physicals, reviewing all physician orders [REDACTED]. Staff #116 stated when a resident is a planned discharged , a MDS-return not anticipated is completed. Staff #116 stated that she will open the discharge MDS like a regular assessment and will verify there are no errors. Staff #116 said that either the Assistant Director of Nursing (staff #117) or the Director of Nursing (staff #160) will sign off when the MDS is complete. Staff #116 stated the MDS would then be ready for transmission to CMS (Centers for Medicare/Medicaid Services). Staff #116 provided the MDS transmission report and stated that the discharge MDS dated [DATE] did not get transmitted. Staff #116 stated that the facility has 20 days to transmit a completed MDS. Staff #116 stated the facility policy is to use the RAI manual to ensure MDS accuracy and transmission. An interview was conducted on 1/8/2019 at 1:01 p.m. with the Director of Nursing (staff #160), who stated the expectation for the MDS nursing staff is to ensure that each MDS is completed and transmitted to CMS, within the required timeframe. Staff #160 stated the facility uses the RAI manual for all MDS expectations. Review of the RAI manual revealed that di… | 2020-09-01 |
| 43 | 43 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 641 | D | 0 | 1 | ZWO111 | **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 accurate for two residents (#'s 36 and 52). Findings include: -Resident #36 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED].#36 revealed that resident #36 had an onset of pneumonia on (MONTH) 24, (YEAR). Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) revealed documentation of an active [DIAGNOSES REDACTED]. However, review of the clinical record revealed that resident #36 had a history of [REDACTED]. An interview was conducted on 1/8/2019 at 11:23 a.m. with the MDS Coordinator (staff #116). Staff #116 stated the MDS assessments are completed by reviewing each chart, checking the history and physical, reviewing all physician orders [REDACTED]. Staff #116 stated the electronic chart is also reviewed for a 7-day look-back period, which includes all progress notes, current diagnoses, medications and treatments. Staff #116 stated that current [DIAGNOSES REDACTED]. Staff #116 stated if it was a non-active diagnoses, it would not be included on the MDS. An interview was conducted on 1/08/2019 at 1:01 p.m. with the Director of Nursing (staff #160), who stated the expectation for the MDS nursing staff is to ensure that each MDS is accurate and completed within the required timeframe. -Resident #52 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 14, (YEAR), revealed the resident did not receive an antipsychotic medication in the past seven days or since admission. However, the MDS assessment also included the following in the Antipsychotic Medication Review section: since admission the resident had received antipsychotic medications on a routine basis only, and that a Gradual Dose Reduction (GDR) had not been atte… | 2020-09-01 |
| 44 | 44 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 689 | D | 1 | 1 | ZWO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation and staff interviews, the facility failed to provide adequate supervision for one resident (#268) with known aggressive behaviors. Findings include: -Resident #268 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment for resident #268 dated (MONTH) 20, (YEAR), revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS also documented that the resident had physical behavioral symptoms against others that significantly interfered with the resident's care and put others at significant risk for injury. An activities note dated (MONTH) 21, (YEAR) stated the resident became agitated during bingo and began throwing bingo cards in the direction of other residents. An activities note dated (MONTH) 22, (YEAR) stated that resident #268 hit a staff member on the arm. Review of a care plan dated (MONTH) 23, (YEAR) revealed the resident exhibited behaviors of physical aggression such as hitting and kicking, during routine care. Interventions included to intervene before agitation escalates, guide resident away from the source of distress, provide one-on-one interaction, staff to re-approach the resident later or have a different staff member attempt to assist the resident, and if the resident becomes aggressive, staff should ensure her safety and give her time to calm down. A nursing note dated (MONTH) 25, (YEAR) included that resident #268 hit three staff members in the stomach and tried to kick them. Review of the behavior monitoring record for (MONTH) and (MONTH) (YEAR) revealed 4 episodes of resident #268 yelling out and 5 episodes of the resident striking out at staff. A physician's orders [REDACTED]. A nursing note dated (MONTH) 24, (YEAR) at 1:08 a.m., stated the resident was awake, roaming the halls and refusing care. The resident's p… | 2020-09-01 |
| 45 | 45 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 758 | E | 0 | 1 | ZWO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews and staff interviews, the facility failed to ensure there was adequate monitoring for adverse side effects for three residents (#10, #52 and #171) on [MEDICAL CONDITION] medications and failed to monitor target behaviors for one resident (#52) on an antidepressant medication. Findings include: -Resident #10 was admitted on (MONTH) 30, (YEAR) and readmitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also included the resident received antipsychotic medication 7 of 7 days and antidepressant medication 6 of 7 days of the lookback period. A review of the resident's care plan regarding the use of [MEDICAL CONDITION] medications included a goal that the resident would remain free of complications related to [MEDICAL CONDITION] drugs. Interventions were to monitor for side effects and effectiveness each shift and to monitor/document/report as needed any adverse reactions of [MEDICAL CONDITION] medications such as: unsteady gait, tardive dyskinesia, shuffling gate, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, [MEDICAL CONDITION], social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting and behavioral symptoms not usual to the person. The physician orders [REDACTED]. The orders did not include to monitor for adverse effects of these medications. Review of the Pharmacist New Admission Medication Review dated (MONTH) 10, (YEAR) revealed a recommendation to the physician/prescriber which stated [MEDICATION NAME] and [MEDICATION NAME] in combination may increase the risk of serotoni[DIAGNOSES REDACTED], if either drug is increased in dose/frequency, moni… | 2020-09-01 |
| 46 | 46 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 880 | E | 0 | 1 | ZWO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, review of the Center for Disease Control (CDC) guidelines and policy and procedures, the facility failed to implement infection control measures for one resident (#222) on contact isolation precautions and failed to ensure infection control measures were implemented regarding catheters for two residents (#41 and #321). Findings include: -Resident #222 was admitted (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Physician orders [REDACTED]. A nursing progress note dated (MONTH) 4, 2019 at 3:30 p.m. revealed the resident was placed on isolation precautions. A care plan dated (MONTH) 5, 2019 revealed the resident had [MEDICAL CONDITION]. Interventions included the following: Contact Isolation: wear gowns and masks when changing contaminated linens; educate resident, family and staff regarding preventive measures to contain the infection; place in private room with contact isolation precautions and disinfect all equipment before leaving the room. An observation was conducted on (MONTH) 5, 2019 at 11:03 a.m., outside of resident #222's room. A visitor was observed inside the resident's room and was wearing a gown that was not secured, and was slipping off her shoulders. The visitor also only had one glove on her right hand. The visitor was observed moving items on and off the bedside table with both hands. During the observation, the visitor stepped into the hallway over the threshold, two times with the unsecured gown and one glove still on, and then re-entered the room. At one point, the visitor removed the gown and one glove, and placed them into the red biohazard bag by the door and exited the room. The visitor did not wash her hands prior to leaving the room. The visitor then picked up her personal items from the top of the isolation cart which was outside of the resident's room, and proceeded to leave the building without washing her ha… | 2020-09-01 |
| 47 | 47 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2018-06-28 | 622 | D | 1 | 0 | KWBO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of hospital documentation, staff interviews and review of facility policies and procedures, the facility failed to ensure there was documentation in one resident's (#2) clinical record regarding the basis for the transfer. The sample size was three. Findings include: Resident #2 was admitted to the facility on (MONTH) 15, (YEAR) with [DIAGNOSES REDACTED]. Nursing Note dated (MONTH) 15, (YEAR) documented Arrived from (name of hospital) at 3:15 p.m .Alert and oriented x 3 but slow to speak appears exhausted .Oxygen two liters - not on home oxygen . Review of a Social Services Note dated (MONTH) 18, (YEAR) at 2:03 p.m. documented .requesting that patient be transferred to (another skilled nursing facility) to continue her skilled related to family's dissatisfaction with her care. Writer obtained telephone order for discharge . Review of a Physician Telephone Order dated (MONTH) 18, (YEAR) at 6:18 p.m. documented Send to ER (emergency room ). There was no documentation on the telephone order as to the reason for the transfer and the order was not signed by the resident's primary physician at the facility. Review of the clinical record revealed no documentation regarding the basis for the transfer to the hospital. Review of hospital documentation dated (MONTH) 18, (YEAR) at 10:30 p.m. documented .per her primary care physician .who saw the patient today, patient was somnolent and hypoventilating this afternoon and hypoxic (83% on room air) . An interview was conducted with the medical records clerk, staff #76 on (MONTH) 27, (YEAR) at 11:38 a.m. The medical records clerk stated that the resident did not get transferred to the other skilled nursing facility because of insurance purposes but that she thought the resident's family took the resident to the hospital. An interview was conducted with the DON (director of nursing), staff #64 on (MONTH) 27, (YEAR) at 2:00 p.m. The DON stated that she did not think t… | 2020-09-01 |
| 48 | 48 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2018-06-28 | 689 | G | 1 | 0 | KWBO11 | **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 facilty failed to ensure that one resident (#1) was transferred appropriately to prevent a fracture to her humerus. The sample size was three. Findings include: Resident #1 was admitted to the facility on (MONTH) 19, 2012 with [DIAGNOSES REDACTED]. Review of an ADL (activities of daily living) care plan dated (MONTH) 13, (YEAR) revealed Resident requires extensive assist with ADLs with two staff members for transfers .due to debility, due [MEDICAL CONDITION] and right sided sensory impairment. A goal documented was Resident will .have daily needs met by staff. Approaches documented were Two staff members for all transfers. Patient and her daughters refuse gait belt use. They have been educated but continue to state their refusal . Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), section G Functional Status revealed the resident required the extensive assistance of 2 for transfers and support. Nursing Note dated (MONTH) 23, (YEAR) documented Resident was being transferred by CNA (certified nursing assistant) from bed to wheelchair. When resident's legs touched the front wheel of the wheelchair and CNA was unable to complete transfer safely that's when CNA lowered resident gently to the floor and called for help. Nursing Note dated (MONTH) 23, (YEAR) documented Resident x-rays came back abnormal for RUE (right upper extremity). Orders were received and transcribed. Family is aware of transportation to (name of hospital) emergency room for further evaluation . An Accident/Incident Report dated (MONTH) 23, (YEAR) by the CNA who transferred the resident when she fell , staff #91, documented We were pivoting to sit in chair. Then she said oh. I looked down and seen her left foot slide behind her small front wheel. I could not hold her up and get her right foot in the right place so I slowly slid down my leg to a… | 2020-09-01 |
| 49 | 49 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2016-10-06 | 241 | D | 0 | 1 | VEV011 | Based on observation, staff interviews, and policy and procedures, the facility failed to promote care for residents in a manner that enhances each resident's dignity and respect, by failing to offer residents condiments with their meals and by failing to promptly clean a resident after a beverage spill. Findings include: A dining observation was conducted on (MONTH) 3, (YEAR) at 11:45 a.m., on the secured dementia unit. Prior to the start of the lunch meal, one resident was observed to spill a can of soda on her clothing and on the table where she was seated. The resident was observed to call out I need some help over here, please. One CNA (Certified Nursing Assistant) responded to the resident's call for help and proceeded to wipe up the soda spill from the table. However; the CNA neglected to clean or offer to change the resident's wet clothing. The resident ate her meal in wet clothing. In addition, during this meal observation no condiments, including salt and pepper were offered to the residents. An interview was conducted on (MONTH) 4, (YEAR) at 12:40 p.m., with a LPN (Licensed Practical Nurse/staff #177). She stated that salt and pepper and other condiments are provided to residents if they ask for it. She stated that if a resident was unable to request any condiments and was eating good, then the food must be alright and the condiments would not be offered. Another interview was conducted on (MONTH) 4, (YEAR) at 12:45 p.m., with a CNA (staff #224). She stated that she had not cleaned the resident after the soda spill, because it was a crazy day. She stated that she should have cleaned and changed the resident right after the spill. An interview was conducted on (MONTH) 4, (YEAR) at 2:30 p.m., with the DON (Director of Nursing/staff #161). She stated that all residents should have been offered condiments for their meal. She also stated that the resident who spilled the soda should have been cleaned and changed, since she would want clean, dry clothing on for her meal. A facility policy titled Condiments, … | 2020-09-01 |
| 50 | 50 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2016-10-06 | 279 | D | 0 | 1 | VEV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that a comprehensive care plan was developed, as indicated in Section V. of the MDS (Minimum Data Set) assessment for one resident (#76). Findings include: Resident #76 was admitted on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A review of Section V. of the admission (Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR), revealed the care area for activities of daily living triggered and a care plan would be developed to address the resident's needs. However, the clinical record did not include any documented evidence that an activities of daily living care plan had been developed. An interview was conducted on (MONTH) 6, (YEAR), with MDS staff #234, who following a review and comparison of the MDS assessment and care plans, stated that an activities of daily living care plan should have been developed as indicated in Section V. of the MDS assessment. An interview was conducted on (MONTH) 6, (YEAR) at 12:13 p.m., with the ADON (Assistant Director of Nursing/staff #178), who following a review of the clinical record stated that the expectation was that care plans would be developed as indicated. Staff #178 also stated that the facility did not have a policy regarding the development of comprehensive care plans based on Section V. of the MDS assessment. | 2020-09-01 |
| 51 | 51 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2016-10-06 | 314 | E | 0 | 1 | VEV011 | **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 that pressure ulcer care and services were consistently provided for one resident (#24). Findings include: Resident #24 was readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. The admission nursing evaluation dated (MONTH) 16, (YEAR), included that the resident's left heel had a round black area, which measured 4 by 4 cm (centimeters) and that it was possibly a deep tissue injury. A pressure ulcer care plan was developed on (MONTH) 16, (YEAR), and included documentation that an unstageable pressure ulcer was present on the resident's left heel. A Braden Risk assessment dated (MONTH) 16, (YEAR), identified that the resident was a high risk for the development of a pressure ulcer. The resident's score was a 12 and according to the Braden risk assessment key, a score of 10 to 12 indicated a high risk. Review of the clinical record revealed there were no specific admission treatment orders for the unstageable pressure ulcer to the resident's left heel. A history and physical dated (MONTH) 22, (YEAR), included that eschar was present on the resident's left heel. A physician's orders [REDACTED]. The (MONTH) (YEAR), TAR included the physician's orders [REDACTED]. The next pressure ulcer assessment was not completed until 13 days later on (MONTH) 29, (YEAR). The documentation included that an unstageable pressure ulcer was present on the resident's left heel, which measured 2.5 by 3 cm and to continue the skin prep every shift and prn. Review of a nurse's note dated (MONTH) 6, (YEAR), revealed the resident had an unstageable pressure ulcer to the left heel, which measured 2 x 4 cm with 100% eschar. A review of the (MONTH) (YEAR), TARs revealed that the skin prep order which was to be done every shift had been transcribed to be done nightly and prn, and not every shift as physician ordered. Further review revealed that the skin prep was only ap… | 2020-09-01 |
| 52 | 52 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2016-10-06 | 334 | D | 0 | 1 | VEV011 | **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 the Pneumococcal vaccine was offered to one resident (#166). Findings include: Resident #166 was admitted (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) recapitulation of physician orders [REDACTED]. However, review of the clinical record revealed no documented evidence that the pneumococcal vaccine was offered to the resident or that the resident refused the vaccine, or that the vaccine was contraindicated. An interview was conducted on (MONTH) 6, (YEAR) at 2:45 p.m., with the Assistant Director of Nursing (staff #178). She was unable to locate any documented evidence that the pneumococcal vaccine had been offered. A facility policy titled, Pneumococcal Vaccine included all residents will be offered the Pneumococcal vaccine to aid in preventing pneumonia/Pneumococcal infection. The policy also included: 1. Prior to admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series., and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 3. Before receiving a Pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of Pneumococcal vaccine. | 2020-09-01 |
| 53 | 53 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2016-10-06 | 364 | D | 0 | 1 | VEV011 | Based on observations and staff interviews, the facility failed to ensure that residents were assisted with their meals in a timely manner, in order to maintain food at preferable temperatures. Findings include: A dinning observation was conducted on (MONTH) 3, (YEAR) at 11:45 a.m. on the Kalmanovitz secured dementia unit. During this observation, two residents were seated in their wheelchairs at the same table. Once the noon meal arrived on the unit, the food was served to both of the residents and the plate covers were removed. At this time, neither resident was observed to attempt to feed themselves, nor did staff attempt to feed either resident. After 15 minutes, a CNA (Certified Nursing Assistant/staff #224) attempted to assist one of the residents with her meal. The resident was observed to not want to eat the meal. After 5 minutes, the CNA moved to the second resident and attempted to feed this resident. However, this resident also did not want to eat her food. Further observations revealed that the CNA, nor any other staff member was observed to offer to re-heat the resident's food. An interview was conducted with staff #224 immediately following this observation. Although the lunch meal had sat uncovered for 15-20 minutes, staff #224 stated that she thought the food would still be warm, because she could feel the warmth from the food, while she cut the noodles up with a spoon. Another interview was conducted on (MONTH) 4, (YEAR) at 2:30 p.m., with the DON (Director of Nursing/staff #161). She stated that the residents' food should have remained covered until staff were ready to assist the residents with their meals. She also stated that the meal could have been re-heated if needed. | 2020-09-01 |
| 54 | 54 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2016-10-06 | 371 | D | 0 | 1 | VEV011 | Based on observation, staff interviews and policy review, the facility failed to ensure that staff did not touch ready to eat food with bare hands. Findings include: A dining observation was conducted on (MONTH) 3, (YEAR) at 11:45 a.m. on the Kalmanovitz secured dementia unit. During this observation, a CNA (Certified Nursing Assistant/staff #185) was observed to touch a resident's muffin, with her bare hands. An interview was conducted on (MONTH) 4, (YEAR) at 12:30 p.m., with the CN[NAME] Although the CNA was unable to recall if she had touched any resident's food with her bare hands, she stated that would be a sanitary problem. Another interview was conducted on (MONTH) 4, (YEAR) at 2:30 p.m., with the Director of Nursing (staff #161) who stated that staff should not handle ready to eat food with their hands and that utensils should have been used. A facility policy titled, Assistance with Meals included: 7. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. | 2020-09-01 |
| 55 | 55 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2016-10-06 | 431 | E | 0 | 1 | VEV011 | Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that medications were properly stored, and that expired medication and laboratory supplies were not expired and available for resident use. The facility also failed to ensure that the medication refrigerator temperatures were consistently monitored. Findings include: A medication storage observation was conducted on (MONTH) 3, (YEAR), on all of the nursing units and the following concerns were identified: Kalmanovitz secured dementia unit: In the Medication storage room, there was an unlocked medication refrigerator which contained a locked plastic narcotic box. However, the narcotic box was not affixed to the inside of the medication refrigerator. Further observations revealed that the plastic narcotic box did not fully close, and the opening was large enough to withdraw medications from the box, without unlocking it. Inside the plastic narcotic box were a total of 23 vials of Lorazepam (an anti-anxiety medication). At this time, the medication refrigerator temperature log for (MONTH) (YEAR) was reviewed and revealed that there was no documentation that the temperature of the refrigerator was monitored on one day. An interview was conducted on (MONTH) 4, (YEAR) at 12:45 p.m., with a LPN (Licensed Practical Nurse/staff #177). She stated that she had contacted the maintaince department and had the narcotic box permanently secured. At this time, another observation of the narcotic box was conducted. Inside of the unlocked refrigerator was a locked plastic narcotic box. The narcotic box was now attached to a shelf in the refrigerator. However, the shelf was able to be easily removed, along with the narcotic box. Rich unit: In the medication storage room there were eight yellow cap laboratory tubes, which had an expiration date of (MONTH) (YEAR). In addition, the medication refrigerator temperature logs were reviewed and revealed the following: in (MONTH) (YEAR), there were four days with no evidence that the … | 2020-09-01 |
| 56 | 56 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2016-10-06 | 441 | D | 0 | 1 | VEV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure that dietary staff used proper handwashing techniques and failed to ensure proper infection control practices were implemented during a pressure ulcer treatment for one resident (#24). Findings include: -Observations were conducted on (MONTH) 5, (YEAR) of multiple dietary staff members washing their hands in the kitchen sinks. The handwashing sinks were equipped with faucet rods in the center of the faucet spigot. The purpose of the faucet rods were to turn the water on and off. To turn on the water, the faucet rod had to be moved and the rod had to be held onto, in order to keep the water flowing. If you let go of the rod, the water turned off. Multiple observations revealed that dietary staff touched the faucet rods with their soiled hands to turn on the water, then let go of the faucet rod and lathered their hands with soap, then they had to touch the faucet rod again with their clean hands to start the flow of water, in order to rinse their hands. An interview was conducted with the dietician (staff #233) on (MONTH) 5, (YEAR) at 11:20 a.m. The dietician stated that the faucet rod was contaminated, unless it was facility procedure to clean the faucet rods after each use. An interview was conducted with the food service assistant manager (staff #63) on (MONTH) 5, (YEAR) at 12:00 p.m. The food service assistant manager did not recognize a problem with this handwashing procedure. A review of the facility's policy on Hand Washing revealed for staff to wash hands following proper hand washing procedures. Instructions on how to wash hands included to turn on the faucet using a paper towel to avoid contaminating the faucet, wet hands and scrub with soap and additional water as needed, rinse thoroughly, dry hands with a paper towel and turn the faucet off with a paper towel. -Resident #24 was readmitted on (MONTH) 1… | 2020-09-01 |
| 57 | 57 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2017-10-19 | 154 | E | 0 | 1 | PP4811 | **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 three residents and/or representatives (#94, #195 and #230) were informed of the risks and benefits of [MEDICAL CONDITION] medications, prior to administering. Findings include: -Resident #94 was admitted (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 1, (YEAR) included that the resident exhibited intrusive behaviors and was difficult to redirect related to [DIAGNOSES REDACTED]. Interventions included for medications to be administered as ordered by the provider. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. The MDS also included the resident received an anti-depressant. The physician's orders [REDACTED]. However, review of the clinical record revealed no evidence that the resident was informed of the risks and benefits of the Trazadone and the [MEDICATION NAME]. In an interview conducted with a Licensed Practical Nurse (LPN/staff #131) on (MONTH) 19, (YEAR) at 9:30 a.m., she stated that before a resident is administered [MEDICAL CONDITION] medications, the risks and benefits should be explained to the resident. Staff #131 stated that an informed consent which includes the risks and benefits of the medication should be signed by the resident or resident representative before administration. During an interview conducted on (MONTH) 19, (YEAR) at 12:11 p.m. with the Director of Nursing (DON/staff 64), she stated that she was unable to locate an informed consent for these medications for this resident. -Resident #195 was admitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated (MONTH) 3, (YEAR) revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. A care plan dated (MONTH) 2, (YEAR) inclu… | 2020-09-01 |
| 58 | 58 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2017-10-19 | 278 | D | 0 | 1 | PP4811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one resident (#195). Findings include: Resident #195 was admitted (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR) revealed the resident was administered an antipsychotic medication for 7 days during the look back period. However, review of the (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. The MDS further included that the resident was administered a hypnotic medication on 5 days, during the look back period. However, review of the (MONTH) 27 through (MONTH) 3, (YEAR) MARs revealed the resident received the hypnotic medication for 3 days during the look back period. In addition, the MDS included that the resident was not administered an anticoagulant medication. However, review of the (MONTH) 27 through (MONTH) 3, (YEAR) MARs revealed the resident was administered an anticoagulant medication for 7 days. The MDS further included the resident was administered an antibiotic medication for 7 days. However, review of the (MONTH) 27 through (MONTH) 3, (YEAR) MARs revealed the resident was administered an antibiotic medication for 5 days during the look back period. An interview was conducted with the MDS coordinator/Assistant Director of Nursing (ADON/staff #8) on (MONTH) 19, (YEAR) at 8:49 a.m. She stated that when coding medications administered on the MDS, the MAR indicated [REDACTED]. Staff #8 stated that the correct coding for the MDS assessment dated (MONTH) 3, (YEAR), should have included that an anticoagulant medication was administered for 7 days, an antipsychotic medication was administered for 6 days, an antibiotic medication was administered for 5 days, and a hypnotic medication was administered for 3 days. She stated… | 2020-09-01 |
| 59 | 59 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2017-10-19 | 281 | D | 0 | 1 | PP4811 | **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 an order was clarified with the physician regarding the frequency for administering a narcotic pain medication to one resident (#257). Findings include: Resident #257 was admitted (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order did not include a frequency for administration. Review of the Medication Administration Record [REDACTED]. However, the MAR indicated [REDACTED]. Review of the clinical record revealed there was no order for the [MEDICATION NAME] to be administered every four hours PRN. An interview was conducted on (MONTH) 18, (YEAR) at 9:28 a.m., with a licensed practical nurse (staff #141). She stated the order for [MEDICATION NAME] did not have a frequency and should have been clarified with the physician. Staff #141 stated that physician's orders [REDACTED]. An interview was conducted on (MONTH) 18, (YEAR) at 9:51 a.m., with the Assistant Director of Nursing (staff #8). Staff #8 stated medication orders should include the frequency. She stated the expectation is for nurses to call the physician to clarify an order. Staff #8 stated the [MEDICATION NAME] order did not have a frequency and the order was not clarified with the physician. During an interview conducted (MONTH) 19, (YEAR) at 11:23 a.m. with the Director of Nursing (staff #64), staff #64 stated medication orders should include the medication frequency, and if the frequency is not written, the nurse is to clarify the order with the physician. Review of the facility's policy regarding Administering Medications revealed that medications must be administered in accordance with the orders, including any required time frame. | 2020-09-01 |
| 60 | 60 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2017-10-19 | 371 | E | 0 | 1 | PP4811 | Based on observations, facility documentation, staff interviews and policy and procedures, the facility failed to ensure that food and kitchenware were stored in a clean and sanitary manner, and failed to ensure sanitation levels for the dishwashing machine were consistently monitored. Findings include: Regarding the food storage: An observation of the kitchen was conducted at 11:00 a.m. on (MONTH) 16, (YEAR) and the following was observed: -A head of romaine lettuce was stored uncovered on a wheeled cart. The lettuce was in contact with the surface of the cart. -In the dry storage room there were multiple tea bags stored on a food rack. The tea bags were uncovered and in direct contact with the rack. In an interview with the assistant food service manager (staff #105) at 11:05 a.m. on (MONTH) 16, (YEAR), he stated that these items should not be stored this way. The Food Storage policy included that sufficient storage facilities are provided to keep foods safe. The policy also included food is stored in an area that is clean, dry, and free from contaminants and that food should be stored in covered containers or wrapped carefully and securely. Regarding the storage of kitchenware: An observation of the kitchen was conducted at 10:35 a.m. on (MONTH) 18, (YEAR) and the following was observed: -A tray with multiple ready-to-use bowls was stored near the dish room. The bowls were observed to be wet and when handled, the water dripped to the floor. -Multiple ready-to-use plastic cups which were stacked on top of each other were observed to be wet and when handled, water dripped onto the floor. -Multiple ready-to-use plates were stored on a rack with food debris on them. The food debris fell to the floor when the plates were lifted. -Two small pans stored ready-to-use had dried food debris on them. -A large rack had stuck-on debris on it and was stored ready-to-use. -Two metal bowl grill covers stored ready-to-use had blackened debris on them. An interview was conducted with staff #105 at 10:45 a.m. on (MONTH) 18, (YEA… | 2020-09-01 |
| 61 | 61 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2017-10-19 | 500 | D | 1 | 1 | PP4811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and facility documentation, the facility failed to ensure that a urology appointment was scheduled in a timely manner for one resident (#173). Findings include: Resident #173 was admitted (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. An interim care plan dated (MONTH) 19, (YEAR) revealed that the resident had a urinary catheter in place. A goal included the resident would be free of complications. Review of an Appointment/Transportation form dated (MONTH) 26, (YEAR) revealed the resident went to a follow up nephrology appointment. At the bottom of this form were progress notes from the nephrologist provider. The notes included for the resident to have a urology evaluation to assess bladder function and possibly remove the urinary catheter. A physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 26, (YEAR) revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The resident was also coded as having an indwelling urinary catheter. Review of the clinical record revealed no documentation of an attempt to schedule the urology appointment or that an appointment had been scheduled from (MONTH) 26-May 11. A nursing note dated (MONTH) 12, (YEAR) included that a family member voiced concerns about the resident's care. The note included that a nurse practitioner (NP) was present and wrote an order for [REDACTED].>A NP order dated (MONTH) 12, (YEAR) included for a urology consult related to [MEDICAL CONDITION]. Review of an Appointment/Transportation form dated (MONTH) 18, (YEAR) revealed the resident went to the urologist appointment. At the bottom of this form were progress notes from the urology provider. The notes included the resident had acute [MEDICAL CONDITION] requiring Foley catheter. The catheter was exchanged in the office today. Will need to come back in one month for a void… | 2020-09-01 |
| 62 | 62 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2019-01-25 | 600 | G | 1 | 1 | NNTV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, facility documents and policy and procedures, the facility failed to ensure one resident (#8) was free from neglect which resulted in harm, failed to ensure one resident (#284) was free from verbal abuse by a staff member and failed to ensure that one resident (#283) was free from physical abuse by another resident (#11). The resident census was 41. Findings include: -Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have severe cognitive impairment. The functional assessment of the MDS indicated the resident had no impairment with range of motion to her extremities. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended mo… | 2020-09-01 |
| 63 | 63 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2019-01-25 | 607 | D | 0 | 1 | NNTV11 | **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 implement their abuse policy, by failing to identify an incident of neglect involving a staff member and a resident (#8), and by failing to report the incident of neglect to the State Agency and Adult Protective Services (APS). The resident census was 41. Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her ne… | 2020-09-01 |
| 64 | 64 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2019-01-25 | 608 | D | 0 | 1 | NNTV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and policy and procedures, the facility failed to report a suspicion of a crime (neglect) to law enforcement involving a staff member and a resident (#8). Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that… | 2020-09-01 |
| 65 | 65 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2019-01-25 | 609 | D | 0 | 1 | NNTV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, facility documentation and policy and procedures, the facility failed to report an incident of neglect involving one resident (#8) to the State Agency and to Adult Protective Services (APS). The resident census was 41. Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the I… | 2020-09-01 |
| 66 | 66 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2019-01-25 | 689 | E | 0 | 1 | NNTV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, facility documents and policy and procedure, the facility failed to ensure safe water temperatures were maintained in eight resident rooms. The facility census was 41. Findings include: During an observation conducted on 1/22/19 at 2:35 p.m., the water temperature of the restroom sink in room [ROOM NUMBER]-1 was checked and was 135 degrees Fahrenheit (F). This resident was able to use the restroom sink. During an observation conducted on 1/22/19 at 2:58 p.m., the water temperature in room [ROOM NUMBER]-1 was 130 degrees F. This resident was able to use the restroom. At this time, a family member stated sometimes the water feels a little hot and we are just careful. Additional water temperatures were taken on 1/22/19 at 3:43 p.m. and the following was found: -room [ROOM NUMBER]: water temperature was 126.6 degrees F -room [ROOM NUMBER]: water temperature was 126.2 degrees F -room [ROOM NUMBER]: water temperature was 130 degrees F -room [ROOM NUMBER]: water temperature was 135 degrees F -room [ROOM NUMBER]: water temperature was 134 degrees F -room [ROOM NUMBER]: water temperature was 131.5 degrees F On 1/22/19 at 4:15 p.m., the Environmental Services manager (staff #5) tested the water temperatures and the following was observed: -room [ROOM NUMBER]: water temperature was 122 degrees F -room [ROOM NUMBER]: water temperature was 132 degrees F -room [ROOM NUMBER]: water temperature was 136 degrees F -room [ROOM NUMBER]: water temperature was 118 degrees F -room [ROOM NUMBER]: water temperature was 140 degrees F -room [ROOM NUMBER]: water temperature was 124 degrees F During this observation, an interview was conducted with staff #5, who stated that water temperatures are checked weekly and documented and there have not been any problems. He stated the water should be run for 3-5 minutes before checking the temperatures. The facility immediately turned down the water temperatures at least twice and monitore… | 2020-09-01 |
| 67 | 67 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2016-09-22 | 241 | D | 0 | 1 | BZVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy review, the facility failed to promote care for residents in a manner that maintains each residents dignity, by having one resident (#151) who was in their bed and their brief and lower extremities were exposed and were visible to others in the hallway. Findings include: Resident #151 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated (MONTH) 15, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated that the resident had moderate cognitive impairment. A review of the admission nursing evaluation revealed the resident had bilateral weakness to the lower extremities. During an observation conducted on (MONTH) 19, (YEAR) at 6:30 a.m., resident #151 was observed inside the room sleeping. The resident was lying on his bed, with his lower legs and brief exposed. The privacy curtains were not pulled and the resident's door was wide open. The resident was visible from the hallway. Another observation was conducted on (MONTH) 19, (YEAR) at 7:35 a.m. The resident was in bed with his lower legs and brief exposed. The door was open and the resident was visible from the hallway. A later observation was conducted at 10:06 a.m. of the resident lying in bed asleep, with the door open. The resident was uncovered and his belly, lower legs and brief were exposed and he was visible from the hallway. This resident's room was directly across from the activity room. During this observation, there was an activity taking place in the activity room. Multiple staff, residents and visitors were observed passing by the resident's room. At 10:11 a.m., a certified nursing assistant (CNA/staff #7) entered the resident's room, but then quickly exited. The resident remained uncovered and his belly, lower legs and brief were still exposed. At 10:21 a.m., staff #7 looked inside the resident's room, but did not notice tha… | 2020-09-01 |
| 68 | 68 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2016-09-22 | 250 | D | 0 | 1 | BZVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and policy review, the facility failed to provide medically-related social services to maintain the highest practicable physical, mental, and psychosocial well-being of one resident (#144). Findings include: Resident #144 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. Physician admission orders [REDACTED]. A care plan initiated on (MONTH) 1, (YEAR) included for the use of antianxiety medications related to an anxiety disorder. Interventions included to administer anxiety medications as ordered and to monitor and document side effects and effectiveness. A social service intervention included to educate the resident/family regarding the risks/benefits and side effects and/or toxic symptoms of antianxiety medication. Another care plan included the resident exhibited behavior problems related to hitting staff, throwing food, and poor safety awareness. Interventions included to administer medication as ordered after non pharmacological interventions are tried and ineffective, monitor side effects, approach resident calmly and provide activities. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) revealed the resident had a Basic Interview for Mental Status score of 13, which indicated the resident was cognitively intact. The mood section indicated the resident had not exhibited any symptoms of depression since arrival. Review of the behavior section revealed the resident had not exhibited any behaviors since admission. Nursing progress notes for (MONTH) 6 and 7, (YEAR) documented the resident complained of increased anxiety and requested the Alprazolam. Review of the Daily Skilled Notes from (MONTH) 8, 9 and 10, (YEAR) included the resident was experiencing confusion and anxiety, and received Alprazolam as ordered. A MAR note dated (MONTH) 10, (YEAR) documented the resident was trying to stand and remove her clothing… | 2020-09-01 |
| 69 | 69 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2016-09-22 | 278 | D | 0 | 1 | BZVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure one resident's (#136) Minimum Data Set (MDS) assessment was accurate. Findings include: Resident #136 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A pressure ulcer assessment dated (MONTH) 26, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. The pressure ulcer care plan dated (MONTH) 27, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. Review of the physician wound care note dated (MONTH) 28, (YEAR) also revealed that the resident had a stage III pressure ulcer located on the sacrum. However, review of the admission MDS assessment dated (MONTH) 1, (YEAR) revealed in Section I. that the resident was coded as having an active [DIAGNOSES REDACTED]. In an interview with the Director of Nursing (DON/staff #6) conducted on (MONTH) 22, (YEAR) at 9:00 a.m., she stated that Section I. of the MDS admission assessment was an error and the resident's pressure ulcer wound was a stage III. In an interview with the MDS Coordinator (staff #55) conducted on (MONTH) 22, (YEAR) at 9:31 a.m., he stated that he bases the MDS entries on therapy documentation, the certified nursing assistant (CNA) notes regarding activities of daily living, the daily assessments of the nurses and physician documentation. He stated that when there are discrepancies on the documentation regarding the stages and locations of pressure ulcers, he will verify it with the physician and the nurse, and will go with what the physician said and documents. He stated that he should have checked and clarified Section I. of the MDS to ensure that the stage of the pressure ulcer matched. Review of the RAI manual for the MDS revealed .the importance of accurately completing and submitting the MDS assessment cannot be over-emphasized. The MDS assessment is the basis for the de… | 2020-09-01 |
| 70 | 70 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2016-09-22 | 281 | D | 0 | 1 | BZVV11 | **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 an interim care plan was developed to address one resident's (#43) needs related to contact isolation. Findings include: Resident #43 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A review of the Infection Surveillance Report dated (MONTH) 1, (YEAR) revealed Pt (patient) arrived to facility with infection .Type of isolation precautions:[MEDICAL CONDITION]-Contact . A physician's orders [REDACTED]. A nurses note dated (MONTH) 2, (YEAR) revealed Resident on isolation precautions related to DX (diagnosis):[MEDICAL CONDITION] of abdominal wound. Resident continues with PO (by mouth) antibiotics this shift without noted signs/symptoms of adverse or side effect. The admission Minimum Data Set assessment dated (MONTH) 8, (YEAR) also identified that the resident was on isolation. However, review of the clinical record revealed there was no interim care plan that was developed to address the residents needs related to contact isolation. During an interview conducted at 9:05 a.m. on (MONTH) 22, (YEAR), a LPN (Licensed Practical Nurse/staff #2) stated the admitting nurse was responsible for the development of the interim care plan. She stated that she would expect the need for contact isolation to be included in the interim care plan, when the resident has a [DIAGNOSES REDACTED]. During an interview conducted at 9:17 a.m. on (MONTH) 22, (YEAR), the DON (Director of Nursing/staff #6) also stated the nurse admitting the resident was responsible for developing the interim care plan. A review of the Care Plans - Preliminary policy and procedure revealed, A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. The policy also stated To assure that the resident's immediate care needs are met and maintained, a preliminary care plan wi… | 2020-09-01 |
| 71 | 71 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2016-09-22 | 314 | D | 0 | 1 | BZVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#136) pressure ulcer was accurately identified and documented. Findings include: Resident #136 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. According to a hospital physician progress notes [REDACTED]. Review of the admission nursing evaluation dated (MONTH) 25, (YEAR) revealed the resident had a wound on the sacrum. However, there was no clinical record documentation of any description of the wound or any measurements. Review of the admission orders [REDACTED]. There were orders to apply EPC (Endothelial Progenitor Cell) to gluteal cleft/coccyx three times a day for skin impairment, however, there was no documentation that this order was clarified with the physician, in order to determine if this treatment was for the sacral pressure ulcer. An initial care plan dated (MONTH) 25, (YEAR) included that the resident had skin breakdown to the sacrum. Interventions included for weekly skin checks and to notify the charge nurse of skin issues. Review of the pressure ulcer assessment documentation dated (MONTH) 26, (YEAR), revealed the resident had a stage III pressure ulcer to the sacrum, which measured 2.1 cm x 2.0 cm x 0.2 cm. Per the documentation, the treatment included for the use of [MEDICATION NAME]. However, there were no wound treatment orders for the use of [MEDICATION NAME]. A physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR (Treatment Administration Record) revealed the above order to the coccyx. However, there was no clinical record documentation that this order was clarified with the physician, in order to determine if the treatment order was for the sacral pressure ulcer or if it was a new wound to the coccyx which had developed. A pressure ulcer care plan dated (MONTH) 27, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. Interventions included monitor… | 2020-09-01 |
| 72 | 72 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2016-09-22 | 514 | D | 0 | 1 | BZVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to maintain clinical records that were accurately documented, by failing to ensure a physician's orders [REDACTED].#5). Findings include: Resident #5 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Discharge orders from the hospital dated (MONTH) 9, (YEAR) included an order for [REDACTED]. However, review of the current physician's orders [REDACTED].>Review of the MAR (medication administration record) for (MONTH) and (MONTH) (YEAR) also revealed the order for [MEDICATION NAME] 27.5 mcg. In an interview with a Licensed Practical Nurse (LPN/staff #35) on (MONTH) 21, (YEAR) at 12:55 p.m., she reviewed the orders and acknowledged that the order for [MEDICATION NAME] 27.5 mcg was incorrect. In an interview on (MONTH) 21, (YEAR) at 1:00 p.m., the Clinical Operations Director (staff #76) reviewed the resident's chart regarding the original admission orders [REDACTED]. She stated somehow the order must have been entered incorrectly into the electronic clinical record. In an interview with the corporate resource nurse (staff #77) on (MONTH) 22, (YEAR) at 8:12 a.m., she stated that the night nurse is responsible for checking the electronic chart to ensure new orders are put in correctly. In addition, she stated that either herself and/or the Director of Nursing, review new orders in an audit report to ensure orders are transcribed correctly. | 2020-09-01 |
| 73 | 73 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2017-10-25 | 156 | D | 1 | 1 | DB1811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, and policy review, the facility failed to provide two residents (#s 13 and 18) with Notifications of Medicare Non-Coverage (NOMNC), prior to discharge. Findings include: -Resident #18 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the Admission Record dated (MONTH) 21, (YEAR) revealed the resident's primary payer source was Medicare [NAME] Review of an undated and unsigned Case Management Activity note revealed DC (discharge) to group Home .will get house cleaned on 6/8 and wants to be home on that day to make sure all goes well. Review of the Physical Therapy Discharge Summary dated (MONTH) 7, (YEAR) revealed the resident's discharge destination was a group home, and the reason for discharge was Highest Practical Level Achieved. A review of the Occupational Therapy Discharge Summary dated (MONTH) 7, (YEAR) revealed the resident's discharge destination was a group home, and the reason for discharge was Highest Practical Level Achieved. Review of the clinical record revealed no documented evidence that a Notice of Medicare Non-Coverage was provided to the resident, prior to being discharged to the community on (MONTH) 8, (YEAR). -Resident #13 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A review of the Admission Record dated (MONTH) 15, (YEAR) revealed the resident's primary payer source was Medicare [NAME] Review of an unsigned and undated Case Management/Interdisciplinary Discharge Plan-Tier Two Active Inpatient Plan revealed Resident wants to return home on date/week of 6/5 for family reunion. Review of the Physical Therapy Discharge Summary dated (MONTH) 6, (YEAR) revealed the resident's discharge destination was Home, and the reason for discharge was Highest Practical Level Achieved. A review of the Occupational Therapy Discharge Summary dated (MONTH) 6, (YEAR) revealed the resident's discharge destination wa… | 2020-09-01 |
| 74 | 74 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2017-10-25 | 281 | D | 1 | 1 | DB1811 | **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 medications were administered as physician ordered for two residents (#143 and #145). Findings include: -Resident #143 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. -[MEDICATION NAME] 325 mg (milligrams) by mouth every six hours PRN (as needed) for a pain level of 1-2. -[MEDICATION NAME] 325 mg two tablets by mouth every six hours PRN for a pain level of 3-4. -[MEDICATION NAME] (non steroidal anti [MEDICAL CONDITION]) 500 mg by mouth every 12 hours PRN for pain level of 5-6. -[MEDICATION NAME] (narcotic) 5-325 mg two tablets by mouth every four hours PRN for a pain level of 7-10. However, a review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed the resident had been administered [MEDICATION NAME] twice for a pain level of seven on (MONTH) 19, and once on (MONTH) 20 for a pain level of 7. Per the physician's orders [REDACTED]. An interview was conducted on (MONTH) 24, (YEAR) at 1:45 p.m., with the ADON (Assistant Director of Nursing/staff #55). Following a review of the physician's orders [REDACTED].#55 stated that the [MEDICATION NAME] was administered for a pain level of seven, which was not as ordered. He stated the physician's orders [REDACTED]. -Resident #145 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. -Tylenol 325 mg two tablets by mouth every four hours PRN for a pain level of 1-5. -[MEDICATION NAME] (narcotic) 15 mg by mouth every four hours PRN for a pain level of 6-10. A review of the (MONTH) (YEAR) MAR indicated [REDACTED]. There was no clinical record documentation that the physician was notified or additional orders were obtained. An interview was conducted on (MONTH) 24, (YEAR) at 10:20 a.m., with a LPN (Licensed Practical Nurse/staff #2)… | 2020-09-01 |
| 75 | 75 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2017-10-25 | 322 | D | 0 | 1 | DB1811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#83) with a feeding tube was provided the appropriate treatment and services. Findings include: Resident #83 was admitted on (MONTH) 1, (YEAR) and readmitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had a percutaneous endoscopic gastrostomy (PEG) tube. A care plan dated (MONTH) 5, (YEAR) included the resident had a feeding tube related to poor nutritional intake. A goal included the resident would be free of aspiration. Interventions were for the nurse to check tube placement per facility protocol, and flush the PEG tube with water. Review of a Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR) revealed the resident had severe cognitive impairment, was unable to speak, and had a feeding tube. A medication administration observation was conducted on (MONTH) 23, (YEAR) at 9:00 a.m., with a Registered Nurse (staff #4). During the observation, the nurse crushed nine medications together and mixed them with 60 cc of water in a cup. Without first checking placement of the PEG tube, the nurse then flushed the resident's PEG tube with 30 cc of water using a 60 cc syringe, by pushing the plunger on the syringe to administer the water, instead of using the gravity flow method. The nurse then drew up the medications which had been mixed with water into the syringe, and pushed the plunger on the syringe to administer the medications into the PEG tube, instead of using the gravity flow method. Next, the nurse flushed the PEG tube with 30 cc of water using a 60 cc syringe and pushed the plunger on the syringe to administer the water, instead of using the gravity flow method. Following the observation, an interview was conducted with staff #4, who stated that she had checked the placement of the tube by looking at a black line on the PEG tube. She stated that if the … | 2020-09-01 |
| 76 | 76 | HAVEN OF SCOTTSDALE | 35059 | 3293 NORTH DRINKWATER BOULEVARD | SCOTTSDALE | AZ | 85251 | 2017-10-25 | 371 | E | 1 | 1 | DB1811 | > Based on observation, staff interview, review of the temperature logs and facility documentation, the facility failed to ensure one nourishment refrigerator temperatures were maintained at or below 41 degrees F. Findings include: During an observation conducted at 12:10 p.m. on (MONTH) 24, (YEAR), the nourishment refrigerator was observed to contain food and snacks for the residents. Review of the Refrigerator Temperature Log Audit for (MONTH) (YEAR) revealed the temperatures were to be checked daily. The log included that the temperature range should be between 35-46 degrees F, instead of at or below 41 degrees F, as required. Per the documentation, there were 12 of 24 days with documented temperatures between 42 to 46 degrees F. During an interview conducted at 1:00 p.m. on (MONTH) 24, (YEAR), the Dietary Manager (staff #35) stated the temperature range for the nourishment refrigerator should be between 35 and 41 degrees F. She stated this log was incorrect and was not the dietary refrigerator log which should be used. She stated she was not aware that the temperatures were often above 41 degrees F. Staff #35 stated that when the temperatures were not within the appropriate range, the food should have been discarded. She also said that snacks for residents are stored in the snack/nourishment refrigerator. Review of a facility's guideline regarding Resident Food Stored in Nourishment Refrigerators revealed that all nourishment refrigerators have a working thermometer and that the temperatures are to be maintained between 36-41 degrees F. | 2020-09-01 |
| 77 | 77 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2020-01-08 | 609 | D | 1 | 0 | DWKV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of policies and procedures, and review of the State Agency data base, the facility failed to ensure that alleged violations involving abuse or mistreatment for [REDACTED].#1, 2, 3, 4) were reported to APS (Adult Protective Services) and failed to ensure that the results of investigation of alleged violations involving abuse or mistreatment for [REDACTED].#1, 3, 4, 5) were reported to the State Agency. The deficient practice could result in additional allegations of abuse or mistreatment not being reported to APS, and additional results of investigations of abuse or mistreatment not being reported to the State Agency. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. A Health Status Note dated (MONTH) 16, 2019 at 1:00 a.m. included that during a smoke break, a peer (resident #5) had grabbed the cigarette supply and that resident #1 had observed resident #5 grab the cigarettes. The note included that resident #1 tried to take the cigarettes from resident #5, and resident #5 then grabbed the sweater of resident #1, who slid to the floor. The note included that there were no injuries. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. The note included that there were no injuries. Review of the plan of care for resident #1 reveale… | 2020-09-01 |
| 78 | 78 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2020-01-08 | 610 | D | 1 | 0 | DWKV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures, the facility failed to ensure that an allegation of resident to resident abuse for two residents (#1, 2) was thoroughly investigated. The deficient practice could result in additional allegations of abuse not being thoroughly investigated by the facility. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. The note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. Th… | 2020-09-01 |
| 79 | 79 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2020-01-08 | 689 | E | 1 | 0 | DWKV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures, the facility failed to ensure that multiple residents with aggressive behaviors (#1, 2, 4, 5) were provided adequate supervision to prevent the residents from behaving in a physically aggressive manner towards other residents. The deficient practice could result in multiple residents behaving aggressively towards other residents. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A written care plan initiated on (MONTH) 25, 2019 and updated on (MONTH) 8, 2019 included that resident #1 had a history of [REDACTED]. A Behavioral Plan dated (MONTH) 9, 2019 included that on admission the resident had a history of [REDACTED]. The behavioral plan included that currently, the resident makes false accusations of peers taking her belongings, and has a history of physical altercations with peers. The behavioral plan listed multiple interventions included to monitor resident #1 for her peer's safety, listen to her concerns and to remove peers for their safety. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. Review of the MAR (Medication Administration Record) for (MONTH) 2019 revealed that resident #1 had the following behaviors which were documented in sections of the record for daily behavioral monitoring: -Verbally abusive behaviors were recorded on (MONTH) 1, 3, 5, 9, 10, 12 and 15, 2019. -Angry outbursts were recorded on (MONTH) 3, 5, 9, 10, and 12, 2019. -Delusions were recorded on (MONTH) 1, 4, 6, 7, 8, 11, 14, and 15, 2019. -False accusations were recorded on (MONTH) 8, 10, and 15, 2019. A Health Status Note dated (MONTH) 16, 2019 at 1:00… | 2020-09-01 |
| 80 | 80 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 154 | D | 0 | 1 | TPN311 | **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's (#88) representative was informed of the risks and benefits of an antipsychotic medication, prior to administering. Findings include: Resident #88 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) and the quarterly MDS assessment dated (MONTH) 7, (YEAR), revealed the resident was rarely or never understood. Review of the clinical record revealed a physician's orders [REDACTED]. Review of the medication administration records for (MONTH) and (MONTH) (YEAR) and for (MONTH) and (MONTH) (YEAR) revealed the [MEDICATION NAME] was administered as ordered. Further review of the clinical record revealed no documentation that the resident's representative was informed of the risks and benefits of [MEDICATION NAME], nor had informed consent been obtained. During an interview conducted on (MONTH) 1, (YEAR) at 10:12 a.m., a Licensed Practical Nurse (staff #54) stated an antipsychotic medication should not be administered before obtaining consent. During an interview conducted on (MONTH) 1, (YEAR) at 10:43 a.m., the acting Director of Nursing (staff #1) stated before administering an antipsychotic medication, a consent is obtained from either the resident or the responsible person explaining the medication and the side effects. Staff #1 further stated there should have been consent for the [MEDICATION NAME]. Review of the policy titled, Antipsychotic Medication Use included the physician and staff will gather and document information to clarify a resident's symptoms and risks. However, the policy did not address the need to inform the resident/representative of the risks and benefits of an antipsychotic medication, prior to administering. | 2020-09-01 |
| 81 | 81 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 225 | D | 0 | 1 | TPN311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews, and policy and procedures, the facility failed to ensure resident to resident altercations involving two residents (#57 and #97) were investigated and reported to the State agency. Findings include: Resident #57 was admitted to the facility in (MONTH) 2014, with [DIAGNOSES REDACTED]. The resident resided in the secured Behavioral Unit. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of resident #57's Nurse's Notes dated (MONTH) 27, (YEAR) and (MONTH) 12, (YEAR) revealed resident #57 reported to staff that she was hit on the arm by resident #97 and no physical injury had occurred. Resident #97 was admitted to the facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. The resident resided in the secured Behavioral Unit and was discharged in (MONTH) (YEAR). Review of the quarterly MDS assessment dated (MONTH) 18, (YEAR) revealed a BIMS score of 13, which indicated the resident was cognitively intact. In an interview on (MONTH) 31, (YEAR) at 9:19 a.m., resident #57 said yes that she was abused by a former roommate, who had hit her on the left arm multiple times. The resident stated these incidents had occurred sometime in the spring of last year and were reported to staff. Resident #57 stated staff had moved the roommate to the other side of the room and at a later date, resident #57 had changed rooms. Resident #57 further stated that the roommate was no longer in the facility and there were no further incidents. During interviews on (MONTH) 1, (YEAR) at 11:27 a.m. and on (MONTH) 2, 2012 at 10:12 a.m. with the Interim Director of Nursing (staff #1/former unit manager of the Behavioral Unit where residents #57 and #97 resided), investigations regarding the incidents were requested. Staff #1 stated the allegations had occurred b… | 2020-09-01 |
| 82 | 82 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 226 | D | 0 | 1 | TPN311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy and procedures, the facility failed to implement their policy regarding an allegation of abuse for one resident (#57), and failed to ensure that two direct care staff's (staff #2 and #63) licenses were verified with the licensing board. Findings include: -Resident #57 was admitted to the facility in (MONTH) 2014, with [DIAGNOSES REDACTED]. The resident resided in the secured Behavioral Unit. Review of resident #57's Nurse's Notes dated (MONTH) 27, (YEAR) and (MONTH) 12, (YEAR) revealed resident #57 reported to staff that she was hit on the arm by another resident (#97). In an interview on (MONTH) 31, (YEAR) at 9:19 a.m., resident #57 said yes that she was abused by a former roommate, who had hit her on the left arm multiple times. The resident stated these incidents had occurred sometime in the spring of last year and were reported to staff. During interviews on (MONTH) 1, (YEAR) at 11:27 a.m. and on (MONTH) 2, 2012 at 10:12 a.m. with the Interim Director of Nursing (staff #1/former unit manager of the Behavioral Unit where residents #57 and #97 resided), investigations regarding the incidents were requested. Staff #1 stated the allegations had occurred in the spring of (YEAR). Staff #1 confirmed an investigation of these reported altercations was not done and stated the incidents were not reported to the State agencies as required. The facility's Abuse Investigations policy and procedures identified that All allegations/signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management .The Administrator or Designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five… | 2020-09-01 |
| 83 | 83 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 241 | D | 0 | 1 | TPN311 | Based on observations, staff interviews and a review of policy, the facility failed to maintain an environment that enhanced each resident's dignity and respect. Findings include: A random observation was conducted on (MONTH) 1, (YEAR) at 12:30 p.m., on the secured male behavioral unit. During this observation, the lunch meal cart was observed to be positioned by the main dining room door and across from the assisted dining room. While conducting observations, a CNA (Certified Nursing Assistant/staff #123) was heard to tell the other CNA's to pull the Feeders trays. The same CNA was again heard to tell the other CNA's to take the Feeders trays into the assisted dining room. An interview was conducted on (MONTH) 1, (YEAR) at 1:50 p.m., with staff #123, who acknowledged that she had referred to the residents as, Feeders. Staff #123 stated that she probably should not have referred to those residents who required assistance with their meals as Feeders, because it was not appropriate. She said she could have called them, Assisted residents. A interview was conducted on (MONTH) 2, (YEAR) at 2:10 p.m., with the Director of Nursing (staff #129). He stated that referring to the residents as, Feeders would be a dignity issue and that they should be referred to as assisted residents. On (MONTH) 2, (YEAR), an interview was conducted with the Administrator (staff #48), who stated that calling a resident a Feeder, is not dignified and that he had just provided an inservice regarding dignity approximately six months ago. A facility policy titled, Assistance with Meals included the following: 3. Residents Requiring Full Assistance: Residents who can not feed themselves will be fed with attention to safety, comfort and dignity, for example: c. Avoiding the use of labels when referring to residents (e.g., feeders). | 2020-09-01 |
| 84 | 84 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 248 | E | 0 | 1 | TPN311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure that an individualized activities program was implemented for one resident (#71). Findings include: Resident #71 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. The resident resided on the male behavioral unit. According to the annual Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR), the resident had severe cognitive impairment. Under the activity section, the documentation included that it was important to the resident to have books, newspapers and magazines available and to listen to music and to go outside for fresh air. A quarterly activities assessment dated (MONTH) 18, (YEAR), identified that the resident's favorite activities were one to one visits, coffee socials, music and conversing with family and friends. An activities care plan was developed and included as goals the following: -Resident will accept one to one visits at least twice a week. -Resident will attend group activity of interest once a week. The interventions included: -Invite to scheduled activities. -Offer to assist/escort the resident to activity functions. -Provide one to one visits twice weekly: conversation, outdoor leisure. -Socials 1-2 times weekly; cognitive games 1-2 times weekly; bingo 1-2 times monthly; education programs 1-2 times monthly; and exercise 1-2 times monthly. A review of the (MONTH) (YEAR) activity calendar revealed that 1:1 visits and coffee chats were scheduled daily, Bingo and a music program were scheduled weekly, and that fitness programs were scheduled several times a week. Review of the resident's one to one visit records from (MONTH) (YEAR) through (MONTH) (YEAR), revealed the following: July: five one to one visits were provided. August: seven one to one visits were provided. September: three one to one visits were provided. December: two one to one visits were provided January (YEAR): three one to one… | 2020-09-01 |
| 85 | 85 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 253 | E | 0 | 1 | TPN311 | Based on observations and staff interviews, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior. Findings include: During the initial tour conducted on (MONTH) 30, (YEAR) at 10:46 a.m., the following was observed: -There was a strong urine odor in the hallway upon entering the Oak unit. -In multiple resident rooms, there were portable oxygen concentrators which had filters that were visible from the outside. The filters had a grayish dust like build up on them. -On all three units, the flooring in multiple resident rooms were stained with a brownish residue. -Multiple ceiling vents throughout the facility were dirty with a gray residue on the vent blades. Additional observations were conducted on (MONTH) 30, (YEAR) at 2:46 p.m. and revealed the following: -In room #7, there was a slight urine odor and there was a full urinal on the bed. -In room #8's bathroom, the flooring had several scuff marks and the floor boards were separated from the wall and there were several small holes in floor at the doorway. -In room #14, there was chipped paint on the walls and the floor boards had a dust build up and were stained. -In room #17, the bathroom door had a walnut sized hole, with jagged edges. The bathroom sink faucet was loose and moved freely. The sink vanity had multiple small gaps in the caulking, and the toilet ran continuously. -In room # 22's bathroom, one wall contained multiple small gouges and scrapes, and the bathroom door had small gouges with rough edges along the hinge side. -In room #26, the bathroom wall contained small gouges and peeling paint. The floor had missing tiles. The cove base was separating from the wall creating moderate sized gaps. There were multiple small gaps between the floor tile with an accumulation of gray/brownish dirt and debris in the gaps. Several window blinds were bent or had broken slats. -The window blinds in room #27 had several bent or broken slats. There was a hole in the bathroom wall o… | 2020-09-01 |
| 86 | 86 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 279 | D | 0 | 1 | TPN311 | **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 comprehensive care plans regarding ADLs (Activities of Daily Living) were developed for two residents (#40 and #88). Findings include: -Resident #40 was admitted on (MONTH) 26, 2013, with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 16, (YEAR), revealed in Section G, Functional Status that the resident required supervision-oversight/cueing with ADLS. An annual MDS assessment dated (MONTH) 18, (YEAR), included the resident now required limited to extensive assistance with ADLs. However, no care plan was developed regarding the resident's ADL needs. An interview was conducted on (MONTH) 1, (YEAR) at 12:50 p.m. with the MDS staff (staff #121), who stated that the MDS assessment was coded to reflect the resident's increased level assistance needed. A second interview was conducted in (MONTH) 1, (YEAR) at 1:30 p.m. with staff #121. Following a review of the (MONTH) 18, (YEAR) MDS assessment, staff #121 stated that although Section V. of the MDS assessment (CAA: Care Area Assessment) did not automatically trigger for initiation of an ADL care plan, she should have developed an ADL care plan, based on the documentation of the resident's increased level of assistance. -Resident #88 was admitted (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A admission MDS assessment dated (MONTH) 7, (YEAR), assessed the resident as requiring extensive assistance to total dependence, with ADLs. However, in Section V., the care area for ADLs did not trigger. A quarterly MDS assessment dated (MONTH) 7, (YEAR), also assessed the resident as requiring extensive assistance to total dependence, with ADLs. Review of the clinical record revealed no care plan was developed based on the resident's ADL needs. During an interview conducted on (MONTH) 1, (YEAR) at 10:48 a.m., the MDS coordinator (staff #121) stated she was una… | 2020-09-01 |
| 87 | 87 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 280 | D | 0 | 1 | TPN311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff interviews and a review of facility policy, the facility failed to ensure that a comprehensive care plan was revised for one resident (#61). Findings Include: Resident #61 was admitted on (MONTH) 20, 2011, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that the resident previously had been on a 960 cc (centimeter) fluid restriction, however, it had been discontinued on (MONTH) 24, (YEAR). Review of the current physician's orders [REDACTED]. However, according to a care plan for potential complications related to [MEDICAL TREATMENT], one of the interventions included for a 960 cc daily fluid restriction. An interview was conducted on (MONTH) 3, (YEAR) at 9:30 a.m., with the Assistant Director of Nursing (staff #45), who stated that care plans were suppose to be updated at the time of the care conference (the resident's last quarterly care plan conference was in (MONTH) (YEAR)). Another interview was conducted on (MONTH) 3, (YEAR) at 9:37 a.m., with the Director of Nursing (staff #129), who confirmed that the 960 cc fluid restriction was still included as a current intervention on the care plan. Staff #129 stated that licensed staff were responsible to update care plans whenever necessary, and that all of the resident's care plans were suppose to be reviewed and revised at the time of the resident's care conference. He stated that the care plan should have been revised to reflect the discontinuation of the fluid restriction. A facility policy titled, Care Plan Goals and Objectives included the following: 2 .Care plans will be modified accordingly and that 5. Goals and objectives are reviewed and/or revised .at least quarterly. | 2020-09-01 |
| 88 | 88 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 314 | E | 0 | 1 | TPN311 | **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 consistently and thoroughly assess pressure ulcers for three residents (#22, #45 and #89). Finding include: -Resident #45 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was admitted with an unstageable pressure ulcer to the left heel. The wound measured 5.9 cm x 6.3 cm, with a black wound bed, with moderate drainage and no tunneling or undermining. An admission MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR) included the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS also included that the resident was admitted with an unstageable pressure ulcer. Further review of the clinical record including the weekly wound reviews revealed the left heel pressure ulcer was assessed weekly from (MONTH) (YEAR) through (MONTH) (YEAR). A care plan dated (MONTH) (YEAR) included the resident had a pressure ulcer. An intervention included for weekly treatment documentation to include measurement of each area of skin breakdown (width, length, depth, type of tissue and exudate). According to the weekly pressure ulcer log dated (MONTH) 3, (YEAR), the left heel pressure ulcer was identified as a stage 3 and measured 4.5 cm x 4.3 cm. The next wound assessment which included measurements was not completed until (MONTH) 30, (YEAR). Per the wound note dated (MONTH) 30, the left heel measured 4.3 cm x 4.2 cm., however, there was no description of the wound bed. Continued review of the clinical record revealed the next thorough wound assessment was completed on (MONTH) 20, (YEAR). Per the Pressure Injury Log dated (MONTH) 20, the left heel wound was a stage 3 and measured 5 x 5 x 0.2 cm, and the wound bed was pink. There were no additional wound assessments which included the measureme… | 2020-09-01 |
| 89 | 89 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 323 | D | 0 | 1 | TPN311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy and procedures, the facility failed to ensure the environment was free from accident hazards, by failing to ensure a physical restraint was properly applied to one resident (#71) and by having resident door frames with exposed sharp edges. Findings include: -Resident #71 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. The resident resided on the behavioral unit. A review of the clinical record revealed a physician's orders [REDACTED]. A fall risk care plan included an intervention for the use of a lap buddy when in a wheelchair for poor safety awareness. The care plan also included to check the lap buddy for positioning and placement every shift. According to the CNA (Certified Nursing Assistant) care sheet, a lap buddy was to be used for this resident. The (MONTH) (YEAR) TAR (Treatment Administration Record) included the physician's orders [REDACTED]. An observation of the resident was conducted on (MONTH) 30, (YEAR) at 1:27 p.m. At this time, the resident was observed sleeping in a wheelchair, with a waist restraint on. The device was a non self-releasing cloth belt. The belt went around the front of the resident's waist and criss crossed behind the resident. The belt then went around the back of the wheelchair and one end was tied to the other end, which was then looped over the back rung of the wheelchair. An interview was conducted on (MONTH) 2, (YEAR) at 10:30 a.m., with the ADON (Licensed Practical Nurse/Assistant Director of Nursing/staff #45). She stated that she had also observed the resident on (MONTH) 30, with the non self-releasing waist restraint on. Staff #45 stated that after her observation, she replaced the non self-releasing waist restraint with a lap buddy. She stated that she had spoken with the staff on duty and they had reported that the night shift had gotten the resident up, and had put the non self-releasing waist restraint on t… | 2020-09-01 |
| 90 | 90 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 364 | D | 0 | 1 | TPN311 | Based on observations, staff interviews and a review of facility policy, the facility failed to ensure that food was served at the proper temperature. Findings include: A lunch observation was conducted on (MONTH) 30, (YEAR), in the main dining room. During this observation the following issues were observed: -After the meal cart arrived in the dining room, 5 residents were served their meal. These residents sat with their covered food plate in front of them for 15 to 35 minutes, before a staff member assisted them to eat their meal. A second dining observation (breakfast) was conducted on (MONTH) 1, (YEAR), in the main dining room. The following issues were identified: -The breakfast meal was scheduled to be served at 7:30 a.m., however, the food cart was not delivered from the kitchen until 7:45 a.m. -The first meal tray was served to a resident at 7:55 a.m., which was 10 minutes after the food cart had arrived from the kitchen. -At this time, four residents were identified to require feeding assistance. The first resident was assisted with her breakfast at 8:10 a.m. and the second resident was assisted with his meal at 8:20 a.m. Although the breakfast plates were covered, the trays had been sitting on the residents' table from approximately 7:55 a.m. -At 8:30 a.m., a CNA (Certified Nursing Assistant) was observed to prepare to feed the third and fourth resident their breakfast. Although the breakfast plates were covered, they had been sitting on the dining room table since 7:55 a.m. At this time, the breakfast food temperature was obtained by the dietary manager. The pureed biscuits and gravy was at 79 degrees F. (Fahrenheit) and the oatmeal was at 113 degrees F. The dietary manager then instructed that another breakfast meal be provided to those residents. An interview was conducted on (MONTH) 1, (YEAR) at 8:40 a.m. with the dietary manager (staff #112). He stated that the covered foods would only stay hot for approximately 20 minutes after it was served. He stated that at the temperatures obtained, the food … | 2020-09-01 |
| 91 | 91 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 371 | E | 0 | 1 | TPN311 | Based on observations, staff interviews and policy review, the facility failed to ensure that ready to eat foods were handled properly, that food and beverages were properly labeled and that the nourishment refrigerator temperatures were consistently obtained and documented. Findings include: -A lunch observation was conducted in the main dining room on (MONTH) 30, (YEAR). During this observation a CNA (Certified Nursing Assistant) was observed to donn gloves, remove a resident's meal tray from the rack, carry the tray to the resident's table and place the food items in front of the resident. The CNA was then observed to butter the resident's bread, with the same gloves on. With the same gloves on, the CNA was then observed to reposition the meal cart in the dining room and removed another resident's meal tray from the rack. Again, the CNA removed the food items and placed them in front of the resident. The CNA then proceeded to butter the resident's bread, with the same gloves on. The CNA was not observed to change her gloves after touching the non-food items or in between assisting residents. An interview was conducted on (MONTH) 1, (YEAR) at 8:40 a.m., with a CNA (staff #32). She stated that gloves were suppose to be changed after touching a non-food item, like the meal cart and were suppose to be worn when handling food. A facility policy titled, Handling Ready to Eat Foods included Nursing staff and other dinning assistive personnel shall provide ready to eat foods while assuring sanitation guidelines are followed. The policy also included the following: 2. If a resident requires assistance with opening and handling of an item the associate assisting shall: a. Wash their hands. b. Caution to only touch the wrapper and avoid touching the food item. c. Wear gloves as appropriate if food item must be handled. d. Gloves shall be changed between service to each resident. 5. As gloves are changed between each resident the associate shall; a. Wash their hands. b. Use a hand sanitizer as indicated by the manufacture… | 2020-09-01 |
| 92 | 92 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 431 | E | 0 | 1 | TPN311 | Based on observations, staff interviews, facility documentation, and policy review, the facility failed to ensure expired medications were not available for use and failed to consistently monitor and document medication refrigerator temperatures on the Oak unit. Findings include: -During a medication storage observation conducted on (MONTH) 2, (YEAR) at 2 p.m., three expired medications were found in the medication room on the Magnolia unit as follows: Calcitrate one bottle with an expiration date of (MONTH) of (YEAR), Vitamin B1 one bottle with an expiration date of (MONTH) of (YEAR), and Loperamide one bottle with an expiration date of (MONTH) (YEAR). An interview was conducted with a Licensed Practical Nurse (LPN/staff #27) on the Magnolia unit on (MONTH) 2, (YEAR) at 2:00 p.m. She stated that the nurses are the ones who check the medications to make sure they are not expired. She stated that she thought the night nurses do the medication room checks to ensure medications are not expired. Review of the facility's policy regarding the Storage of Medications revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. -Review of the temperature logs for the medication refrigerator on the Oak unit revealed the following: No temperatures were recorded for nine days in (MONTH) (YEAR), for six days in (MONTH) (YEAR), for nine days in (MONTH) (YEAR), for ten days in (MONTH) (YEAR), for twenty days in (MONTH) (YEAR), and for fourteen days in (MONTH) (YEAR). An interview was conducted with an LPN (staff #28) on (MONTH) 2, (YEAR) at 1:45 p.m. He stated that the refrigerator temperatures are to be checked every night and recorded by night shift. An interview was conducted with a unit manager (Registered Nurse/staff #1) on (MONTH) 2, (YEAR) at 3:03 p.m. She stated that for the medication refrigerators, they keep a log of what the temperature is, and if a temperature is out of range, they have to document what the… | 2020-09-01 |
| 93 | 93 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 441 | D | 0 | 1 | TPN311 | Based on observation, staff interviews, and policy review, the facility failed to ensure proper handwashing techniques were followed during a pressure ulcer treatment. Findings include: A pressure ulcer treatment observation was conducted on (MONTH) 1, (YEAR) at 7:30 a.m., with the wound nurse (staff #25). Prior to beginning the wound treatment, the nurse was not observed to wash her hands or use sanitizer gel. Following the wound treatment, the nurse removed her gloves and cleansed several items and then exited the room and placed the items back into the cart. The nurse was not observed to wash or sanitize her hands. In an interview with the wound nurse (staff #25) on (MONTH) 2, (YEAR) at 2:33 p.m., she stated her regular procedure is to wash her hands or use an antibacterial gel before, during and after treatment. In an interview with the Director of Nursing (staff #129) on (MONTH) 2, (YEAR) at 2:46 p.m., he stated that the expectation of staff during wound treatments is to wash or sanitize hands before, during, and after wound care. Included in a policy titled, Pressure Ulcer Treatment it stated to wash hands before treatment and to wash and dry hands thoroughly after performing ordered treatment. | 2020-09-01 |
| 94 | 94 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 465 | E | 0 | 1 | TPN311 | Based on observations, staff interviews and review of the safety data sheet, the facility failed to provide a safe environment, by failing to ensure the facility was free from chemical odors. Findings include: During a random observation conducted on (MONTH) 2, (YEAR) at 9:30 a.m. on the secured Oak nursing unit, a strong chemical odor was detected upon entry into the unit. The odor started at the entry door and proceeded 3/4 of the way down the hall. A small floor fan was on and positioned halfway down the hall. At this time, a resident who was self-propelling himself in a wheelchair to his room, which was located in the area of the chemical odor stated, What is that bad smell. Several other residents were observed in their rooms, which were also located in the area of the chemical smell. No windows or doors were observed to be opened to allow for more ventilation. The nursing staff on the unit were then interviewed and stated that they did not know what was causing the strong chemical odor. An environmental staff member (staff #13) was on the unit at this time and stated that her supervisor had instructed her to spray paint the ceiling air vent covers, in resident rooms. Staff #13 stated that she had just spray painted the ceiling air vent covers in six resident rooms. During this interview, another environmental staff person produced the spray paint can. The product was identified as Appliance Epoxy with warnings on the spray can which included: -Danger-extremely flammable liquid and vapor. -Vapor harmful. -Vapors may cause flash fires. Immediately following, an interview was conducted with the Administrator (staff #48), who was on the Oak unit. He agreed that a strong, chemical odor was present on the unit and directed staff to obtain another fan, to open the resident's room windows and doors, and to move those residents who were in their rooms to the dining room, which was farther away from the chemical odor. Staff #48 stated that the air vent covers should have been removed and spray painted outside. An int… | 2020-09-01 |
| 95 | 95 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2017-02-03 | 520 | E | 0 | 1 | TPN311 | Based on concerns identified during the survey, staff interview and policy and procedures, the facility failed to identify quality concerns through their QA (Quality Assurance) program regarding consistently and thoroughly assessing pressure ulcers. Findings include: During the survey, concerns were identified that pressure ulcers were not being thoroughly and consistently assessed to include measurements and a description of the wound bed. During the survey, interviews were conducted with the interim Director of Nursing (DON/staff #1) and the wound nurse (LPN/staff #25), and both stated that there were no wound assessments performed during the time period when there was no wound nurse. During an interview conducted with the Administrator (staff# 48) on (MONTH) 3, (YEAR) at 12:30 p.m., he stated that they had not identified any issues in QA regarding pressure ulcers. A review of the Quality Assessment and Assurance Committee policy and procedure revealed the committee shall serve as the final authority for implementing the facility's quality assessment and assurance programs. The policy included the committe shall meet as necessary, but at least quarterly to assure that the QA program is meeting the needs of the facility. | 2020-09-01 |
| 96 | 96 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2018-03-30 | 567 | B | 0 | 1 | WXKF11 | Based on observation, facility documentation, resident and staff interviews, and policy and procedures, the facility failed to ensure that residents have access to their personal funds on the weekends. Findings include: Review of facility documentation revealed that multiple residents had trust fund accounts through the facility. During the survey, an observation was conducted of a sign which was posted in the business office. The sign read that the resident trust fund bank was open Monday through Friday from 9:00 a.m. until 3:00 p.m., and that the bank was closed on the weekends and holidays. An interview was conducted with a resident at 9:45 a.m. on (MONTH) 26, (YEAR). She stated that she does not have access to her trust fund on the weekends, as the bank is closed. An interview with the business office manager (staff #113) was conducted at 11:20 a.m. on (MONTH) 29, (YEAR). She said that there are a lot of residents who have trust fund accounts in the facility. She stated that she manages these accounts and is the one who provides money for the residents at their request. Staff #113 stated that the banking hours that are posted are correct and are from 9:00 a.m. until 3:00 p.m., Monday through Friday. She said that this is the only time that residents can get their money. She stated that residents are not able to get money on the weekends or holidays. Staff #113 stated the residents and their families are aware of this and they make provisions to get money on Friday, before the bank closes. She said that she has never heard that residents should have access to their accounts on the weekends. Another interview was conducted with the same resident as above on (MONTH) 29, (YEAR) at 1 p.m. She stated that it is a pain that she cannot get money out of her trust fund on the weekends. She said that she has wanted to get money out of her account on the weekends at times, but is unable too. She said that it is hard for some residents because they may have relatives that come to the facility on the weekends and they will… | 2020-09-01 |
| 97 | 97 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2018-03-30 | 600 | D | 1 | 1 | WXKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to ensure one resident (#74) was free from physical abuse by another resident (#49). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR), included a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severe cognitive impairment. Review of resident #49's current care plan revealed the resident was exit seeking and displayed wandering, pacing, or roaming behaviors. The care plan included the resident required psycho-active medications to help manage mood and behavior symptoms which included hitting and combativeness. The care plan also included the resident utilized a wheelchair. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. An annual MDS assessment dated (MONTH) 27, (YEAR) identified the resident had been assessed with [REDACTED]. A review of the resident's current care plan revealed documentation that the resident demonstrates limited social interaction related to [DIAGNOSES REDACTED]. The care plan included the resident exhibited behaviors of yelling, verbal aggression towards staff and that the resident spends most of his time alone watching television and isolating self in his room. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the unit dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. An interview was conducted with a CNA (Certified Nursing Assistant/staff #35) on (MONTH) 27, (YEAR) at 11:30 a.m. Staff #35 stated that resident #74 and resident #49 were in the dining room during breakfast. Staff #35 stated she was assisting other residents in the dining room and heard resident #49 and #74 yelling at eac… | 2020-09-01 |
| 98 | 98 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2018-03-30 | 604 | E | 0 | 1 | WXKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff and resident interviews and policy and procedures, the facility failed to ensure that three residents (#68, #20 and #75) were assessed and/or monitored for the use of physical restraints. Findings include: -Resident #68 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 22, (YEAR) included for a Velcro self releasing belt when in wheelchair, due to poor safety awareness. A physical restraint informed consent was completed on (MONTH) 22, (YEAR). The documentation indicated that the restraint being used was a self releasing belt, when in the wheelchair. The documentation included specific target behaviors and that the resident had poor safety awareness. The form was signed by the resident's Power of Attorney (POA). However, an initial restraint evaluation could not be located in the resident's clinical record. There was no clinical record documentation that the resident was assessed for the use of the device, in order to determine if the device was a restraint. Review of a physical restraint evaluation dated (MONTH) 16, (YEAR) revealed the resident had an unsteady gait, agitated behavior, aggressive behaviors, attempts to self-transfer, and climbs out of bed. It was noted that the resident continues to ambulate and get out of bed, without assistance. The evaluation indicated that the restraint (self releasing belt) was effective and to continue it's use. The documentation did not include if the resident was assessed to be able to release the self releasing belt. Another physical restraint evaluation dated (MONTH) 18, (YEAR), included that the restraint (was considered to be effective and would be continued. The documentation did not include if the resident was assessed to be able to release the self releasing belt. Review of the nursing notes revealed that the resident was discharged on (MONTH) 24, (YEAR). The clinical record do… | 2020-09-01 |
| 99 | 99 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2018-03-30 | 607 | D | 1 | 1 | WXKF11 | **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 implement their Abuse policy regarding four residents (#18, #49, #58 and #74). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the unit dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. Further review of the facility's investigative report revealed a statement from a staff member who had witnessed the incident, however, there were no statements from other staff and there was no documentation that resident #49 or #74 were interviewed regarding the incident. An interview was conducted with the DON (Director of Nursing/staff #18) on (MONTH) 27, (YEAR) at 12:42 p.m. Staff #18 stated that he did not interview other staff who may have witnessed the incident between resident #49 and resident #74. In a later interview on (MONTH) 27, (YEAR) at 2:16 p.m., staff #18 stated that he did not interview resident #49 or #74, due to the resident's having cognitive impairment. -Resident #18 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 26, (YEAR), a Certified Nursing Assistant (CNA) was providing care to the resident in his room. The CNA called for help and staff assisted the CN[NAME] The resident was observed to be bleeding from a laceration above his eyebrow. When questioned, the CNA stated that the resident had started to become combative during care and was swinging and hit himself in the head, causing the laceration. Further review of the investigative documentation revealed it did not include interviews with other residents, who may ha… | 2020-09-01 |
| 100 | 100 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2018-03-30 | 608 | D | 1 | 1 | WXKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation, and policies and procedures, the facility failed to ensure that staff reported a reasonable suspicion of a crime to law enforcement regarding a resident to resident altercation involving two residents (#49 and #74). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severe cognitive impairment. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. An annual MDS assessment dated (MONTH) 27, (YEAR) included the resident had been assessed with [REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. Further review of the facility's investigative documentation revealed that there was no documentation that law enforcement had been notified. An interview was conducted with the DON (Director of Nursing/staff #18) on (MONTH) 27, (YEAR) at 12:42 p.m. Staff #18 stated that he did not call law enforcement, due to the residents' cognitive impairments and that resident #49 was not able to make informed intent to hit resident #74. Staff #18 stated he had informed staff to report to him and that he would make the determination as to whether a call needed to be made to law enforcement. During an interview with a LPN (Licensed Practical Nurse/staff #63) on (MONTH) 27, (YEAR) at 1:24 p.m., staff #63 stated that she had not witnessed the incident, but she did assess the residents and no injuries were found. Staff #63 stated she did not notify law enforcement, as there was no physical injuries and the incident was defused, immediately. Staff #63 stated she had received in-ser… | 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 );