cms_AZ
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7,860 rows sorted by facility_id
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| Link | rowid | facility_name | facility_id ▼ | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 |
| 2663 | 2663 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2016-08-05 | 223 | D | 0 | 1 | C5IT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#17) was free from staff abuse. Findings include: Resident #17 was admitted on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS) assessment dated (MONTH) 11, (YEAR), revealed a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. A nursing note dated (MONTH) 16, (YEAR) included the resident was seen with multiple areas of bruising to the left wrist and forearm and also had three small skin tears with dried blood noted. Skin tear #1 measured 1 cm long, skin tear #2 measured 1.5 cm long and skin tear #3 was 3.5 cm long. The total area of the bruising was 10 cm x 7 cm. Further documented was that the resident stated that the mean nasty man with a beard did it last night. Review of the facility's investigative report revealed the resident was observed by staff on (MONTH) 16, (YEAR), to have bruising and skin tears on her left arm. When asked how they occurred, the resident stated a Certified Nursing Assistant (CNA/staff #77) caused them the night before. The report included that staff #77 was taking the resident's vital signs and the resident was not cooperating. The report further included an interview with staff #77, who stated that Maybe I held her arm down to get the vitals but I really don't know how the bruise occurred. Per the report, Administrative staff were unable to determine the cause of the bruising, however, they concluded that the bruising had not been previously seen on the resident and it became evident on the day shift after he left. An interview was conducted with staff #77 on (MONTH) 4, (YEAR) at 9:58 a.m. He stated he had been told by his nurse manager to take the vital signs of resident #15 during the night shift on (MONTH) 15 and 16, (YEAR). He stated the resident was moving around and he tried to get h… | 2019-11-01 |
| 2664 | 2664 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2016-08-05 | 247 | D | 0 | 1 | C5IT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure two residents (#'s 7 and 96) were provided notice before a room change. Findings include: -Resident #96 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident census form revealed the resident had a room change on (MONTH) 23, (YEAR). During an interview conducted on (MONTH) 1, (YEAR) at 2:15 p.m., the resident stated he had a room change, however; he was not told prior to the actual move. -Resident #7 was admitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident census form revealed the resident had a room change on (MONTH) 8, (YEAR). During an interview conducted on (MONTH) 2, (YEAR), the resident stated that she had a a room change, however; was not told prior to the actual move. In a review of the clinical records for both residents there was no documented evidence that the residents had been given notice, prior to the room changes. During an interview with a social worker (staff #58) on (MONTH) 5, (YEAR) at 10:00 a.m., she stated that she and other staff are responsible to inform residents of room changes prior to the change, however; this is not always documented. An interview was conducted with the Administrator (staff #68) on (MONTH) 5, (YEAR) at 10:22 a.m. He stated that it was the responsibility of the social worker and admissions staff to inform and document when there is a room change. He further stated that there was no documentation for these two residents. According to a facility policy regarding a room move the following was included: Room moves will be made for resident choice and comfort. Social Services will document in their computer program and in the resident's file that the room move was made. | 2019-11-01 |
| 2665 | 2665 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2016-08-05 | 278 | E | 0 | 1 | C5IT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and the Resident Assessment Instrument manual (RAI), the facility failed to ensure the Minimum Data Set (MDS) assessments for three residents (#17, #30 and #35) were accurate. The sample size was 31. Findings include: -Resident #35 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Significant Change MDS assessment dated (MONTH) 1, (YEAR) included the resident had a BIMS (Brief Interview for Mental Status) score of 14, indicating intact cognition. Also, in Section O. under Special Treatments, Procedures and Programs, hospice care was coded. Review of a Weekly Progress Summary dated (MONTH) 6, (YEAR) revealed the resident continued on hospice services. Review of the Nutritional Care plan with a revision date of (MONTH) 16, (YEAR) revealed the resident was receiving hospice care. On (MONTH) 22, (YEAR), the care plan was revised to reflect that the resident had a terminal prognosis and was on hospice services. Review of the attending physician notes dated (MONTH) 28, (YEAR) revealed the resident was admitted for long term care under hospice services. Under assessment it included the resident had severe debility and the plan was to provide comfort care under hospice. Despite the documentation that the resident was currently receiving hospice services, the MDS quarterly assessment dated (MONTH) 1, (YEAR), did not code the resident as having hospice care services. Further review of the clinical record revealed no documentation that hospice services were discontinued. In an interview with the hospice nurse (staff #81) conducted on (MONTH) 5, (YEAR) at 11:00 a.m., she stated that resident #35 is currently under hospice care. An interview with the MDS coordinator (staff #24) was conducted on (MONTH) 5, (YEAR) at 11:59 a.m. She stated that when there is an order for [REDACTED]. At this time, the MDS quarterly assessment dated (MONTH) 1, (YEAR) was reviewed… | 2019-11-01 |
| 2666 | 2666 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2016-08-05 | 309 | D | 0 | 1 | C5IT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to provide the necessary care and services to maintain the residents highest practicable physical well-being, by failing to ensure one resident's (#35) blood sugar was adequately monitored and documented. Findings include: Resident #35 was readmitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. A Significant Change MDS (Minimum Data Set) assessment dated (MONTH) 1, (YEAR) included the resident had a BIMS (Brief Interview for Mental Status) score of 14, which indicated that the resident was cognitively intact. The MDS also included that the resident received insulin injections. A physician's orders [REDACTED]. The nutritional care plan included that the resident had nutritional problems related to diabetes. Interventions included for the administration of medications and as ordered. A diabetic care plan included interventions to monitor the side effects and effectiveness of diabetic medications and to monitor, document and report to the physician any signs and symptoms of [DIAGNOSES REDACTED]. In a nursing progress note dated (MONTH) 15, (YEAR) at 12:03 p.m., documentation included the resident was tired and was falling asleep frequently at the dining room table. In a later nursing progress note written at 9:14 p.m., the documentation included the resident was noted with a low blood sugar and that orange juice and a ham sandwich were offered, with good effect. The note further included that the resident was resting in bed with eyes closed and will continue to monitor. Further review of the clinical record revealed there was no documentation of what the resident's BS level had been at this time, nor documentation if the BS was rechecked, nor that the physician was notified. Review of the Medication Administration Record [REDACTED].m and 1 unit of Humalog insulin was administered. At 9:00 p.m., the resident's BS… | 2019-11-01 |
| 2667 | 2667 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2016-08-05 | 329 | D | 0 | 1 | C5IT11 | **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 one resident (#35) was free from an unnecessary drug. Findings include: Resident #35 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Significant Change assessment dated (MONTH) 1, (YEAR) included the resident had a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident was cognitively intact. It also included that the resident received antipsychotic medication. A physician's orders [REDACTED]. The order also included to monitor and record the number of behaviors every shift, as manifested by hallucinations and paranoia (must specify behavior). A care plan for [MEDICAL CONDITION] medications included that the resident was on [MEDICATION NAME] related to [MEDICAL CONDITION]. The goal included to reduce the use of psychoactive medication through the review date. Interventions included administration of medications as ordered and to monitor and record occurrences of target behaviors symptoms. The interventions did not address the behaviors of hallucinations and paranoia, as noted in the above physician's orders [REDACTED].>The order for [MEDICATION NAME] was changed on (MONTH) 14, (YEAR) to [MEDICATION NAME] 25 mg by mouth one time a day and [MEDICATION NAME] 50 mg by mouth in the evening for [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed staff were to monitor the residents behaviors every shift related to the use of [MEDICATION NAME] for [MEDICAL CONDITION], as manifested by hallucinations or paranoia. The TAR included to record the number of episodes at the end of each shift (must specify behavior). Further review of the TAR revealed that from (MONTH) 9 through 14, the documentation showed that the resident had no behaviors. In addition, review of the clinical record revealed no documentation that the resident was exhibiting any inc… | 2019-11-01 |
| 3551 | 3551 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2015-05-06 | 274 | D | 0 | 1 | CBHN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual and policy, the facility failed to ensure that a comprehensive assessment for a significant change in condition was completed for one resident (#106) who was admitted to hospice care. Findings include: Resident #106 was admitted to the facility on (MONTH) 7, 2014, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR) revealed it was a quarterly assessment that was completed and not a significant change comprehensive assessment. An interview was conducted on (MONTH) 6, (YEAR) at 11:10 a.m., with the MDS coordinator who stated that she had missed the change in condition assessment. A review of the facility's policy revealed a significant change of condition is a decline or improvement in the status that requires interdisciplinary review and/or revision to the care plan. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing residents assessments and as outlined in the MDS RAI Instruction Manual. According to the MDS RAI Manual, a significant change MDS assessment is required to be done when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The assessment must be done within 14 days from the effective date of the hospice election. | 2018-10-01 |
| 3552 | 3552 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2015-05-06 | 279 | D | 0 | 1 | CBHN11 | **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 hospice care and services was developed for one resident (#106). Findings include: Resident #106 was admitted to the facility on (MONTH) 7, 2014, with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR) and (MONTH) 14, (YEAR), did not reflect that the resident was receiving hospice services. A review of a Interdisciplinary Care Plan Summary note dated (MONTH) 23, (YEAR), revealed the resident was currently on hospice services. However, review of the clinical record revealed that no care plan had been developed to address the resident's hospice needs. An interview was conducted with the MDS coordinator on (MONTH) 6, (YEAR), who stated that she does the significant change in condition assessments and updates the care plan when the resident is placed on hospice services. She stated that she missed this resident's care plan. The facility's policy regarding Care Plan - Comprehensive revealed that the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning that the resident may be expected to attain. Each resident's comprehensive care plan is designed to .Identify the professional services that are responsible for each element of care .Identify problem areas and there causes, and develop interventions that are targeted and meaningful to the resident and are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. | 2018-10-01 |
| 3553 | 3553 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2015-05-06 | 281 | E | 0 | 1 | CBHN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure a physician's order regarding a supplement was implemented for one resident (#46). The sample size was three. Findings include: Resident #46 was readmitted to the facility on (MONTH) 18, 2014, with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 25, (YEAR), included the resident was to be administered 8 ounces of Ensure (nutritional supplement) daily, with the noon meal. Review of the Medication Administration Records (MARs) for March, April, and (MONTH) (YEAR), revealed there was no evidence that the order had been transcribed onto the MARs, and therefore; there was no documentation that the physician ordered supplement was given. Interviews were conducted with the Director of Nursing and the Assistant Director of Nursing on (MONTH) 6, (YEAR). They both stated that there had been a data entry error with this order and because of that, the order did not get transcribed onto the MAR. Both staff stated that the nurses did not have the information on the MAR and did not have the means to document that the Ensure was administered per orders. Both staff stated that all physician orders needed to be carried out and documented on the corresponding MAR and this would be standard nursing practice. | 2018-10-01 |
| 3554 | 3554 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2015-05-06 | 431 | E | 0 | 1 | CBHN11 | Based on observations, staff interviews, facility documentation, and review of the manufacturer's instructions and facility policies, the facility to ensure that medication was stored properly, failed to reconcile the narcotic emergency kit (E-kit) and failed to ensure narcotics on one medication cart were reconciled from shift to shift. Findings include: -An observation on (MONTH) 6, (YEAR) of the Malachite medication cart revealed an unopened box of Humalog Insulin, with a sticker on the box that stated refrigerate until opened. An interview was conducted on (MONTH) 6, (YEAR), with a License Practical Nurse (LPN) who stated that the insulin bottle should be placed in the refrigerator until needed, as there was already an opened bottle in the medication cart. A review of the manufacturer's instructions for the insulin revealed to store all unopened (unused) Humalog in the original carton in a refrigerator at 36 degrees to 46 degrees Fahrenheit. According to the facility's policy titled Storage of Medications included that Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secure location. -The medication storage task was conducted on (MONTH) 6, (YEAR) at 2:30 p.m. on the Malachite unit, with a licensed nurse. Inside the locked medication room was a narcotic E-kit, which was locked with a plastic numbered lock on each end. The license nurse was questioned regarding the facility's process for reconciling the plastic numbered locks on the narcotic E-kit from shift to shift, in order to determine if the E-kit had been accessed during the shift. The nurse stated that the nurses do not complete a shift to shift count on the narcotic E-kit. The nurse stated the E-kit was only to be opened if the nurse sent the pharmacy the script and then two nurses must be present when opening the E-kit. An interview was conducted with the Director of Nursing (DON) on (MONTH) 6, (YEAR), who stated the pharmacy picks up the E-kit and replaces the missing medicat… | 2018-10-01 |
| 3555 | 3555 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2015-05-06 | 441 | K | 0 | 1 | CBHN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, documentation from the Centers for Disease Control (CDC) and policy review, the facility failed to ensure that contact precautions were in place for two residents (#113 and #377) with symptomatic Clostridium Difficile (C-diff). As a result, the Condition of Immediate Jeopardy (IJ) was identified. Findings include: On (MONTH) 5, (YEAR) at 2:20 p.m., the Condition of Immediate Jeopardy was identified. The Administrator and Director of Nursing (DON) were informed of the facility's failure to implement contact precautions for two residents with known symptomatic[DIAGNOSES REDACTED] infections. Staff were observed entering both residents' rooms, without applying gloves and gowns. Observations revealed that there was no PPE (personal protective equipment) available for staff outside of the residents rooms or in the hallway, and the Administrator stated that gowns would need to be ordered. Also, there were no signs outside of the resident's room to alert visitors and residents to check with the nurse before entering. In addition, resident #113 and #377 were also observed in the facility's dining room on (MONTH) 4 and 5, (YEAR), without gloves and gowns in place. The Administrator and DON presented a plan of correction on (MONTH) 5, (YEAR) at 4:30 p.m. The plan presented was returned for additional corrective measures that were to be included. The final plan of correction was accepted at 4:55 p.m. Multiple observations were conducted on (MONTH) 6, (YEAR) of the facility implementing their plan of correction, which included in-services regarding infection control and implementing contact precautions for[DIAGNOSES REDACTED] for the two residents. Observations revealed that PPE was stationed outside of the two residents rooms and staff were donning gloves and gowns, prior to entering those rooms. The Condition of Immediate Jeopardy was abated on (MONTH) 6, (YEAR) at 12:00 p.m… | 2018-10-01 |
| 3556 | 3556 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2015-05-06 | 520 | E | 0 | 1 | CBHN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on concerns identified during the survey, staff interviews, and facility documentation, the facility failed to ensure that the quality assurance (QA) committee identified quality concerns regarding infection control and implemented corrective action. Findings include: During the survey process, concerns were identified regarding the facility's failure to implement infection control procedures for two residents with symptomatic [MEDICAL CONDITION], who were not on contact precautions. Staff were observed entering and exiting the resident's rooms, without donning the appropriate PPE. Observations revealed that there was no PPE (personal protective equipment) available for staff outside of the residents rooms or in the hallway, and the Administrator stated that gowns would need to be ordered. Also, there were no signs outside of the resident's room to alert visitors and residents to check with the nurse before entering. In addition, resident #113 and #377 were also observed in the facility's dining room on (MONTH) 4 and 5, (YEAR), without gloves and gowns in place. As a result, the Condition of Immediate Jeopardy (IJ) was identified. An interview was conducted on (MONTH) 6, (YEAR), with the Administrator who stated that they had not identified any concerns regarding infection control measures related to contact precautions/[MEDICAL CONDITION] and that these concerns were not in QA. Regarding a policy for QA, the Administrator stated that they are using the Quality Assurance and Performance Improvement (QAPI) System. Review of this information provided by the facility revealed that QAPI is a systematic, comprehensive, data-driven, proactive approach to performance management and improvement. An effective QAPI plan creates a self-sustaining approach to improving safety and quality while involving all nursing home caregivers in practical and creative problem solving. It also stated that QA is a process of meeting quality standards and assurin… | 2018-10-01 |
| 4673 | 4673 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2014-03-28 | 241 | D | 0 | 1 | 25SJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interview, and review of facility policy and procedure, the facility failed to promote care in a manner that enhanced one resident's (#60) dignity, by failing to provide assistance in a timely manner. Findings include: Resident #60 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the State agency documentation revealed a concern that on December 31, 2013, resident #60 waited over 20 minutes, after activating his call light for assistance with a urinal. Review of the facility's Alert Reports which track call light system response times for each resident room, revealed that on December 31, 2013, the call light response time for resident #60 was 26 minutes, spanning from 2:48 p.m. to 3:15 p.m. During an interview on March 28, 2014 at 11:10 a.m., a CNA stated that staff work with one another to answer call lights timely. She explained that if she is in a resident's room or involved in a long procedure, she would inform other staff so that her hallway could be covered for call lights to ensure residents are safe and needs were met. A facility policy and procedure on Answering Call Lights dated as last revised in September 2003, documented the purpose was to respond to the resident's requests and needs and to answer the resident's call lights as soon as possible. | 2017-07-01 |
| 4674 | 4674 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2014-03-28 | 323 | G | 0 | 1 | 25SJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed and current clinical record reviews, observations, facility documentation, staff interviews, and review of facility policies and procedures, the facility failed to ensure that two residents (#60 and #108) were provided care and services to prevent falls with injuries and failed to ensure that two residents (#26 and #55) were assessed for the safe use of quarter bed rails. Findings include: -Resident #60 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed an initial nursing assessment dated [DATE], which identified the resident to be a high risk for falls, with a score of 19. Narrative nursing documentation dated December 30, 2013, included the resident was alert but confused and that safety awareness was an issue. A care plan for fall risk related to a history of falls and impaired balance, included interventions to report and document all falls, teach/encourage the resident to use handrails/assistive devices properly, and to wear proper non-slip footwear when out of bed. A care plan related to the hip fracture due to a fall, included as an intervention to place the resident's bed in the lowest position, with wheels locked. An admission Minimum Data Set (MDS) assessment dated [DATE], reflected the resident required extensive assistance of two plus person physical assistance during transfers. In addition, the resident was assessed to be unsteady during surface-to-surface transfers and only able to stabilize with human assistance. Review of the interdisciplinary progress notes from January 6 through 24, 2014, revealed the resident had orthostatic hypotension, with episodes of tremors during therapy related to Parkinson's disease. The resident was also documented to demonstrate mild to moderate confusion at times. An occupational therapy (OT) note dated January 24 at 3:51 p.m. revealed that .during episodes of postural hypotension, patient's level of awareness is reduced as well as, de… | 2017-07-01 |
| 4675 | 4675 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2014-03-28 | 329 | D | 0 | 1 | 25SJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of facility policy and procedures, the facility failed to ensure that two residents (#106 and #73) were assessed prior to and/or after the administration of pain medication. The facility also failed to follow the physician ordered pain scale parameters for the administration of pain medication for one resident (#73). Findings include: -Resident #106 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed an Order Summary Report for February 2014, that included orders for [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg by mouth, one tablet every 8 hrs as needed for moderate to severe pain scale of 6-10. The March 2014 Medication Administration Record [REDACTED]. Further review of the clinical record including progress notes revealed there was no documentation that the resident's pain was assessed using the pain scale, after the administration of pain medication on March 23. In addition, there was no documentation that the residents pain was assessed using the pain scale, prior to or after the administration of pain medication on March 24. During an interview with a licensed practical nurse (LPN) on March 26, 2014 at 2:30 p.m., she stated that residents' pain assessments would be located in the progress notes. She stated that the nurses should do a pre and post medication assessment using the pain scale. She stated that the MAR indicated [REDACTED]. -Resident #73 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed an Order Summary Report for December 2013, that included orders for [MEDICATION NAME] 5/325 mg one tablet every 4 hrs as needed via an enteral tube for moderate to severe pain scale of 6-10. Review of the March 2014 MAR indicated [REDACTED]. Review of the clinical record including progress notes for March 10, 24, and 25, revealed there was no documentation that the resident's pain was assessed usin… | 2017-07-01 |
| 4676 | 4676 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2014-03-28 | 371 | E | 0 | 1 | 25SJ11 | Based on observations, staff interviews and review of facility policies, the facility failed to serve food under sanitary conditions, as evidence by touching the inside of custard dishes and by handling food with bare hands. Findings include: -During a dining observation conducted on March 25, 2014 at 12 noon, a dietary staff member was observed placing her fingers inside of multiple custard dishes, while serving the residents. Following the observation, a CNA (Certified Nursing Assistant) who was helping with passing out the dishes stated that the dishes should always be picked up from the bottom and never from the inside. On March 26, 2014 at 3:32 p.m., the dietary manager stated that when passing out meal trays to residents, plates/cups should be held from underneath and not held by the lip of the container, with fingers inside. -During a lunch observation conducted on March 25, 2014 at 12:22 p.m., a resident was served a sandwich. The resident then requested assistance from a CNA to cut her sandwich. The CNA proceeded to pick up the resident's butter knife and with bare hands, held the bread in place, while cutting the sandwich in half. An interview following this observation was conducted with the above CNA. The CNA stated that she should have used a fork or gloves to hold down the sandwich, because it contaminated the food. She stated if this should happen in the future, she would need to get the resident another sandwich or have the kitchen cut the sandwich ahead of time. On March 26, 2014 at 3:32 p.m., the dietary manager stated that food is not be handled with bare hands, due to cross contamination and that staff are taught to use utensils to handle food. A facility policy and procedure on Sanitation and Infection Control revised in November 2002, was reviewed. However, the policy did not outline specific procedures for the sanitary delivery of food and only referred to compliance with regulatory and voluntary requirements, within this category. | 2017-07-01 |
| 4677 | 4677 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2014-03-28 | 431 | D | 0 | 1 | 25SJ11 | Based on observation, staff interviews and policy review, the facility failed to ensure that medications were secured. Findings include: During a medication pass observation on March 27, 2014 at 3:15 p.m., a LPN (Licensed Practical Nurse) walked away from the medication cart and went to the nurses station and left the cart unlocked. Visitors and a CNA (certified nurse assistant) were around the medication cart at the time it was unlocked. Following the observation an interview was conducted with the LPN who stated she should never leave the cart unlocked. During another medication pass observation on March 28, 2014 at 7:45 a.m., a LPN left a bottle of Humalog insulin out on top of the medication cart and went into a resident's room. Visitors were observed in the hallway near the cart. Following the observation, an interview was conducted with the LPN who stated that she should have lock up the insulin inside the cart. Review of a facility policy included that compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biological shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. | 2017-07-01 |
| 5532 | 5532 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2013-03-13 | 280 | E | 0 | 1 | 718011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to revise the plan of care for three residents (#s 17, 152, and 117) after a fall. The facility failed to revise the care plan for one resident (154) regarding a urinary tract infection [MEDICAL CONDITION]. The sample size was four. Findings include: Issue regarding falls: -Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated March 6, 11:08 a.m., 2013, revealed that the resident was found on the floor laying next to her bed with her wheel chair at her feet. The resident was assisted off of the floor and placed in the bed. Review of the Nurse's Notes dated March 6, 3:15 p.m., 2013, revealed that the resident was complaining of right knee pain and was given [MEDICATION NAME] 1/2 tablet for pain scale 6-7 as ordered by physician. Review of the resident's care plan for falls dated November 14, 2012, revealed that the last revision date November 26, 2012, however, there was no documented evidence identified that the falls care plan was revised or re-evaluated after the resident's fall on March 6, 2013. An interview was conducted on March 14, 2013, with a licensed practical nurse (LPN). The LPN stated that the resident's care plan for falls should be updated after a fall. -Resident #152 was admitted to the facility on [DATE],with [DIAGNOSES REDACTED]. A review of the fall assessment dated [DATE], revealed a score of 7 indicating that the resident was at a low risk for falls. A review of the minimum data set (MDS) dated [DATE], revealed documentation that the balance during transitions and walking is only able to stabilize with staff assistance. A review of the clinical record revealed that the resident had experienced a fall on March 6, 2013, sustaining bruses to the face. A review of the care plan revealed that fall risks had been initiated on March 12, 2013 and revised on March 12, 2013. A… | 2016-09-01 |
| 5533 | 5533 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2013-03-13 | 282 | D | 0 | 1 | 718011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that the falls plan of care was implemented for two residents (#s 17 and 117). Findings include: Resident #17 was admitted to the facility on [DATE]. Review of falls care plan dated November 14, 2012, revealed the following interventions: analyze previous falls to determine whether pattern/trend can be identified; document findings and dates of review; assure that assistive devices are placed appropriately in the room when not in use; assure that commonly used items are within easy reach for the resident; assure that the resident is able to use assistive devices correctly, bed in lowest position when the resident is in bed; complete Falls Risk assessment quarterly and after each fall event; compare score to previous findings; encourage the use of hand rails, grab bars when attempting to stand; report and document all falls; use bed and wheelchair alarm to alert the staff that the resident is getting out of bed or wheelchair; the resident to wear proper non-slip footwear when out of bed; and, to administer medications as ordered. Review of the Nurse's Notes dated March 6, 2013, revealed that the resident was found on the floor laying next to her bed with her wheel chair at her feet. It was noted that the resident did not have an alarm on her wheel chair at the time of the fall per her care plan. The housekeeper who found her on the floor reported that no alarm was going off when she entered the room. Review of the clinical record revealed no documented evidence that a Falls Risk Assessment was done per the resident's care plan after a fall on March 6, 2013. An interview was conducted on March 13, 2013, with a licensed practical nurse (LPN). The LPN stated that she does not know why the care plan was not followed for this resident. An interview was conducted on March 14, 2013, with the director of nursing (DON). The DON stated that the c… | 2016-09-01 |
| 5534 | 5534 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2013-03-13 | 323 | E | 0 | 1 | 718011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that three residents received adequate supervision and assistance to prevent further accidents for three residents (#s 17, 152, and 117). The sample size was three. Findings include: Resident #17 was admitted to the facility on [DATE]. Review of the clinical records revealed a falls care plan dated November 14, 2012, due to impaired balance, impaired safety awareness, and one sided weakness. The interventions included to assure that assistive devices are placed appropriately in the room when not in use and to assure that the resident is able to use assistive devices correctly. Review of nurse's notes dated March 6, 2013, revealed that on March 6, 2013, at 10:00 a.m. the certified nursing assistant (CNA) reported that the resident was found on the floor laying next to her bed with her wheelchair at her feet. The resident did not have an alarm on her wheelchair at the time of the fall. Housekeeper who found her on the floor reported that no alarm was going off when she entered the room. An interview was conducted on March 14, 2013, with a licensed practical nurse (LPN). The LPN stated that when a resident has a fall they would be assessed, an incident report would be done, all the proper people would be notified. -Resident #152 was admitted to the facility on [DATE]. A review of the fall assessment dated [DATE], revealed a score of seven indicating that the resident was at a low risk for falls. A review of the minimum data set (MDS) dated [DATE], revealed documentation that the balance during transitions and walking is only able to stabilize with staff assistance. A review of the care plan revealed that fall risks had been initiated on March 12, 2012, and revised on March 12, 2012. A review of the clinical record lacked documented evidence that a fall assessment had been implemented following a fall on March 6, 2013, in which the residen… | 2016-09-01 |
| 6524 | 6524 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2012-01-05 | 226 | D | 1 | 1 | GVCP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility investigations, staff and resident interviews, and review of facility policy, the facility failed to implement their abuse policy regarding investigations of abuse for two residents (#s 20 and 42), and failed to train facility staff in reporting abuse in a timely manner. The allegatiosn were unable to be substantiated. The sample size was four residents. Findings include: -Resident #20 was readmitted to the facility March 12, 2011, with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE], coded the resident as cognitively independent without memory problems. During the night shift on November 25, 2011, resident #20 called to be assisted to the bathroom. She alleged that when staff #1 and #2 came into her room, that they asked the resident why she did not wait for the male certified nursing assistant (CNA), to which the resident replied that she had to go to the bathroom now. She also alleged that during the toileting, one of the CNAs (she did not know which) asked her if she had ever had her tongue around a black man's sausage, to which the resident replied no, and that she did not appreciate that kind of language. The incident was reported to the day shift administrative staff, and the facility investigation was provided to the State Agency within the required time limits. A review of additional facility documentation included all the information that had been faxed to the State agency, as well as personnel information, and information related to the facility reporting the CNAs to the State Board of Nursing. The investigation included interviews with the two CNAs accused, another CNA and a licensed practical nurse who were working on the night shift the night the incident occurred, and who spoke to the resident about the incident. Further review of the investigational documentation did not include that any alert and oriented residents were interviewed to determi… | 2015-08-01 |
| 6525 | 6525 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2012-07-06 | 225 | D | 1 | 0 | 74Y311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident family member interviews, a review of a clinical record, and facility documents, the facility failed to report an allegation of misappropriation of resident property to the state agency and to provide evidence that the allegation was thoroughly investigated. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the facility's Grievance Log 2012 revealed that on February 24, 2012, "Daughter stated resident missing purse." A review of the 'How Are We Doing' form revealed that the resident's family member reported the nature of the event was "Theft of personal items". The form also revealed that the family member reported that three items were missing: a black cotton sweater approximate value $50, a khaki/gray open weave sweater approximate value $40 and a new Brooks Brothers clutch purse "stolen between 2/16 and 2/18" valued at $98. A copy of the facility's investigation regarding the allegation of misappropriation of the resident's property was requested. The documentation provided was an undated written statement signed by the administrator stating that he had investigated by speaking with licensed staff and certified nursing assistants (CNAs) regarding the matter to determine whether or not the items were indeed missing or possibly misplaced in another resident's room. He also stated that he asked the CNAs to check other room and laundry was also contacted." The administrator also provided Staff Daily Sign In Sheets dated January 8,and 17, and February 14 and 20, 2012, with the names of multiple CNAs and two licensed practical nurses with check marks by the names. A review of the state agency's Aspen Complaint Tracking database revealed that the Administrator or their designee failed to report the resident's family members allegation regarding the theft of two sweaters and a purse to the state agency. | 2015-08-01 |
| 6526 | 6526 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2012-07-06 | 226 | D | 1 | 0 | 74Y311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident family member and staff interviews, and reviews of a clinical record, facility documentation, and facility policy and procedures, the facility failed implement their policies on misappropriation of property for one resident (#1). Findings include: Resident #1 was admitted to the facility on [DATE]. During an interview conducted on July 6, 2012, the Administrator stated that the facility staff believed that the confused resident misplaced or discarded the items and the value of the items was reimbursed to the resident as a sign of good will. A review of an undated facility document faxed to the state agency on July 9, 2012, was conducted. The Administrator revealed that a concern from the resident's family was received regarding alleged missing items and was investigated by speaking with licensed staff and certified nursing assistants. He also revealed that he items were not found and the resident was reimbursed for the three items. No information was provided regarding: the investigator's report, a copy of the Resident Abuse Report Form, or written statements by the staff interviewed. A review of the facility Reporting Abuse to Facility Management policy and procedure revealed that "To assist one in recognizing incidents of abuse, the following definitions of abuse are provided:" and "h. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent." The policy also revealed "All reports of abuse... are promptly investigate." and "When an alleged or suspected case of...abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident as required: a. The State licensing/certification agency responsible for surveying/licensing the facility: b. The local/State ombudsman...d. Adult protective services; 3. Law enforcement offici… | 2015-08-01 |
| 6527 | 6527 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2012-07-06 | 241 | D | 1 | 0 | 74Y311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, a review of a clinical record, and facility investigation, the facility failed to provide care for one resident (#2) in a manner that maintained the resident's dignity and respect of his individuality. Findings include: Resident #2 was readmitted to the facility on [DATE]. A review of the sign in schedule for April 2, 2012, indicated that staff members #1 and 2 were assigned to care for the residents on the Malachite unit were the resident's room was located. A review of the male certified nursing assistant (CNAs) written statement dated April 3, 2012, revealed that the male CNA said "I said sir I have to clean you; your brief is very dirty and wet your laying on your[***]" During an interview conducted at 2:00 p.m. on July 5, 2012, the resident stated that he remember that he was standing up in his room when a man came in and started to hit him. He also stated that the man hit him several times on his right side very hard, but the hits did not leave any bruises. He further stated that he did not know who the man was or what he wanted, but later found out the man worked there. He said that he began yelling and another staff member came in the room, but that person did not do anything. During a telephone interview conducted at 3:20 p.m. on July 5, 2012, the female CNA (staff member #2) stated that she recalled the events that occurred on April 3, 2012, between the resident and the male CNA (staff member #1). She stated that the resident's call light was on and she went into the room and found the resident cross wise on the bed. She told the resident she was going to get help to get him up and help him into the wheelchair (w/c). She also stated that she went out and asked the male CNA to help her transfer the resident into the wheelchair. When they went into the room, they noticed that the resident had soiled his adult brief. She further stated that she asked the male CNA to help her transfer the resident… | 2015-08-01 |
| 7173 | 7173 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2011-01-03 | 282 | D | 0 | 1 | ZJSS11 | **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 provide one resident (#9) with a physician ordered dietary supplement per the resident's plan of care. The sample size was seven residents. Findings include: Resident #9 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed an admission dietary assessment dated [DATE], that documented the resident ate less than 75% of her meals and that her intake did not meet her nutritional needs. A physician's orders [REDACTED]. A care plan identified the resident was at risk for nutritional decline. The care plan further documented that the resident would receive Resource 2 ounces, three times a day with medication pass. On September 16, 2010, a physician's orders [REDACTED]. The care plan was updated to reflect the change to Breeze Resource 2 ounces four times a day with medication pass. According to the Medication Administration Record [REDACTED]. However, the recapitulation of physician's orders [REDACTED]. Review of the MAR from November 16 to December 30, 2010, revealed there was no documentation that the resident received the nutritional supplement, as per the care plan. During an interview conducted on December 30, 2010, the LPN (licensed practical nurse) who administered medications to the resident stated that she had not been giving the resident any nutritional supplements. She stated that the CNAs (certified nursing assistants) were giving the resident the Boost Breeze off the snack cart. An interview was conducted with a CNA on December 30, 2010, who was passing snacks in the room of resident #9. The CNA stated that she had not offered or had been giving the resident Boost Breeze, just items off the snack cart, such as crackers, cookies, and juice. The CNA stated she was not aware the resident was to have Boost Breeze. On December 30, 2010, an interview was conducted with the dietary consultant who stat… | 2015-01-01 |
| 7174 | 7174 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2011-01-03 | 431 | D | 0 | 1 | ZJSS11 | Based on observations, staff interview, and review of refrigerator monitoring logs, the facility failed to ensure that one of two medication refrigerators were monitored to ensure medications were stored at proper temperatures. Findings include: Observations were conducted on December 27, 2010 of the medication room refrigerator on the north hallway, with licensed staff present. A refrigerator log to document the temperatures was posted on the refrigerator. Review of the log revealed that 13 days in December were missing refrigerator temperatures. In an interview immediately following, licensed staff stated that the charge nurse on nights is to check the refrigerator temperatures and record them on the refrigerator monitoring log. | 2015-01-01 |
| 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 |
| 3264 | 3264 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 225 | D | 0 | 1 | 4FGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that an allegation of misappropriation of resident property involving one resident (#4) was reported to the State agency. Findings include: Review of the facility's investigative documentation revealed that on (MONTH) 19, (YEAR), resident #4 reported to the unit manager that money had been stolen out of her wheelchair the night before. Although the facility conducted an investigation regarding the missing money, the allegation of the misappropriation of resident property had not been reported to the State agency. A resident interview was conducted on (MONTH) 1, (YEAR). At this time, the resident reported that approximately two weeks ago, she had $60.00 stolen from her wheelchair. According to the resident, she put the $60.00 in the side pocket of her wheelchair instead of her locked drawer in her room, and the next morning, the money was missing. Per the resident, she reported the missing money to the unit manager, but the money has not been found. Immediately following this interview, an interview was conducted with the unit manager, who confirmed that the resident had reported the missing money to her. The unit manager confirmed that the resident's allegation had not been reported to the State agency, because the resident had a history of [REDACTED]. An interview was conducted on (MONTH) 2, (YEAR), with the DON (Director of Nursing), who confirmed that the resident had reported an allegation that money had been stolen. Per the DON, the allegation was not reported to the State agency, because the resident had a history of [REDACTED]. A review of a facility policy titled, Abuse Prevention Program included Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The policy also included: Our abuse prevention pro… | 2019-03-01 |
| 3265 | 3265 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 226 | D | 0 | 1 | 4FGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy and procedures regarding the misappropriation of resident property were implemented for two residents (#4 and 86). Findings include: -A review of the facility's investigative documentation revealed that resident #4 had alleged that money was stolen from the side pocket of her wheelchair on (MONTH) 18, (YEAR). According to the report, the resident had reported the incident to the unit manager, and an investigation had been conducted. However, the documentation did not include any evidence that the allegation of misappropriation of resident property had been reported to the State agency, per the facility's abuse policy. An interview was conducted on (MONTH) 5, (YEAR), with the Director of Nursing (DON) who initially stated that the allegation of misappropriation of resident property had not been implemented, because the resident had a history of [REDACTED]. The DON later stated that the facility's policy and procedure regarding an allegation of misappropriation of resident property should have been implemented. -During the survey, on (MONTH) 2, (YEAR), the DON was informed that resident #86 had reported an allegation of resident to resident physical abuse. During an interview with the DON on (MONTH) 3, (YEAR), which was 24 hours after the DON had been provided this information, the DON stated that she had not initiated an investigation. She stated this was due to the fact that there had been no evidence that this resident had been involved in a physical altercation with any other resident. She further stated that based on that, she had no need to initiate an investigation. According to the abuse policy, the purpose is to provide guidelines and specific procedures for the protection of residents and the investigation of allegations of abuse, neglect, or an injury of an unknown sou… | 2019-03-01 |
| 3266 | 3266 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 247 | D | 0 | 1 | 4FGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, the facility failed to inform one resident (#56) in advance of a roommate change. The sample size was 13. Findings include: Resident #56 was admitted to the facility on (MONTH) 12, 2005, with [DIAGNOSES REDACTED]. During an interview conducted with the resident on (MONTH) 2, (YEAR) at 9:50 a.m., the resident stated that staff never informed him that he was getting a new roommate, before the new roommate was admitted to the room. The resident further stated that he was surprised to see that he had a new roommate. Review of the clinical record revealed there was no documentation that the resident was informed of the roommate change. An interview was conducted with the social worker on (MONTH) 5, (YEAR). The social worker stated that resident's are informed prior to getting a new roommate. The social worker stated that this notification should be documented in the resident's clinical record. The social worker stated that the resident received a new roommate on (MONTH) 16, (YEAR), and that he was notified of the new roommate, but the notification was not documented in the resident's clinical record. The social worker said that the facility has a form which is completed when a resident has a room change. The social worker further stated that the facility did not have a policy regarding notifying a resident before a roommate change. | 2019-03-01 |
| 3267 | 3267 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 250 | E | 0 | 1 | 4FGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, facility documentation and staff interviews, the facility failed to ensure that medically related social services were provided for one resident (#53). Findings include: Resident #53 was readmitted on (MONTH) 3, 2013, with [DIAGNOSES REDACTED]. The resident currently resides on the male secured behavior nursing unit. A Notice of Filing Request for Judicial Review from the Pima County Mental Health Defender dated (MONTH) 4, (YEAR), which was addressed to the resident, included that a recommendation had been made for the resident not to be released from the court-ordered treatment. However, the clinical record did not include any documented evidence that the resident had been informed of the (MONTH) 4, (YEAR), judicial review communication and/or finding. An interview was conducted on (MONTH) 4, (YEAR), with the Social Service Director, regarding the judicial review notice to the resident. She stated that she could not recall if she had reviewed it with the resident. The Social Service Director stated that either herself or the Activities Director, would have been responsible to review the judicial findings with the resident. During an interview conducted on (MONTH) 4, (YEAR), with the Activities Director, she stated that she does not discuss or review any judicial review communications with residents. In addition, a Superior Court psychiatric examination review dated (MONTH) 24, (YEAR), included the following: the resident's cognition was severely impaired; the resident did not have a guardian; and that the resident was to be released without delay from the court ordered treatment status. An annual MDS (Minimum Data Set) assessment dated (MONTH) 5, (YEAR), included that the resident's Brief Interview for Mental Status score was 9, which indicated the resident had moderate cognitive impairment. A social service note dated (MONTH) 7, (YEAR), included that the resident was alert and oriented to self and t… | 2019-03-01 |
| 3268 | 3268 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 253 | E | 0 | 1 | 4FGO11 | Based on observations, staff interview, and review of facility policies and procedures, the facility failed to maintain a sanitary, orderly, and comfortable interior in multiple areas throughout the facility. Findings include: An environmental tour was conducted on (MONTH) 4, (YEAR), with the maintenance director and housekeeping director. Multiple areas of concern were observed: -Room A1: A baseboard was loose in the bathroom. An interview was conducted with the maintenance director on (MONTH) 4, (YEAR). The maintenance director stated that he was not aware of the baseboard being loose in the bathroom, but that staff were usually pretty good about completing work orders. -Room A10-2: The wall guard near the resident's bed was secured to the wall with duct tape and the curtain rod was bent. An interview was conducted with the maintenance director. The director stated that someone just glued the wall guard over the weekend and did not take the duct tape off. The director stated that more glue needed to be applied to the wall guard. He also said that if he was aware of the bent curtain rod, he would have fixed it. -Room A3-2: The curtain rod was bent. -Room A20-1: The over the bed light would not turn on when the string was pulled. An interview was conducted with the maintenance director who stated that he was not aware that the light switch was broken and it would be fixed today. -Room A21-2: The wall by the resident's bed had old tape on it and the wall was in need of painting. The bathroom also had a strong smell of urine. An interview was conducted with the maintenance director who stated that he guessed someone just took stuff down off the wall. -Room A24-2: The door frames and the bathroom wall were gouged. The maintenance director stated that he was working on repairing all of the door frames. -Room A24-1: The top of the back rest of a resident's wheelchair was torn. An interview was conducted with the maintenance director on (MONTH) 4, (YEAR). The director stated he only repairs the wheelchairs that the fac… | 2019-03-01 |
| 3269 | 3269 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 282 | E | 0 | 1 | 4FGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, staff interview and policy review, the facility failed to ensure that a hospice care plan reflected the disciplines that would provide services to one resident (#20) and failed to implement the care plan for one resident (#72). Findings include: -Resident #20 was admitted to the facility on (MONTH) 13, 2014, with [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR) revealed the resident was receiving hospice services. A review of the clinical record revealed a hospice care plan with multiple interventions to address the residents needs. However, in the section to document what discipline would provide each service, no disciplines were listed. In an interview on (MONTH) 2, (YEAR) at 2:00 p.m., a licensed practical nurse (LPN) was unable to provide documentation as to which discipline was to provide what services on the hospice care plan. Review of a facility policy regarding care plans revealed to Identify the professional services that are responsible for each element of care . -Resident #72 was admitted to the facility on (MONTH) 18, 2010, with a [DIAGNOSES REDACTED]. Review of care plan last reviewed on (MONTH) 29, (YEAR) revealed that the resident had impaired physical mobility related [MEDICAL CONDITIONS], manifested by inability to purposefully move within the environment including bed mobility, transfers and ambulation. The resident was also identified to have alteration in comfort related to right [MEDICAL CONDITION] and muscle spasm. Approaches included for a gerichair cushion for comfort, repositioning for comfort as needed using pillow support, and repositioning and assisting the resident to assume and maintain a comfortable position. An observation of the main dining room was conducted on (MONTH) 1, (YEAR) at 11:56 a.m. Resident #72 was observed sitting in the gerichair, and her head and neck were bent and were leaning to the right side, with t… | 2019-03-01 |
| 3270 | 3270 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 309 | D | 0 | 1 | 4FGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on multiple resident observations, clinical record review, and staff and resident interviews, the facility failed to ensure that one resident (#72) was provided care and services to promote the resident's highest practicable well being. Findings include: Resident #72 was admitted to the facility on (MONTH) 18, 2010, with a [DIAGNOSES REDACTED]. Review of care plan last reviewed on (MONTH) 29, (YEAR) revealed that the resident had impaired physical mobility related [MEDICAL CONDITIONS], manifested by inability to purposefully move within the environment including bed mobility, transfers and ambulation. The resident was also identified to have alteration in comfort related to right [MEDICAL CONDITION] and muscle spasms. Approaches included for a gerichair cushion for comfort, repositioning for comfort as needed using pillow support, and repositioning and assisting the resident to assume and maintain a comfortable position. According to the annual MDS (Minimum Data Set) assessment dated (MONTH) 31, (YEAR), the resident was assessed with [REDACTED]. Under the section for functional range of motion, the resident was assessed to have impairment on one side to the upper extremity and both sides on the lower extremity. In addition, the resident was totally dependent on staff for bed mobility, transfers and hygiene. Review of the medication review report for (MONTH) and (MONTH) (YEAR) revealed an order for [REDACTED]. An observation of the main dining room was conducted on (MONTH) 1, (YEAR) at 11:56 a.m. Resident #72 was observed sitting in the gerichair and her head and neck were bent and were leaning to the right side, with the resident's face staring at the ceiling. It was observed that there was a pillow behind the back of the resident's head, however; there was no pillow to support the resident's neck and head to ensure proper positioning. The resident's right hand was on the resident's right chin supporting her head. In addition, there wer… | 2019-03-01 |
| 3271 | 3271 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 323 | E | 0 | 1 | 4FGO11 | Based on observations and staff interviews, the facility failed to ensure the resident environment was free of accident hazards as is possible. Findings include: An environmental tour was conducted on (MONTH) 4, (YEAR), with the maintenance director and the housekeeping director and revealed the following: On the Tu Jhanu unit: -There were multiple over the bed tables that had gouged and jagged edges. An interview was conducted with the maintenance director on (MONTH) 4, (YEAR). The maintenance director stated that no one told him that the over the bed tables were damaged. -The back rest of a resident's wheelchair was torn, with rough edges. An interview was conducted with the maintenance director who stated that he only repaired the wheelchairs that the facility owned and did not know if this wheelchair belonged to the facility or not. -On (MONTH) 3, (YEAR) at 7:26 a.m., a dining observation on the Tu Jhanu station was conducted. It was observed that there was one resident sitting at a table that was chipped on the top side of the table. Another resident was sitting at a different table, and that table also had a chipped area. The chipped areas were rough and jagged and measured approximately 2 1/2 feet long and 2 inches wide. The resident's were leaning their forearms against the chipped areas of the tables. An interview with the maintenance personnel was conducted on (MONTH) 4, (YEAR) at 10:30 a.m. and he stated that he did not know that the tables were damaged. He said that he relies on staff to tell him about it. He further stated that he does not have a maintenance repair log that tracks equipments that needs repair. An interview with the unit manager was conducted on (MONTH) 5, (YEAR) at 9:23 a.m. She said that staff who identify the broken or damaged equipment are to fill out a maintenance work order and submit the order form to the maintenance department. She said that depending on the degree of damage and if the equipment is still usable, the resident can use the equipment, but if it is badly broken, th… | 2019-03-01 |
| 3272 | 3272 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 329 | E | 0 | 1 | 4FGO11 | **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 informed consents were obtained prior to the use of [MEDICAL CONDITION] medication, and failed to ensure that complete and thorough behavior monitoring assessments were provided for one resident (#53). Findings include: Resident #53 was readmitted on (MONTH) 3, 2013, with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident currently resided on the male secured behavior nursing unit. A review of an annual MDS (Minimum Data Set) assessment dated (MONTH) 5, (YEAR), revealed the resident's Brief Interview for Mental Status score was 9, which indicated the resident had moderate cognitive impairment. A review of the (MONTH) (YEAR), recapitulation of physician's orders [REDACTED]. -[MEDICATION NAME] 1.5 mg (milligrams) by mouth three times a day for anxiety state (original order date was (MONTH) 2, (YEAR)). -[MEDICATION NAME] 2 mg by mouth every four hours prn (as needed) for agitation, irritability, and aggression related to anxiety state (original order date was (MONTH) 7, 2013). -[MEDICATION NAME] 2 mg/ml (milliliters) inject 1 ml intramuscularly every four hours prn for non redirectable restlessness (original order date was (MONTH) 8, 2014). -[MEDICATION NAME] HCL 20 mg by mouth daily for depression (original order date was (MONTH) 10, 2013) -[MEDICATION NAME] 20 mg by mouth twice a day for aggression, and delusions related to [MEDICAL CONDITION] (original order date was (MONTH) 27, (YEAR)). -[MEDICATION NAME] inject 10 mg intramuscularly every eight hours prn for aggression and delusions related to [MEDICAL CONDITION] (original order date was (MONTH) 27, (YEAR)). Review of the clinical record revealed that from (MONTH) (YEAR) through (MONTH) (YEAR), the resident was administered the [MEDICAL CONDITION] medications as ordered. However, there was no documented evidence that an informed consent, inclusive of the risk and b… | 2019-03-01 |
| 3273 | 3273 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 371 | E | 0 | 1 | 4FGO11 | Based on observations, staff interviews, and review of facility policies and procedures, the facility failed to ensure that accurate temperature logs were maintained for the reach-in refrigerator in the kitchen and failed to ensure that a window screen in the dishroom was not torn. Findings include: During an initial inspection of the kitchen on (MONTH) 1, (YEAR) at 10:30 a.m., the thermometer inside of the reach-in refrigerator was observed to be at 28 degrees Fahrenheit. A temperature log posted on the outside of the refrigerator documented that the temperature of the refrigerator for (MONTH) 1, was 22 degrees Fahrenheit. None of the food stored inside of the reach-in refrigerator appeared to be frozen. An interview was conducted with the dietary manager on (MONTH) 1, (YEAR). The dietary manager stated that she would obtain a new thermometer for the reach-in refrigerator. During the initial inspection of the kitchen on (MONTH) 1, (YEAR), the entire top of a screen to a window in the dishroom was observed to be torn, with a four inch opening. An interview was conducted with the dietary manager on (MONTH) 1, (YEAR). The dietary manager stated that no one told her that the screen was torn and that she would have it repaired immediately. During another tour of the kitchen on (MONTH) 3, (YEAR) at 10:00 a.m., the thermometer inside of the reach-in refrigerator was observed to be at 40 degrees Fahrenheit. A temperature log posted on the outside of the refrigerator for (MONTH) 3, documented that the temperature of the refrigerator was 20 degrees Fahrenheit. Review of a previous temperature log for (MONTH) (YEAR) revealed that temperatures recorded for the month were between 16 and 28 degrees Fahrenheit. Another interview was conducted with the dietary manager on (MONTH) 3, (YEAR). The dietary manager stated that it was the night shift supervisor's responsibility to ensure that the temperatures of the refrigerators are recorded and if they were inaccurate, she should have been notified. A review of the facility's policy… | 2019-03-01 |
| 3274 | 3274 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 431 | E | 0 | 1 | 4FGO11 | Based on a review of facility documentation, observations, staff interviews, and a review of facility policies, the facility failed to discard an expired medication, failed to ensure that a glucose control solution included the date when opened and implemented corrective action when test results were out of range, and failed to ensure that three narcotic boxes were permanently affixed. Findings include: -During an observation conducted on (MONTH) 1, (YEAR), of the A nursing unit medication room, a tube of Triamicinole acetate cream 1% was observed to have an expiration date of (MONTH) (YEAR). An interview was conducted at that time with the unit manager, who stated that the night shift was responsible to check the medication room to ensure that any expired medications are disposed of. -On (MONTH) 5, (YEAR), observations were conducted of the facility's medication carts. The following was observed: A wing nursing unit: the blood glucose control solution, which had been used, did not include the date when opened. The blood glucose control record for (MONTH) (YEAR), included that on (MONTH) 15, (YEAR), the test result was out of the test control range. The record did not include any documentation that any corrective action had been implemented to ensure the accuracy of residents' blood glucose test results. La Pagosa nursing unit: the blood glucose control record included documentation that on (MONTH) 11, and 19, (YEAR), the control test results were out of the test control range. The record did not include any documented evidence that any corrective action had been taken to ensure the accuracy of residents' blood glucose test results. In addition, the narcotic box, which was observed to be locked and inside of the medication cart, was not permanently affixed. The narcotic box, which contained numerous controlled medications was able to be lifted out of the medication cart. An interview was conducted on (MONTH) 5, (YEAR), with the LPN (Licensed Practical Nurse) on the A wing nursing unit. The LPN stated that the blo… | 2019-03-01 |
| 3275 | 3275 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 441 | E | 0 | 1 | 4FGO11 | Based on observations, staff interviews and policy review, the facility failed to ensure that appropriate infection control practices were implemented regarding a suprapubic catheter and the use and disinfecting of the facility's nail clippers. Findings include: -During an observation conducted on (MONTH) 1, (YEAR), one resident's catheter tubing was observed laying on the dining room floor. Interviews were conducted on (MONTH) 5, (YEAR), with a LPN (Licensed Practical Nurse), the unit manager, and DON (Director of Nursing), who all stated that the catheter tubing should be kept off the floor, because of infection control issues. A facility policy titled, Urinary Catheter Care included The purpose of this procedure is to prevent infection of the resident's urinary tract. The policy also included to be sure the catheter tubing and drainage bad are kept off the floor. -During medication storage observations conducted on (MONTH) 5, (YEAR), the following was observed: A wing nursing Unit: Two fingernail clippers were observed in the medication cart along with oral, and injectable medications and eye drops. An interview was conducted on (MONTH) 5, (YEAR), with a LPN, who stated that the fingernail clippers should not have been in the medication cart because of potential infection control issues. Tu Jhanu nursing unit: Two fingernail clippers were observed laying on the ledge by the sink in the medication storage room. An interview was immediately conducted with the LPN, who confirmed that the fingernail clippers were used for residents and stated that they are cleaned with alcohol after use. B wing nursing unit: One small fingernail clipper was observed in the medication cart. An interview was conducted with the LPN, who stated that the fingernail clippers should not have been kept in the medication cart. The LPN stated the fingernail clipper was used for residents and that they should be disinfected before use. However, according to the LPN, the facility was out of the Barbicide disinfectant used to disinfect the cli… | 2019-03-01 |
| 3276 | 3276 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 467 | E | 0 | 1 | 4FGO11 | Based on observations and staff interviews, the facility failed to ensure odor levels were acceptable throughout the facility. Findings include: Pervasive odors were noted throughout the facility on all days of the survey, from (MONTH) 1 through 5, (YEAR). Odors were noted to be the strongest in the central hallway of the facility. An interview was conducted with the housekeeping director on (MONTH) 4, (YEAR). The housekeeping director stated that sometimes the facility has odors when residents are being changed after an incontinent episode. An interview was conducted with the maintenance director on (MONTH) 4, (YEAR). The director stated that he just sprayed all the halls. The maintenance director stated that the facility was aware of odors in the facility periodically and that this could possible be due to the ventilation system. An interview was conducted with the administrator on (MONTH) 5, (YEAR). The administrator stated that she was not aware of any odors throughout the facility, but it could possibly be due to the ventilation. | 2019-03-01 |
| 3277 | 3277 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 469 | E | 0 | 1 | 4FGO11 | Based on observations, and staff interviews, the facility failed to ensure that flies were not present in the residents' dining room. Findings include: Multiple dining observations were conducted on the La Oneita nursing unit on (MONTH) 1, and 3, (YEAR). During these meal observations, the dining room door was observed to be opened to the outside and despite a fly light on the wall, multiple flies were observed in the dining room and on the resident's drinking cups. An interview was conducted on (MONTH) 3, (YEAR) , with the unit manager and Licensed Practical Nurse. According to the staff, the door was opened to the outside, because residents frequently go in and out of the dining room and because some residents become agitated when the dining room door is closed. The staff also stated that the flies in the dining room were unavoidable. An interview was conducted on (MONTH) 5, (YEAR), with the Maintenance Director, who stated that he conducted monthly checks of the bug light in the dining room to ensure that it was not too full of flies. However, he was unable to provide any documented evidence that the bug lights were maintained. The Maintenance Director also stated that the current bug light was not very effective and that he plans on replacing it with a more effective system. | 2019-03-01 |
| 3278 | 3278 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2015-06-05 | 520 | E | 0 | 1 | 4FGO11 | Based on concerns identified during the survey and staff interviews, the Quality Assessment and Assurance (QA) program failed to identify multiple quality concerns, in order to implement corrective action. Findings include: During the facility's annual survey, concerns were identified regarding the following areas: -Reporting and investigating allegations of abuse and misappropriation of resident property. -Provision of medically related social services. -Housekeeping and maintenance services. -Provision of care and services regarding proper positioning. -Free of accident hazards. -Informed consents and behavior monitoring for psychoactive medications. -Infection control practices. -Pervasive odors throughout the facility. -Maintain an effective pest control program. An interview was conducted on (MONTH) 5, (YEAR), with the administrator. The administrator stated that the facility had a Quality Assurance (QA) committee that met monthly, but the QA committee did not identify any of the issues identified by the survey team. The administrator further stated that the facility did not have a QA policy. | 2019-03-01 |
| 4332 | 4332 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2014-03-27 | 221 | D | 0 | 1 | 8MM911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#18) was free from a physical restraint imposed by a certified nursing assistant (CNA/staff #1). The sample size was 3. Findings include: Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required limited assistance with one person assist for moving on and off the unit. Review of the facility investigative documentation revealed that on March 14, 2014, the resident was found with a plastic bag tied around his wheelchair and the handrail, preventing movement. Per the report, a CNA who witnessed the incident, had walked out of a resident's room and saw resident #18 tied to the handrail in the wheelchair. This CNA untied the resident and went to report the incident. When she came back, the resident was tied again to the handrail. One of the nurses on the unit was alerted and removed the restraint. No injuries were noted. Staff #1 admitted to tying the resident to the handrail, because the hallway was very busy and she didn't want the resident wandering, as he might get hurt. Staff #1 was afraid an agitated resident was going to get in the way. According to the report, staff #1 had no intention of hurting the resident and was only trying to multitask. The CNA was terminated as a result of this incident. Review of the resident's clinical record revealed no evidence that the resident was to have any restraints. An interview was conducted on March 25, 2014 at 11:30 a.m., with one of the CNA's who witnessed the incident. She stated that she walked out of a room into the hallway and saw the resident's wheelchair tied to the handrail. She said she untied him and then walked off the unit to report the incident and when she returned, the resident's wheelchair was again tied to the handrail. I… | 2017-11-01 |
| 4333 | 4333 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2014-03-27 | 279 | D | 0 | 1 | 8MM911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of facility policies and procedures, the facility failed to develop a comprehensive care plan for urinary incontinence for one resident (#53). The sample size was thirty four. Findings include: Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's admission MDS (Minimum Data Set) assessment dated [DATE] in Section H. Bladder and Bowel revealed the resident was occasionally incontinent. In Section V. Care Area Assessment (CAA) Summary revealed urinary incontinence triggered and to proceed to care planning. According to a physician progress notes [REDACTED].feels she is incontinent because she cannot get to toilet fast enough . A review of the resident's clinical record did not reveal that a care plan for urinary incontinence had been developed. An interview was conducted with the MDS coordinator on March 26, 2014. The MDS coordinator stated that the resident's incontinence status varied. The MDS coordinator stated that she documented on the CAA Summary that a care plan would be developed, however, she was unable to locate a care plan for urinary incontinence and stated that one should have been developed. A review of the facility's policy regarding Comprehensive Care Plans documented .The comprehensive care plan has been designed to: Incorporate problem areas . | 2017-11-01 |
| 4334 | 4334 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2014-03-27 | 281 | E | 0 | 1 | 8MM911 | **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 resident's (#134) medication was not expired. Findings include: Resident #134 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the March 2014 physician's orders [REDACTED]. During a medication administration observation with a LPN (licensed practical nurse) on March 26, 2014, it was observed that resident #134's [MEDICATION NAME] medication card with multiple medications enclosed, had expired in February 2014. An interview was conducted with the LPN immediately following the observation. The LPN stated that she did not notice that the [MEDICATION NAME] had expired. She also stated that there was another medication card of the [MEDICATION NAME] that had not been used, which was not expired. An interview was conducted with the Director of Nursing (DON) on March 26, 2014. The DON stated that it is the responsibility of nursing to remove all expired medications from stock. | 2017-11-01 |
| 4335 | 4335 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2014-03-27 | 323 | D | 0 | 1 | 8MM911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, current and former staff interviews, review of facility documentation, and review of facility policies and procedures, the facility failed to provide adequate supervision for two residents (#'s 38 and 81) to prevent an altercation, which resulted in injury. The sample size was seven. Findings include: Resident #81 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE], in Section E. Behaviors, revealed resident #81 had physical behavioral symptoms directed toward others. A psychosis care plan updated on March 10, 2014, included a problem of Episodic Mood Disorder .manifested by .combative behavior . An approach documented was to .remove resident from situation when combative, intervene and redirect . Nurse's Notes dated March 22, 2014 documented Increased agitation noted. Redirection effective. Resident sitting on bed in room. Ambulated with walker to door of room, other resident sitting to resident's left, CNA (certified nursing assistant) to right side. Resident grabbed other resident's (#38) right hand and bit thumb area as per other resident. Other resident (#38) screamed .both residents removed from area and separated. This nurse examined other resident's (38) broken skin. Cut around thumb of right hand . Review of the facility's Reportable Event Record/Report included the following: At 10:30 a.m. resident #38 was sitting in a chair to the left of resident #81's bedroom doorway when resident #81 came out of her room and grabbed resident #38's right hand and bit her thumb. Resident #38 screamed and staff immediately separated both residents. Resident #38 was noted to have her right thumb scratched, open and bruised. The report further included that the CNA was terminated for failure to follow unit policy, by sitting in the hallway when she was supposed to be standing supervising resident safety and failed to prevent a reside… | 2017-11-01 |
| 4336 | 4336 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2014-03-27 | 354 | F | 0 | 1 | 8MM911 | Based on facility documentation and staff interviews, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours per day, seven days per week. Findings include: As part of the sufficient staffing task review, facility staffing documentation was reviewed and revealed that there was no evidence that an RN was working in the facility on February 22 and 23, 2014 and on March 8 and 23, 2014. An interview was conducted with the staffing coordinator on March 27, 2014. The staffing coordinator stated that no RN worked on February 22 and 23 and March 8 and 23, 2014. He also stated that the RN that was scheduled to work on some of those days had called off. An interview was conducted with the Administrator on March 27, 2014. The Administrator stated that she did not know that they were required to have an RN in the facility at least eight hours per day, seven days a week. She also stated that the facility does not have a policy regarding an RN being in the facility at least eight hours per day, seven days per week. | 2017-11-01 |
| 4337 | 4337 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2014-03-27 | 441 | D | 0 | 1 | 8MM911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, Centers for Disease Control (CDC) Guidelines and policy review, the facility failed to ensure that glucometers were properly disinfected. Findings include: -During a medication storage mandatory task on March 26, 2014, an observation was made of a licensed practical nurse cleaning the glucometer with an alcohol pad. An interview was conducted immediately following the observation. The LPN stated that she uses alcohol to clean the glucometer between residents. An interview was conducted with the unit manager on March 26, 2014. The unit manager stated that the staff should know that it is the facility policy to use a disinfecting wipe with an active ingredient of ammonium chloride. -During a medication administration observation on March 26, 2014 at 7:45 a.m., a LPN was observed testing a resident's blood sugar with a glucometer. Afterwards, the LPN cleaned the glucometer with an alcohol wipe. During an interview following the observation, the LPN explained that he uses an alcohol wipe to clean the glucometer. During an interview conducted on March 26, 2014 at 8:30 a.m., the DON stated that the glucometers should be cleaned with a germicide that is recommended by the CDC. A review of the CDC website under frequently asked questions regarding Assisted Blood Glucose Monitoring and Insulin Administration revealed that glucometers need to be cleaned and disinfected after each use. It further documented the disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus .70% [MEDICATION NAME] solutions are not effective against viral bloodborne pathogens. Review of the facility's policy on Disinfection of the Glucose Monitoring System revealed .Disinfection of the Blood Glucose Monitoring System is best accomplished with an EPA registered product which is effective against bloodborne pathogens HBV, HCV and HIV. The product should not require dilution, be pre-moistened and a… | 2017-11-01 |
| 6528 | 6528 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2011-10-27 | 156 | F | 1 | 1 | KVZJ11 | Based on family and staff interviews and a review of facility admission documents, the facility failed to provide residents and/or their family members/legal representative with a written list of the items and services that were included in the nursing facility's services under the State plan and for which the resident may not be charged or the other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services upon admission or periodically. Findings include: During interviews conducted on October 25, 2011, two residents' family members stated that they were not informed of the cost of services or any changes in cost for services for their family members who were residents in the facility. A review of the written documentation provided to residents and their family members or legal representatives upon admission revealed no written list of the items and services that were included in nursing facility services under the State plan and for which the resident may not be charged or the other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services. During an interview conducted at 2:05 p.m. on October 26, 2011, the Admission Coordinator stated that she did not have a written list of charges that she provided to the residents or their family members upon admission. During an interview conducted at 2:15 p.m. on October 26, 2011, the administrator stated that she did not have a list of cost for services that was provided to residents or their family members. During an interview conducted at 2:25 p.m. on October 26, 2011, the business office manager stated that he did not have a written list of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged or the other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services. The b… | 2015-08-01 |
| 6529 | 6529 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2011-10-27 | 223 | D | 1 | 1 | KVZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility self -report, interviews and facility policy the facility failed to ensure that one resident (#53) was free from abuse. The sample size was two. Findings include: Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the care plan dated November 17, 2010, revealed the care plan addressed the resident's physical aggressiveness and the intervention to provide a slow approach when providing care. A self-report provided by the facility on March 15, 2011, revealed that the resident was involved in a staff to resident physical altercation in which the resident was hit by a certified nursing assistant (CNA/Staff #1). A review of the facility report revealed that the perpetrator denied hitting the resident and refused to write out a statement. Witness of the incident, staff #2 was interviewed on October 25, 2001. Staff # 2 was in the resident's room performing a one on one duty with the resident's roommate. She stated that while staff # 1 was changing the resident's brief the resident hit CNA # 1 who then hit the resident on his arm/hand. The resident brought his arm up to ward off any further strikes but did not hit staff # 1 again. According to staff #2, she asked staff #1 if she wanted her to call for help but she said no. Staff #2 said that she put the call light on twice but staff # 1 would turn the light off each time. Staff #2 then stated that she reported the incident to the charge nurse. A review of the facility policy, abuse prevention, documents the following policy statement: "...Our residents have the right to bee free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion..." | 2015-08-01 |
| 6530 | 6530 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2011-10-27 | 246 | D | 1 | 1 | KVZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews of staff and resident, and clinical record review the facility failed to accommodate the needs of one resident (#42) regarding her need for water at bedside. Findings include: Resident #42 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician recapitulation orders dated October 1, 2011, did not reveal an order for [REDACTED]. An observation of the resident's room on October 25 at 9:54 AM and October 26, 2011, revealed the lack of a water pitcher and or drinking cup. The resident's night stand was utilized as a TV stand at the end of her bed. There was no furniture in her room that could be utilized to hold a water pitcher except for a chair which contained clothing and basin. An interview with the resident conducted on October 25, 2011, revealed that the resident did not receive enough fluids between meals. The stated that she never had a water pitcher, that she must request a drink when she wanted one and she did not find this agreeable. An interview with the registered nurse (RN) on the unit conducted on October 26, 2011, revealed that the nurse was not aware that the resident did not have a water pitcher in their rooms. An interview with the nurse unit manager conducted on October 26, 2011, revealed that he was not aware that the resident did not have a water pitcher in their rooms. He further stated that he had previously worked on the behavioral unit where residents were not allowed water pitchers. . An interview with the director of nursing (DON) revealed that she was not aware that multiple residents. Observations were then made of four resident rooms and there were no water pitchers. | 2015-08-01 |
| 6531 | 6531 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2011-10-27 | 431 | E | 1 | 1 | KVZJ11 | Based on observation and facility policy the facility failed to secure narcotics in one of five units. Findings include: Observation conducted on October 26, 2011, revealed that the narcotics box was not secured in a refrigerator in an unlocked room. A review of the facility policy on securing narcotics revealed the following: "...4. Medications listed in Schedule II, including those requiring refrigeration are stored under separately locked permanently affixed compartments". Interview with the director of nursing was conducted on October 27, 2011, revealed that she was not aware that the narcotics were not fully secured on this unit. | 2015-08-01 |
| 6532 | 6532 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2011-10-27 | 441 | D | 1 | 1 | KVZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of personnel records and staff interview the facility failed to ensure that staff # 3 was free of [DIAGNOSES REDACTED]. Findings include: A review of personnel records of staff #3 revealed that the staff member was hired on June 18, 2010. Her personnel file lack documentation that she had obtained a [DIAGNOSES REDACTED] test in June of 2011. An interview with human resource on October 27, 2011, revealed that the staff's [DIAGNOSES REDACTED] test was not available. | 2015-08-01 |
| 7605 | 7605 | SANTA ROSA CARE CENTER | 35004 | 1650 NORTH SANTA ROSA AVENUE | TUCSON | AZ | 85712 | 2010-12-21 | 323 | E | JYJP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one resident (#1) was provided adequate supervision to prevent an elopement from the facility through an unlocked gate. The sample size was seven. Findings include: Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had short and long term memory problems and required supervision with locomotion off of the nursing unit where he resided. The resident resided on a locked behavioral unit. A review of the resident's clinical record revealed a Bi-Weekly Behavior Summary dated June 17, 2010, which documented "Resident had...2 episodes of exit seeking...Resident also yelled at the staff when they would not let him out of the secured door and back gate." The resident's clinical record revealed a Bi-Weekly Behavior Summary dated July 15, 2010 which documented "Resident has had...1 episode of exit seeking...Resident went to back gate and pushed button. Staff redirected resident back into building. Resident just sat at gate. Did not attempt to open the gate. Just wondered what the button did." The resident's clinical record revealed Nurse's Notes dated August 19, 2010, which documented "Resident set the alarm off today and tried again a second time but was stopped before he could do it. When asked what he was doing resident stated 'I want to get the...out of here...Resident was redirected to go the opposite direction in wheelchair and cursed the whole way back. Will continue to monitor." The resident's clinical record revealed a Bi-Weekly Behavior Summary dated August which documented "Resident at least once will verbalize exit seeking or seek out exit." The resident's clinical record revealed a Bi-Weekly Behavior Summary dated September 2 which documented "Resident daily … | 2014-04-01 | ||
| 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 |
| 3168 | 3168 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2015-08-05 | 154 | D | 0 | 1 | YQF311 | **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 (#112) was informed of the risks and benefits of [MEDICAL CONDITION] drug use. Findings include: Resident #112 was readmitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The resident was transferred to the hospital on (MONTH) 15, (YEAR) and returned to the facility on (MONTH) 17, (YEAR). The (MONTH) (YEAR) recapitulation of physician's orders [REDACTED]. [MEDICATION NAME] (antianxiety) 5 milligrams (mg) one tablet by mouth every eight hours as needed for anxiety (order date was (MONTH) 12). A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. [MEDICATION NAME] and [MEDICATION NAME] administration began on the morning of (MONTH) 12. Physician orders [REDACTED]. The clinical record contained a Consent for the Use of [MEDICAL CONDITION] Medications, which was undated. [MEDICATION NAME] and [MEDICATION NAME] were listed on the consent form, along with the resident's signature. Also on this form, staff had handwritten [MEDICATION NAME] and initialed and dated it (MONTH) 23, (YEAR). However, the clinical record did not contain any documentation that the resident was informed of the risks and benefits of the use of the antipsychotic medication [MEDICATION NAME], prior to it's administration. An interview was conducted with a registered nurse (RN) on (MONTH) 5, (YEAR) at 1:30 p.m. The RN stated that if he recognized that a resident received a medication not contained on the consent form, the ADON (Assistant Director of Nursing), DON and physician would be notified and a new consent obtained from the resident. An interview was conducted with the ADON on (MONTH) 5, (YEAR) at 1:35 pm. The ADON stated that he reviews charts and if something was missing from the consent, he would add the missing medication to the consent and initial and date it. He was unable to provide documentation that the resident was informed o… | 2019-04-01 |
| 3169 | 3169 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2015-08-05 | 159 | D | 0 | 1 | YQF311 | Based on resident interviews, staff interviews, and review of facility policies and procedures, the facility failed to ensure that two residents had access to their funds from the resident trust account on the weekends. Findings include: During resident interviews conducted on (MONTH) 3, (YEAR), two residents stated they were unable to readily obtain access to funds. One resident stated that on weekends it is closed and if money is wanted you must get it out on Friday. A second resident stated that they don't believe a resident can get money out on weekends because no one is available. An interview was conducted with the Business Office Manager on (MONTH) 4, (YEAR) stated residents can obtain money from their trust accounts Monday through Friday from 8:30 a.m. until 5:00 p.m. During other hours no one is available to provide access to the resident funds. The Business Office Manager indicated the residents requested access to personal funds at the Resident Council meeting held on (MONTH) 14, (YEAR). The Business Office Manager stated she is in discussions with the DON to develop a plan that she hopes to share at the (MONTH) Resident Council meeting and implement by the end of August. However, she does not have any documentation on the discussions, planned process, or implementation plan in meeting minutes or quality processes. An interview was conducted with the Director of Nursing (DON) on (MONTH) 4, (YEAR), who stated she is working with the Business Office Manager to develop a plan for residents to access personal funds. She also indicated she does not have any documentation on the discussions, planned process, or implementation plan in meeting minutes or quality processes. A review of the Buisness Office records on resident personal funds indicated there are 32 residents that have personal funds accounts and these 32 residents are unable to access their personal funds outside the hours of Monday through Friday 8:30 AM to 5:00 PM. An interview was conducted with the Activities Director on (MONTH) 4, (YEAR) who … | 2019-04-01 |
| 3170 | 3170 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2015-08-05 | 278 | D | 0 | 1 | YQF311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff interview, and a review of facility policy, the facility failed to ensure that a MDS (Minimum Data Set) assessment was accurate regarding a weight loss, for one resident (#98). Findings include: Resident #98 was admitted on (MONTH) 19, (YEAR), for rehabilitation. The resident's [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the weight record documentation revealed the following: -April 23, (YEAR): weight 145 lbs. -April 29, (YEAR): weight 141 lbs. -May 5, (YEAR): weight 132 lbs., which was a 13 lb. or 9% weight loss. However, a review of a MDS assessment dated (MONTH) 10, (YEAR), did not reflect that the resident had a weight loss. An interview was conducted on (MONTH) 5, (YEAR), with the DON (Director of Nursing), who following a review of the clinical record documentation, agreed that the MDS was not accurate regarding the presence of a weight loss. The DON also stated that the previous dietary technician had entered the incorrect MDS data. A facility policy titled, Accuracy of Assessment, included, It is the policy of this facility to ensure that the assessment accurately reflect the resident's status. The policy also included the following: 7. Each individual who completes a portion of the assessment must sign and certify that accuracy of that portion of the assessment. | 2019-04-01 |
| 3171 | 3171 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2015-08-05 | 279 | D | 0 | 1 | YQF311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and policy review, the facility failed to develop a comprehensive care plan to address one resident's (#27) activities of daily living (ADL) regarding bathing. Findings include: Resident #27 was readmitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR), the resident was a supervision with assistance of one for personal hygiene. A review of the Care Area Assessment (CAA) revealed that ADL's had triggered as a problem area and it would be addressed in a care plan. However, review of the clinical record revealed there was no care plan developed regarding ADL's. During an interview conducted on (MONTH) 5, (YEAR) at 2:00 p.m., a MDS staff member stated that either the nurse or the MDS coordinator should have completed a comprehensive care plan regarding ADL's. A review of the Care Planning policy and procedure revealed, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. A comprehensive care plan is developed within seven (7) days of completion of the Resident Minimum Data Set (MDS). | 2019-04-01 |
| 3172 | 3172 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2015-08-05 | 281 | E | 0 | 1 | YQF311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility policy review, the facility failed to ensure that an initial care plan was developed for one resident (#291) regarding a foley catheter, failed to ensure that nutritional recommendations were implemented for one resident (#98) and failed to ensure that medications were not administered to one resident (#75) based on physician established parameters for administration. Findings include: -Resident #291 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission assessment dated (MONTH) 25, (YEAR), revealed the resident was admitted with an indwelling foley catheter for [MEDICAL CONDITION] bladder. A review of the resident's clinical record revealed physician orders [REDACTED]. Further review of the clinical record revealed there was no interim care plan for the foley catheter. An interview was conducted with the Director of Nurses (DON) on (MONTH) 4, (YEAR). Upon review of the clinical record, the DON stated there was no initial care plan for the foley catheter and there should have been an initial care plan in the clinical record. The DON stated that the only policy the facility has is in regards to comprehensive care plans. A review of the Care Planning policy revealed no information regarding initial care plans. -Resident #98 was admitted on (MONTH) 19, (YEAR), for rehabilitation. The resident [DIAGNOSES REDACTED]. The resident was discharged from the facility on (MONTH) 10, (YEAR), to home. A review of the physician's orders [REDACTED]. The clinical record documentation also included that the resident had been prescribed vitamins and minerals. A review of the weight record documentation revealed the following: -April 23, (YEAR): weight 145 lbs. -April 29, (YEAR): 141 lbs. -May 5, (YEAR): 132 lbs., which was now a 13 lb or 9% weight loss. A nutritional interdisciplinary progress note dated (MONTH) 30, (YEAR), included that the resident'… | 2019-04-01 |
| 3173 | 3173 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2015-08-05 | 315 | D | 0 | 1 | YQF311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and policy review, the facility failed to provide appropriate care and treatment for two resident's (#35 and #291) with an indwelling urinary catheter. Findings include: -Resident #35 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR), the resident was admitted with an indwelling urinary catheter. Review of physician orders [REDACTED]. An observation of foley catheter care was conducted with a certified nursing assistant (CNA) on (MONTH) 4, (YEAR) at 2:45 p.m. During the procedure, the CNA donned gloves and proceeded into the bathroom to wet the wash cloth in the sink. The wet wash cloth, dry wash cloth and towel were placed on top of the residents sheets with no barrier between the sheets, wash cloths and towels. The CNA then cleaned the vaginal area and catheter tubing with the wet wash cloth, rotating the wash cloth several times in no specific order. He then used the dry wash cloth and dried the vaginal area and tubing. He then made the resident comfortable and then proceeded to wash his hands. -Resident #291 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission assessment dated (MONTH) 25, (YEAR), revealed that the resident was admitted with an indwelling urinary catheter for [MEDICAL CONDITION] bladder. Review of physician orders [REDACTED]. An observation of foley catheter care was conducted with the same CNA on (MONTH) 4, (YEAR) at 3:00 p.m. During the procedure, the CNA donned gloves and proceeded to wet the wash cloth in the bathroom sink. Again, he placed the towel and wash cloths on the sheets with no barrier in between. He proceeded to use the wet wash cloth to clean the resident's penis in no specific order and then dried the area with the dry wash cloth. He then made the resident comfortable and then proceeded to wash his hands. A… | 2019-04-01 |
| 3174 | 3174 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2015-08-05 | 323 | D | 0 | 1 | YQF311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of facility policies and procedures, the facility failed to revise one resident's (#296) falls care plan following the implementation of an alarm and failed to ensure that the alarm was on at the time the resident sustained [REDACTED]. Findings include: Resident #296 was admitted to the facility on (MONTH) 7, 2014 with [DIAGNOSES REDACTED]. A Fall Risk Evaluation dated (MONTH) 7, 2014 revealed the resident was alert and oriented to time, place, and person and had a history of [REDACTED]. The Fall Risk Evaluation revealed the resident was a low risk for falls. The resident's clinical record revealed a Change of Condition Note dated (MONTH) 8, 2014 at 3:57 a.m. which documented At 3:40 a.m. patient was found sitting on the floor. When asked what happened. patient reported that he rolled out of bed and fell . Patient also said that he was trying to get to the rest room. Patient denied any pain at this time and said that 'he did not hit anything or hurt anything.' Patient was instructed to use his call light when getting out of bed to prevent recurrence of fall .Skin assessment was performed and dry blood was noted on his left arm. Blood was cleansed with wound cleanser. Patient denied any pain. When blood was cleaned, no signs of skin tear was found. Bruising was noted however on his left forearm. Will continue to monitor. MD notified. Another Fall Risk Evaluation was completed on (MONTH) 8, 2014 which revealed that the resident was now a medium risk for falls. The resident's clinical record revealed a Daily Skilled Note dated (MONTH) 8, 2014 documented Resident's balance/gait is unsteady. Resident has weakness. Patient to start work with physical therapy/occupational therapy. He had a fall early this morning during night shift. An Interdisciplinary Team Note dated (MONTH) 8, 2014 documented Interdisciplinary team met and discussed fall this morning. No injury noted. Physical therapy a… | 2019-04-01 |
| 3175 | 3175 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2015-08-05 | 441 | D | 0 | 1 | YQF311 | Based on observations, staff interviews and review of facility policies, the facility failed to ensure that one staff member (#1) used proper hand washing techniques following foley catheter care. Findings include: A foley catheter care observation was conducted on (MONTH) 4, (YEAR). After the foley catheter observation the CNA was observed washing his hands. He turned the faucet on, wet his hands, applied soap, rinsed his hands, turned the faucet off with bare hands and then dried hands with a paper towel. During an interview with the CNA on (MONTH) 4, (YEAR) immediately after the observation, he stated that he is suppose to turn the faucet off with the paper towel not his bare hands. An interview was conducted with the Director of Nursing on (MONTH) 5, (YEAR), who stated that a paper towel is to be used to turn the faucet off. Review of the facility's policy titled Hand Washing included to dry hands with a paper towel and turn faucet off with the paper towel. | 2019-04-01 |
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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 );