rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
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,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 administered by mouth. An interview was conducted with resident #7 on (MONTH) 20, (YEAR) at 10:24 a.m. The resident stated that he receives his food and medications through his PEG tube. On (MONTH) 21, (YEAR) at 10:58 a.m., an interview was conducted with RN/staff #6 who stated that she administers all the medications for resident #7 via his PEG tube and that the resident has been NPO (nothing by mouth) since admission. Staff #6 stated the resident is administered the [MEDICATION NAME] on the night shift, but that she knows that the resident receives all medications via the PEG tube. A review of the facility's medication administration policy revealed that the individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.",2020-09-01
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,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 further stated that an antibiotic administered without an appropriate [DIAGNOSES REDACTED]. An interview was conducted with a Registered Nurse (RN/staff #29) and a Licensed Practical Nurse (LPN/staff #32) on (MONTH) 23, (YEAR) at 10:48 a.m. They stated that if a resident was admitted with an antibiotic order for a non-infection diagnosis; they would need to notify the physician to clarify the order. Review of the facility's policy regarding the antibiotic stewardship program revealed that overuse and misuse of antibiotics includes the use of antibiotics when not needed and continued treatment when no longer necessary. The policy included the goal is to optimize treatment of [REDACTED]. The policy also included that each order is to contain a stop order.",2020-09-01
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 and one lid was fully open. The other lid was not able to be closed all the way because the dumpster was overfilled. An interview was conducted with the director of dining services (staff #114) at 11:10 a.m. on 8/21/18. He stated that he did not know why there were refuse/garbage bags on the ground on 8/20/18. He stated that the dumpster next to the compacter is used by housekeeping and that the lids should be down. Staff #114 also stated that dietary only uses the compacter and not the dumpster. During an interview conducted with the clinical nutrition manager (staff #113) at 11:20 a.m. on 8/21/18, she stated that the lids on the dumpsters should be closed. She stated that she did not know when the refuse/garbage is collected. The administrator (staff #59) was interviewed at 11:30 a.m. on 8/21/18. He stated that the refuse/garbage should be collected two times per day at the skilled nursing center and that the refuse/garbage is collected at the main kitchen when a sensor in the compacter communicates with the refuse/garbage disposal service that it is full. The facility's refuse disposal policy and procedure revealed all waste, garbage, glass, tin cans, paper, etc. generated within the entire community shall be disposed of in a sanitary manner. The procedure included that all refuse containers are leak-proof, adequate in number and size, emptied frequently, and covered with tight-fitting lids.",2020-09-01
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, artificial ventilation, defibrillation, administration or advanced cardiac life support drugs and related emergency medical procedures. Further review of the clinical record revealed no evidence the physician order [REDACTED]. During an interview conducted with the resident on (MONTH) 15, 2019 at 8:49 a.m., the resident stated that he did not want CPR. In an interview conducted on (MONTH) 16, 2019 at 12:13 p.m. with a registered nurse (RN/staff #49), she stated advance directives are completed upon admission. She stated that if the resident is a full code, the nurses will fill out the advance directive form with the resident and make sure that the electronic clinical record reflects the goals stated on the form. She further stated that if the resident's code status is DNR, the nurse will explain the DNR status before the resident, nurse and a witness signs the form. The RN stated that the physician will be notified that the resident is a DNR and will complete the pre-hospital medical care directive form with the resident. She stated the nurse that completes the form is expected to update the advance directives in the electronic clinical record. The RN stated that the day shift will usually tell the supervisor who will update the care plan, but the other shifts will update the care plan themselves. She states that this resident's code status was a mistake because the paper clinical record should be the same as the electronic clinical record, and that this could be a problem as most nurses would check the electronic clinical record and not the paper clinical record. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 16, 2019 at 12:38 p.m. The DON stated that whoever put the DNR status in the paper clinical chart would be expected to change the status in the electronic clinical record as well. The DON stated that she remembers the resident's POA made this change and that it should have been updated in the electronic clinical record. Review of the facility's policy for Advance Directives revised (MONTH) (YEAR), revealed advance directives will be respected in accordance with state law and facility policy. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The Care Plan Team should be informed of changes or revocations of a directive so appropriate changes can be made in the care plan. The DON or designee will notify the physician so that appropriate orders can be documented in the clinical record. The policy also revealed that if the resident or the resident representative refuses treatment, the facility and care providers will modify the care plan as appropriate.",2020-09-01
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 walk around her room without assistance. An interview was conducted with the MDS coordinator (staff #92) on (MONTH) 17, 2019 at 9:15 a.m. Staff #92 stated resident #13 uses the bed rails to assist her with getting in and out of bed. Staff #92 stated the resident has had the bed rails for a long time, and the resident feels safer with the bed rails up. Staff #92 stated she has checked the RAI manual guidelines and believes any use of bed rails qualifies as a restraint and must be coded as such on the MDS assessment. Staff #92 stated anyone in the facility with bed rails will have a restraint coded on their MDS assessment since the resident is not able to remove the bed rail in case of an emergency. She also stated the bed rail is not used as a restraint, but for mobility assistance. Another interview was conducted with the MDS coordinator (staff #92) on (MONTH) 17, 2019 at 10:45 a.m. Staff #92 stated that after checking with other staff, she has modified the resident's MDS assessment to remove the restraint. Staff #92 stated she was informed that since the bed rails do not restrict the resident's movement or ability to get in and out of bed, they are not classified as a restraint. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 17 at 10:57 a.m. The DON stated the facility is restraint free and no resident should have a restraint coded on their MDS assessment. The DON stated that the bed rail does not restrict the resident's movement, and the resident is still able to get in and out of bed without assistance with the bed rails in place. Review of the RAI manual revealed physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The manual also revealed the assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definition; remember the decision about coding a restraint depends on the effect it has on the resident. The RAI manual included that it is required that the assessment accurately reflects the resident's status and that the importance of accuracy completing and submitting the MDS assessment cannot be overemphasized.",2020-09-01
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 the Dietary Manager (staff #125) on 10/16/19 at 01:18 PM. She stated she was not aware the resident had an order for [REDACTED].>The facility policy titled Care Planning with an effective date of 11/28/2016 revealed care plan for residents is a critical job function for licensed nurses when new orders are received. The policy also revealed physician orders [REDACTED].",2020-09-01
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. The resident's breakfast was sitting in front of her on a bedside table. The breakfast was a full size waffle, fries and bacon. The resident was not observed to attempt to eat the food in front of her and no staff were observed in the resident's room. During a lunch observation conducted on 10/15/19 at 12:53 PM, a Certified Nursing Assistant (CNA) was observed to deliver the resident's tray, raise the head of the bed, set up the tray, and leave the room. An observation was conducted of the resident in the north dining room on 10/16/19 at 12:10 PM. She was sitting at a table with three other residents and a CNA was sitting across from the resident assisting two other residents. The resident was observed drinking out of a cup without assistance. The resident was observed unable to grasp the spoon on the table to eat the bowl of food in front of her. The resident was unable to eat until staff assisted her. An attempt was made to interview the resident however; the resident was unable to answer questions. The resident would say one word and make facial expressions. In interview conducted with a CNA (staff #20) on 10/16/19 at 10:39 AM., she stated the resident makes up her own mind about where and when she eats. The CNA stated that when the resident eats her meals in her room sometimes she eats by herself because if staff stays in the room, the resident will not eat. She stated that they will leave the resident alone to eat and will check back on her. The CNA stated that if they notice the resident needs help, they will help her. An interview was conducted with a Licensed Practical Nurse (LPN/staff #61) on 10/16/19 at 12:44 PM. She stated that if the staff is concerned with the resident's meal intake, they can obtain an order for [REDACTED].#61 stated staff will leave the resident alone when she eat her meals in her room but will pop in to check on her every 15-20 minutes. She stated they follow the care plan for the resident's nutritional needs. She also stated the resident is weighed monthly now because she is not a high risk for weight loss. During an interview conducted with the Director of Nursing (DON/staff #4) on 10/16/19 at 12:54 PM., she stated that if a resident is not eating more than 50% of their meals, she expects the CNA to report it to the nurse so the Interdisciplinary Team (IDT) team can address it in the morning meeting. She stated the staff should also address the lack of intake with the resident and offer other options. The DON stated that when a resident is a high risk for weight loss they are weighed weekly. She stated this resident is not at high risk and is weighed monthly. She stated she was not aware there was an order for [REDACTED]. In an interview conducted with the Dietary Manager (staff #125) on 10/16/19 at 01:18 PM., she stated this resident is not at risk for weight loss based on the resident's intake per meal, Body Mass Index (BMI), lab work, and the quarterly/annual reviews. She stated she was not aware the resident had an order for [REDACTED].>The facility's policy titled Clinical Nutrition Services: Nutrition Assessment and Monitoring revised 8/2019 revealed the individualize plan of care will be written and reviewed regularly when changes are noted. The plan of care will be shared with and agreed upon by the resident and/or representative. The nutrition assessment will include data from staff members including meal intake and appetite. Interval assessments will be completed for nutritional concerns such as poor intake of food/fluid and refusal to eat.",2020-09-01
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 coming out of the bathroom and lying on the floor next to the resident's bed. The label on the tubing was dated (MONTH) 12. The tubing for the nasal cannula was on the table next to the resident's bed, and the label was dated (MONTH) 5. An observation was conducted of resident #8's room on (MONTH) 17 at 10:20 a.m. The oxygen concentrator was observed in the resident's bathroom. The tubing was wrapped around the grab bars behind and next to the toilet, coming out of the bathroom and lying on the table next to the resident's bed. The label on the concentrator tubing contained the date 12. The label on the nasal cannula tubing contained the date (MONTH) 19. An interview was conducted with a Registered Nurse supervisor (RN/staff #102) on (MONTH) 16, 2019 at 2:59 p.m. The RN stated the night shift staff changes the oxygen tubing for all residents who have that order. Staff #102 stated the tubing should be changed at least weekly, and should be done on schedule. She stated once the tubing has been changed and labeled it will documented on the TAR. The RN stated that the night nurse may have missed changing resident #8's oxygen tubing. She also stated that it should not have been documented as done on the TAR if it was not done. The RN stated that the date on the labels is the date the tubing is supposed to be changed. The supervisor stated that she did not want to observe the tubing at this time, and that she would ask the night nurse what happened when she reported for work. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 17, 2019 at 10:38 a.m. The DON stated all oxygen tubing should be changed weekly and as ordered. She also stated the labels on the tubing should be updated when the tubing is changed, and documentation on the TAR should reflect the task was done. She stated it was brought to her attention yesterday that resident #8's oxygen tubing had not been changed as ordered. She stated the tubing was changed last night (October 16, 2019). The DON stated she did not know why it was documented on the TAR that the oxygen tubing was changed when the labels on the tubing did not reflect it was changed. She stated that the date on the tubing should be the date the tubing was last changed. During an interview conducted with a Certified Nursing Assistant (CNA/staff #68) on (MONTH) 17, 2019 at 12:58 p.m., the CNA stated the oxygen tubing should be kept in a bag in the resident's room when not in use. Another interview was conducted with the DON on (MONTH) 17, 2019 at 1:05 p.m. She stated that all oxygen tubing should be kept in a black antimicrobial bag when not in use. She stated this bag should be stored somewhere near the concentrator. She also said they change the bags every 30 days to prevent infections. The DON stated the tubing should never be stored on the floor. The DON also indicated that she was not aware of how resident #8's oxygen tubing was being stored. The facility's policy and procedure regarding Respiratory Therapy Prevention of Infection revised (MONTH) 2011 revealed the purpose of the procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. The policy instructs to change the oxygen cannula and tubing every seven days or as needed, and to keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use.",2020-09-01
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 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The assessment included the resident exhibited verbal behavioral symptoms such as threatening and screaming directed toward others Review of the monthly behavior summary report dated (MONTH) 20, (YEAR) dated (MONTH) 20, (YEAR) revealed the resident was being monitored for physical aggression as evidence by striking out and verbal aggression as evidence by yelling and antagonizing others. Interventions included 1:1 redirection, activities, and to anticipate possible triggers. A nursing note dated (MONTH) 9, (YEAR) at 12:00 p.m. revealed a CNA called the nurse to the patio area and that the nurse noticed resident #94 had multiple scratches to her right cheek, back of neck, and right upper arm. The note included resident #94 stated resident #30 scratched her and that resident #30 stated resident #94 was trying to take her bread. A behavioral health team progress note dated (MONTH) 11, (YEAR) revealed resident #30 was seen for a resident to resident altercation. Per the note, staff reported the resident was experiencing increased aggression and had an altercation. The progress note included that when the resident was asked about the altercation, she stated that she had the altercation with resident #94 because she gets in my way. Review of the facility's documentation dated (MONTH) 13, (YEAR) revealed that on (MONTH) 9, (YEAR) at 12:00 p.m., resident #94 and resident #30 were in the patio when a Certified Nursing Assistant (CNA/staff #14) saw resident #30 hands on resident #94 shoulders. Per the documentation, staff intervened and scratches were noted on resident #94's right shoulder, right cheek, and right biceps area. Review of the behavior and intervention monthly flow record for (MONTH) (YEAR) dated (MONTH) 16, (YEAR) revealed the resident (#30) was being monitored for yelling and striking out. The record included the resident exhibited multiple episodes of yelling out but no episodes of striking out were documented. During an interview 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 at the time of the incident resident #30 was exhibiting more aggression and hallucinations and that she was diagnosed with [REDACTED]. He further stated resident #30 had no prior altercations with other residents. An interview was conducted on (MONTH) 24, 2019 at 10:34 a.m. with a CNA (staff #14). She stated resident to resident altercations are a form of abuse. She stated resident #94 is not aggressive and does not fights with other residents but that she does yell loudly. The CNA stated that during lunch the residents were outside on the patio when she observed resident #30's hands on resident #94's neck. She stated resident #94 was trying to get away from resident #30 and yelled get her off of me. The CNA stated that when she called out to the residents, the residents separated and that she observed scratches on resident #94. She stated she notified the licensed practical nurse (LPN/staff #15). Staff #14 further stated resident #30 and resident #94 were good friends prior to the incident. An interview was conducted on (MONTH) 24, 2019 at 11:05 a.m. with an LPN (staff #15). He stated that he did not recall the altercation between the two residents. During an interview conducted on (MONTH) 24, 2019 at 1:45 p.m. with resident #30, she stated that she did not have an altercation with resident #94. During an interview conducted on (MONTH) 25, 2019 at 9:31 a.m. with resident #94, she stated that she and resident #30 were outside on the patio arguing about money when resident #30 scratched her. She stated that she told resident #30 to get away. An interview was conducted on (MONTH) 25, 2019 at 10:58 a.m. with the Director of Nursing (DON/ staff #99). The DON stated resident #30 was experiencing an acute episode of [MEDICAL CONDITION] related to an infection at the time of the altercation. He stated that to his knowledge resident #30 had no prior incidents of verbal or physician aggression toward other residents. The DON stated that it was not witnessed how the altercation occurred, but that it was witnessed that resident #30 had her hands on resident #94 shoulders and resident #94 had scratches afterward. He stated the incident was identified as a behavioral occurrence because he was unable to conclude if there was intent or if resident #30 was responding to internal stimuli. He stated when resident #30 was questioned, she ignored him and did not say if she was trying to hurt resident #94. -Resident #109 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 2, 2019 revealed the resident scored a 14 on the BIMS indicating the resident was cognitively intact. -Resident #33 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 3, (YEAR) revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) indicating that the resident was cognitively intact. A behavior Care Plan revised on (MONTH) 15, (YEAR) revealed the resident had chronic combative and disruptive behavior and had the potential for violence toward himself and others. Interventions included assessing and monitoring the resident's agitation and combativeness which included hitting, pinching, kicking etc. and removing the resident from situations when he was combative. Review of the facility's investigative documentation dated (MONTH) 2, 2019 revealed that on (MONTH) 29, (YEAR) at 6:45 a.m., resident #33 was using the adjoining bathroom to his room, which is shared with resident #109. The toilet was clogged and resident #109 opened the bathroom door to tell resident #33 that the toilet was clogged and asked him not to flush the toilet. Resident #33 then pushed the bathroom door open and jumped on resident #109. The documentation included resident #33 choked resident #109 leaving red marks on his neck and scratched his right cheek. Resident #33 was not injured. When staff heard yelling, they responded and pulled the residents apart. The documentation included resident #33 agreed to move to another room further away from resident #109. On (MONTH) 23, 2019 at 1:40 p.m., an interview was conducted with resident #109 who stated that on the day resident #33 attacked him; the toilet in the bathroom located between their adjoining rooms was clogged. He stated resident #33 entered the bathroom from his room to use the toilet and that he barely opened the bathroom door from his room to asked resident #33 not to flush the toilet because the toilet was clogged. He said that resident #33 then pushed the door open and jumped on him. He said he fell and hit his head on the floor and resident #33 scratched the right side of his face and put both of his hands around his neck. He stated that he did not hit resident #33, but he did grab his head with both hands and tried to push him off of him. Resident #109 stated that resident #33 jumped on him twice. He stated staff came quickly to help him and were trying to pull resident #33 off of him. He said the police came and asked him if he wanted to press charges and he said, Yes, but that he has not heard anything. During an interview conducted on (MONTH) 24, 2019 at 8:49 a.m. with a CNA (staff #81), the CNA stated that there is always a CNA monitoring the hallway and completing room checks every 15 minutes. He stated that he has not seen resident #33 strike anyone because as soon as resident #33 begins raising his voice he intervenes before the resident becomes physically aggressive. An interview was conducted on (MONTH) 24, 2019 at 9:10 a.m. with a Licensed Practical Nurse (LPN/staff #90) who stated that resident #33 is very vocal when he is upset and that she knows to redirect him when he is upset and/or yelling before his behavior can escalate to physical aggression. The LPN stated that she will try to redirect him to the hallway area when he is upset, so that he can be monitored more closely. She said that resident #33 is checked on every 15 minutes. The LPN stated that the residents were educated to lock the bathroom door when they are in the bathroom. She also stated that when the bathroom door is locked, residents are to ask staff for assistance if they need to use the bathroom. Review of the facility's abuse policy revealed the facility is committed to protecting residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies. The facility's abuse prevention program policy revealed residents have the right to be free from abuse, neglect, and exploitation and that the facility is committed to protecting residents from abuse by anyone including other residents.",2020-09-01
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 on (MONTH) 25, 2019 at 10:58 a.m. with the Director of Nursing (DON/ staff #99). He stated staff are expected to immediately intervene if abuse is witnessed. He stated the abuse is then reported to the DON and administrator. The DON stated the State Agency is notified as soon as possible once a allegation of abuse has been reported. He stated that the incident between the resident #94 and resident #30 occurred at 12 p.m. and that he notified the State Agency at 8:30 p.m. The facility's policy regarding reporting allegations of resident abuse revealed the administrator must report incidents or allegations of abuse to the State Agency immediately in accordance with State and Federal regulations/statues.",2020-09-01
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 on (MONTH) 25, 2019 at 10:58 a.m. with the Director of Nursing (DON/ staff #99). He stated staff are expected to immediately intervene if abuse is witnessed. He stated the abuse is then reported to the DON and administrator. The DON stated the State Agency is notified as soon as possible once a allegation of abuse has been reported. He stated that the incident between the resident #94 and resident #30 occurred at 12 p.m. and that he notified the State Agency at 8:30 p.m. The facility's policy regarding reporting allegations of resident abuse revealed the administrator must report incidents or allegations of abuse to the State Agency immediately in accordance with State and Federal regulations/statues.",2020-09-01
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 medications, high risk concerns, and activities of daily living. The DON stated a final summary of the baseline care plan is given to the resident or the resident's representative. He stated on the baseline care plan summary form the resident will sign indicating the resident received or refused a copy of the baseline care plan. He stated that it is the facility's expectation that a copy of the baseline care plan is given to the resident or the resident's representative. The DON also stated that the facility does not have a policy for baseline care plans.",2020-09-01
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 nightlight on the wall near the door was observed to be torn. An interview was conducted with staff #44. He stated that he had to cut the wallpaper in order to repair it and that he had a work order regarding this. Review of facility documentation revealed that a Maintenance Work Order for the wallpaper was dated (MONTH) 30, (YEAR). -Room A24: There were several slats which were missing from the window blinds. An interview was conducted with the maintenance director. He stated that he was probably told about this, but probably overlooked it. Review of the Morning Walk Through Rounds documentation dated (MONTH) 29, (YEAR) revealed there was no mention regarding the missing slats. -Room B11: There were multiple screw/nail holes and chipped paint on the wall near the door. An interview was conducted with staff #44 on (MONTH) 16, (YEAR). He stated that he was not aware of how long the wall had been in need of repair. The Morning Walk Through Rounds documentation dated (MONTH) 31, (YEAR) did not include that the wall needed to be repaired. An interview was conducted with the Administrator on (MONTH) 14, (YEAR) at 3:30 p.m. The Administrator stated that the facility did not have a policy on routine maintenance. The Administrator stated that rounds are supposed to be done daily and work orders filled out if repairs need to be made. -During an interview with a resident on the A hall on (MONTH) 13, (YEAR) at 10:50 a.m., the resident stated that the whole facility smelled like dirt and bowel movements. During the survey on (MONTH) 13 and 14, (YEAR), pervasive odors were noted throughout the facility. The odors were noted to be the strongest on the central hallway, on the A hall, and on the La Onieta unit. 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). At this time, strong urine odors were noted in two rooms on the A hall. An interview was conducted with staff #23 on (MONTH) 14, (YEAR) at 1:20 p.m. Staff #23 stated that sometimes the facility has odors when residents are being changed or after an incontinent episode. She said that she ordered new chemicals, which pretty much got rid of the odor problem within the facility. An interview was conducted with the Administrator (staff #8) on (MONTH) 14, (YEAR) at 3:30 p.m., who stated that the facility did not have a policy regarding the prevention of odors, but facility rounds are supposed to be done daily. The Administrator further stated that environmental issues are discussed every morning in the facility's department head meeting.",2020-09-01
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,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 the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the clinical record revealed documentation that as of (MONTH) 14, (YEAR), two stage 4 pressure ulcers were still present on the right and left ischium. A pressure ulcer treatment observation was conducted on (MONTH) 14, (YEAR) at 10:13 a.m., with a LPN (staff #127). The LPN was observed to wash her hands, donn gloves, and then removed the soiled dressing from the resident's left ischium pressure ulcer. Staff #127 did not remove her gloves or wash her hands, after removing the soiled dressing. Using the same gloved hands, she cleansed the pressure ulcer with puracyn and packed it with calcium alginate. Staff #127 then removed her gloves, however; she was not observed to wash her hands or use a disinfectant. She then proceeded to donn clean gloves, removed the soiled dressing from the resident's right ischium pressure ulcer, cleansed it with puracyn, and packed the wound with the calcium alginate. She was not observed to change her gloves, wash her hands or use a disinfectant, after removing the soiled dressing from the resident's right ischium pressure ulcer. An interview was conducted with staff #127 on (MONTH) 14, (YEAR) at 11:44 a.m. She stated she should have washed her hands, after the removal of the soiled dressings and before she started the treatment. She also stated that handwashing should have been done between the treatments of the two pressure ulcers. An interview was conducted with the the DON (staff #109) on (MONTH) 14, (YEAR) at 11:50 a.m. He stated that handwashing was required between the removal of soiled dressings and before treatment was provided. He also stated that good handwashing needed to be done between the treatments of the pressure ulcers to aid in preventing infection. A facility policy titled, Handwashing/Hand Hygiene included the following: Objective-to prevent and control the spread of infectious disease. The policy also included the following: 3. The use of gloves does not replace handwashing. 4. If hands are not visibly soiled, use an alcohol based hand rub for all of the following: e. Before handling clean or soiled dressings, gauze pads, etc.; f. Before moving from a contaminated body site to a clean body site during resident care; h. After handling used dressings, contaminated equipment, etc.; j. After removing gloves. Another facility policy titled, treatment of [REDACTED]. Wash your hands thoroughly with soap and water at the following intervals: d. When changing/removing gloves or any personal protective equipment.",2020-09-01
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 sticky paper was last changed, prior to this date. In regards to the air blower, he stated that he had installed it about four months ago and agreed that the blower did not produce much air current. On (MONTH) 14, (YEAR) at 9:00 a.m., an interview was conducted with the Administrator (staff #8). She stated that she thought the fly problem in the La Oneita dining room had been taken care of. Staff #8 later provided a form titled Fly Trap Changing Schedule, which was suppose to be used by the maintenance department. However, during a follow up interview with staff #4, he stated that he had not been aware of this form.",2020-09-01
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 the Orientation of Registry CNA Personnel for abuse training. During an interview conducted with the Director of Nursing (staff #107) on (MONTH) 4, (YEAR) at 9:54 a.m., staff #107 stated the (MONTH) 28, (YEAR) allegation of verbal abuse between staff #147 and resident #7 was reported on (MONTH) 2, (YEAR). The policy Investigation and Reporting of Allegations of Resident Abuse, Neglect, Exploitation, Resident Injuries of Unknown Origin or Misappropriation of Resident Property included that any employee who receives a report or allegation of abuse, neglect, or misappropriation from any source, including the alleged victim, must IMMEDIATELY inform the following: Administrator, Director of Nursing or Assistant Director of Nursing, Director of Social Work, Attending Physician, Adult Protective Services, Resident's guardian, POA and/or emergency contact, Payer Source Case Manager and Ombudsman.",2020-09-01
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/staff #130). She stated that a resident would be marked edentulous when they have no teeth and no tooth fragments, just gum tissue in oral cavity. Staff #130 stated that she coded the MDS based on the monthly summary for dentition done by the nurses on the floor. She stated that she does not personally do an oral assessment. Staff # 130 further stated I could have made a mistake. An interview was conducted on (MONTH) 5, (YEAR) at 12:20 p.m. with the Director of Nurses (DON/staff #107). He stated that his expectation of the MDS assessment is that it would accurately reflect the resident's level of care. The RAI manual for Oral Status instructs to conduct an exam of the resident's oral cavity and to code edentulous if the resident lacks all natural teeth or parts of teeth. -Resident #106 was admitted (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Review of the Weekly Pressure Ulcer Quality Improvement Log dated (MONTH) 25, (YEAR) revealed the resident had a left upper buttock stage 4 and a left lower buttock stage 4 pressure ulcer that were facility acquired with an onset date of (MONTH) 15, (YEAR) and a right buttock stage 4 pressure ulcer which was facility acquired with an onset date of (MONTH) 30, (YEAR). However, review of the quarterly MDS assessment dated (MONTH) 27, (YEAR) revealed three stage 4 pressure ulcers that were present on admission. An interview was conducted on (MONTH) 4, (YEAR) at 12:49 p.m. with MDS LPN/staff #130. She stated the pressure ulcers on the Quarterly MDS assessment dated (MONTH) 27, (YEAR) were marked as present on admission in error. An interview was conducted with the DON/staff #107 on (MONTH) 5, (YEAR) at 12:20 p.m. He stated that the MDS assessments are coded based off the floor nurses documentation and that he expects the MDS assessment to accurately reflect the resident's level of care. The RAI instructs in order to determine Present on Admission for each pressure ulcer, determine if the pressure ulcer was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home.",2020-09-01
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 interview with staff #70 conducted on (MONTH) 2, (YEAR) at 11:40 a.m., the nurse stated that she had review the policy and that she should have removed the plunger on the syringe and allowed gravity to pull the flushes and the medication into the PEG tube, and not pushed the water and medication into the tube. The policy Enteral Tubes included the statement Allow medication to flow down tube via gravity. -During a review of the controlled substance sheets conducted (MONTH) 4, (YEAR) at 1:03 p.m. with Licensed Practical Nurse (LPN/staff #45), it was observed that 6 narcotic controlled count sheets did not match the 6 narcotic count medication cards. The narcotic count medication card had less than indicated on the narcotic controlled count sheets. Review of the Medication Administration Record (MAR) for these six narcotics revealed 3 had been initialed as having been administered on the MAR and 3 were not. Staff #45 stated he administered the medications and proceeded to sign the narcotic controlled count sheets and the MAR indicating that the medications had been administered. Continued observation with staff #45 revealed another narcotic count medication card had one more narcotic than the narcotic controlled count sheet. Staff #45 stated he signed out the narcotic on the narcotic controlled count sheet by mistake because he usually works the evening shift. An observation was conducted (MONTH) 4, (YEAR) at 1:13 p.m. with staff #45. Review of the narcotic controlled count sheet revealed that a dose of [MEDICATION NAME] extended release 15 milligrams was signed out by staff# 45 at 8 a.m. and that the remaining doses should be 25, however, it was observed that there was 26 doses remaining of the medication. Review of the MAR revealed the medication was initialed as administered. Staff #45 stated I must not have given it. An interview was conducted with staff #45 on (MONTH) 4, (YEAR) immediately following the above observations. He stated that the expectation is that the nurse signed out the medication immediately after the medication is administered. He further stated that as a result of not administrating the scheduled narcotic medication he would need to evaluate the resident for pain, notify his supervisor, and then follow the direction given by the physician. An interview was conducted with the Director of Nurses (DON/staff #107) on (MONTH) 4, (YEAR) at 1:26 p.m. He stated that the expectation is that the nurse is to sign out a medication as soon as it is administered. Staff #107 also stated he expects the nurses to observe the five rights of medication administration which are: the right patient, the right drug, the right dose, the right route, and the right time. He further stated that medication administration is supervised by the Unit Coordinators on each unit to assure compliance with policy. An interview was conducted with the Unit Coordinator (LPN/staff #113) on (MONTH) 5, (YEAR) at 10:39 a.m. He stated that the expectation is that the nurses follow the five rights of medication administration when administering medication. The policy Medication Administration included medications are administered as prescribed, medications are administered within 60 minutes of scheduled time unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. The individual who administers the medication dose records the administration on the resident's MAR immediately following the medication being given.",2020-09-01
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 is not what is meant by bed bolsters and that she was going to find out if maybe bed bolsters were unavailable for some reason. At 12:31 p.m. the same day, staff #78 stated that the pillows should not have been there and the proper bed bolster would be only one wedge which would be in the middle of the resident's bed. In an interview conducted (MONTH) 5, (YEAR) at 12:35 p.m. with the Director of Nursing (DON/staff #107), he stated when a resident has an order for [REDACTED]. Staff #107 also stated that bolsters are to help with positioning the resident and that the bolsters can be obtained from central supply. During this interview, a staff member was observed carrying a blue triangular wedge with straps into the resident's room. Staff #78 was by the resident's door and stated that was a bed bolster was going to be applied to the resident's bed. Staff #107 stated that his expectation is that no improvisations are to be made with equipment and that staff should have the right equipment to use correctly. A report sheet for this unit was provided, it included that this resident was a fall risk and had bed bolsters. In an interview with the Administrator (staff #9) on (MONTH) 5, (YEAR) at 1:30 p.m., she stated this sheet is used so that staff can be on the same page regarding knowing important information about residents and responsibilities. A policy Follow through of MD Orders included if orders are unable to be carried out for any reason the health care provider should be notified and it should be documented in nurses' notes, including any further orders.",2020-09-01
23,SANTA ROSA CARE CENTER,35004,1650 NORTH SANTA ROSA AVENUE,TUCSON,AZ,85712,2017-10-05,441,E,0,1,2ZZS11,"Based on staff interviews, the facility failed to implement a water management program that included environmental testing for pathogens including the bacterium Legionella. Findings include: During an interview with the Director of Nursing (staff #107) conducted on (MONTH) 4, (YEAR), at 10:40 a.m., staff #107 stated that the facility's water softener and cooling systems were maintained by outside vendors. However, the facility did not have a policy or a program to test the facility's water for pathogens including the Legionella bacterium. During an interview conducted on (MONTH) 4, (YEAR) at 10:45 a.m. with the Administrator (staff #9), the administrator stated that the facility did not have a policy or program for testing the facility's water supply for waterborne pathogens including Legionella.",2020-09-01
24,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,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,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 ask the resource nurse how to code this resident's behaviors. The RN stated that her instructions would be to include the resident's behaviors in the behavior section of the assessment and develop a care plan for the behaviors. They both agreed that they use the RAI Manual as the policy and procedure guide for coding the MDS assessment. The RAI manual revealed the behavior section of the MDS assessment focuses on the resident's actions, not the intent of the resident's behavior. The RAI Manual also included that once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. -Resident #81 was admitted on (MONTH) 15, 2019, with a [DIAGNOSES REDACTED]. Review of the closed record revealed a discharge summary progress note dated (MONTH) 24, 2019 that the resident was discharged home on (MONTH) 24, 2019. However, review of the discharge MDS assessment dated (MONTH) 25, 2019, revealed the resident was discharged to an acute care hospital on (MONTH) 24, 2019. An interview was conducted on (MONTH) 7, 2019 at 1:23 p.m. with the MDS coordinator (staff #22). The MDS coordinator stated the resident was discharged home and not to the hospital. Staff #22 also stated that the discharge MDS assessment regarding the resident's discharge location was an error. An interview conducted on (MONTH) 8, 2019 at 8:20 a.m. with the Director of Nursing (DON/staff #56). She stated the resident was discharged home and that the MDS assessment was coded incorrectly. The DON stated that they follow the RAI manual for coding the MDS assessments. The RAI manual instructs to review the medical record including the discharge plan and discharge orders for documentation of discharge location and select the code that corresponds to the resident's discharge status. The RAI manual also included that it is required that the assessment accurately reflects the resident's status and that the importance of accurately completing and submitting the MDS assessments cannot be over-emphasized.",2020-09-01
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 plan will be developed and implemented within 48 hours of admission.",2020-09-01
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/or as needed with changes in condition.",2020-09-01
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,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 asked her if she was going to eat her lunch. The resident said she wanted her yogurt, but took only one bite. The resident appeared to be sleepy. Another observation was conducted on (MONTH) 6, 2019 at 1:37 p.m., in the dining room. Resident #36 was still sitting at the table, asleep. An interview was conducted on (MONTH) 8, 2019 at 8:18 a.m., with a Licensed Practical Nurse (LPN/staff #62). She said she administers medications according to the physician's orders [REDACTED]. An interview was conducted on (MONTH) 8, 2019 at 10:20 a.m., with a LPN (staff #123). She said that she would not go outside of the ordered parameters when administering medication. An interview was conducted on (MONTH) 8, 2019 at 10:32 a.m., with the Director of Nursing (DON/staff #56). She stated that her expectation is for the nurses to administer medications according to the proper timeframe and pain scales. She said she expects the nurses to administer medications according to the order and within the parameters.",2020-09-01
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,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 dental provider after the consultation to ensure that any recommendations were initiated. An interview was conducted on (MONTH) 2, (YEAR) with the social service staff (staff #91), who confirmed that she had not followed up with the dental provider but was unable to state why. A facility policy, titled, Social Services Policy and Procedure Manual-Subject Dental, Optometry and Audiology Evaluations, included, It is the policy of this facility that Social Services staff will coordinate Dental, Optometry, and Audiology evaluations for resident. The policy also included the following: 1. Social Services will maintain a system to monitor the Dental, Optometry, and Audiology evaluations. 3. Evaluation dates will be documented on the Social Services concrete needs sheet and/or in the Social Services progress notes.",2020-09-01
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,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 included documentation that the resident had only received three days of antianxiety medication. An interview was conducted with the MDS coordinator (Licensed Practical Nurse/LPN/staff #116) on (MONTH) 1, (YEAR) at 9:31 a.m. She stated that in coding Section N of the MDS, she pulls up the MAR and counts the days the resident received the medications during the 7 day look back period. At this time, the MDS was reviewed for antibiotic and antianxiety medication use. She stated that the MDS was inaccurate as the MAR showed that the resident received an antibiotic and had received the antianxiety medication on 4 days. Staff #116 stated the expectation is that the MDS is accurate regarding the care the resident is receiving during the look back period of the MDS. During an interview conducted on (MONTH) 1, (YEAR) at 9:43 a.m. with the Director of Nursing (DON/staff #66), she stated the expectation is that the MDS would accurately reflect the residents status and care. Staff #66 stated that the MDS nurse is to follow the RAI manual in completing the assessment. She further stated that the facility has no policy regarding the accuracy of the MDS, as the facility uses the RAI manual. Review of the RAI manual for the MDS revealed the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The MDS assessment is the basis for the development of an individualized care plan.",2020-09-01
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,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 the social workers office during the meeting time, instead of the conference room where the meeting was held. Staff #92 further stated she offered to hold another care plan conference the next week for the resident, but the resident never followed up to schedule a time. Staff #92 stated when a care conference meeting is held, there should be an IDT (interdisciplinary team) note that can be found in the resident's record regarding what was discussed in the meeting, who attended, if there were any concerns, and if there was anything that needs to be followed up on. Review of the clinical record revealed no documentation of a care plan meeting taking place in (MONTH) (YEAR). An interview with staff #92 was conducted on (MONTH) 5, (YEAR) at 3:05 p.m. She stated that there was no documentation of the care plan meeting which was held for this resident and there should have been documentation of it. In an interview with the Director of Nursing (DON/staff #66) on (MONTH) 4, (YEAR) at 3:08 p.m., she stated the expectation is that there should be documentation of the care plan meetings, whether the resident is in attendance or not, and it should be documented as to what was discussed and if there was anything to follow up on. Review of a policy titled Care Planning included that the resident should participate to the extent possible, in the development of the care plan. The policy also included that Every effort will be made to schedule care plan meetings to accommodate the availability of the resident.",2020-09-01
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 orders for the left outer leg was conducted with staff #48. She stated that the frequency of wound treatment for [REDACTED]. A review of the Wound Administration Record was then conducted with staff #48, who stated the record only shows that the treatment was done on the day shift and was not done on the evening shift. An interview with the Assistance Director of Nursing (ADON/staff #61) was conducted on (MONTH) 5, (YEAR) at 1:15 p.m. She stated the wound treatment should be done as ordered by the physician. Staff #61 stated that if a treatment is ordered twice daily, it should be done on the day shift and on the evening shift. Review of a facility policy regarding Physician order [REDACTED].",2020-09-01
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 [REDACTED]. A physician's note dated (MONTH) 23, (YEAR) included the resident was alert and oriented to person and purpose and that the left lower extremities could not be accurately assessed, due to orthopedic splinting. The note did not include that the resident had a pressure ulcer to the left leg. Per the Weekly Skin Evaluation dated (MONTH) 23, (YEAR), the pressure ulcer continued to be documented as a stage II to the inner leg, with slough. No measurements or description of the pressure ulcer was included. A review of the Dietary Admission Evaluation dated (MONTH) 27, (YEAR) revealed the resident had a stage II pressure ulcer to the left leg. The admission MDS (Minimum Data Set) assessment dated (MONTH) 27, (YEAR) included the resident had one stage II pressure ulcer, with slough which was present on admission. However, a stage II pressure ulcer as defined in the MDS includes partial thickness loss of dermis, presenting as shallow open ulcer with a red pink wound bed, without slough. Per the Wound Administration Record for (MONTH) (YEAR), the treatments were provided as ordered. In the Weekly Skin Ulcer Note dated (MONTH) 5, (YEAR), the pressure ulcer to the left inner leg was not included in the documentation. Despite documentation that the resident had a pressure ulcer with slough to the left inner leg, there was no documentation that it had been thoroughly and accurately assessed from admission through (MONTH) 5, (YEAR). An interview with a wound nurse (staff #48) was conducted on (MONTH) 5, (YEAR) at 8:56 a.m. She stated that she conducts a head to toe assessment of the resident the day after admission and is responsible to ensure accurate identification, including staging, a description of the wound bed, surrounding skin and measurements. She stated that the floor nurses are not allowed to identify the specific type of wound and cannot stage a pressure ulcer. She said that pressure ulcers are assessed twice daily. Further, she stated that each wound is documented separately and pressure ulcers are documented on the Weekly Pressure Ulcer note. Staff #48 stated that the documentation should include the stage, measurements a description of the wound bed and surrounding area. She also stated that the status of the wound whether it is improving or not should be in the wound notes. Staff #48 stated that resident #147 has one stage II pressure ulcer to the back of the left ankle, which was first identified on (MONTH) 21. In an interview with a licensed practical nurse (LPN/staff #73) conducted on (MONTH) 5, (YEAR) at 11:27 a.m., she stated that when a wound is observed on a resident, she will notify the wound nurse who will accurately identify, stage and provide daily treatments to the wounds. She stated that she cannot identify the type of wound but would describe what she sees in her notes. During an interview with the Assistant Director of Nursing (ADON/staff #61) conducted on (MONTH) 5, (YEAR) at 1:15 p.m., she stated that if the resident has any type of wound, the floor nurses will only describe what they see. She stated that the wound nurse ensures weekly measurements of wounds and documentation includes measurements, description of the wound bed, any drainage and surrounding skin. In an interview with the Director of Nursing (DON/staff #66) conducted on (MONTH) 5, (YEAR) at 3 p.m., she stated the resident has one stage II pressure ulcer to the left inner lower leg, which was identified upon admission. She stated that the wound nurses have not been documenting the assessment of the resident's pressure ulcer and she has educated them to document the assessments on the pressure ulcer sheet. During another interview with staff #66 conducted on (MONTH) 5, (YEAR) at 3:20 p.m., she stated that there were no complete assessments of the resident's pressure ulcer, prior to (MONTH) 5, (YEAR). Review of the NPUAP Pressure Injury Staging guidelines revealed that a stage II pressure injury was described as having partial-thickness skin loss with exposed dermis, with a viable, pink or red, moist wound bed and slough and eschar are not present. Further, a stage III pressure injury was defined as a full-thickness skin loss and slough and/or eschar may be visible. Regarding the CAM boot: The Physical Therapy (PT) Evaluation and Plan of Treatment dated (MONTH) 21, (YEAR) included the resident was status [REDACTED]. The section on Medical Precaution/Contraindications included for a left CAM (Controlled Ankle Motion) boot. However, there was no documentation as to when this boot should be applied or removed, or the duration (days, weeks etc) the boot was to be utilized. Review of the resident's care plans dated (MONTH) 21, (YEAR) revealed the use of a cam boot to the left lower leg was not included as an intervention. A nurse practitioner (NP) progress note dated (MONTH) 22, (YEAR) included an alert and oriented resident with an assessment of polytrauma and difficulty of walking. Musculoskeletal findings included the left lower extremity had a dressing and a stabilization splint. The plan included for physical and occupational therapy, and to monitor the resident's progress. There was no documentation regarding the use of the CAM boot as part of the plan of care. A physician's note dated (MONTH) 23, (YEAR) included the left lower extremity could not be accurately assessed, due to orthopedic splinting. Review of the physician's orders [REDACTED]. Review of the clinical record including the Treatment Administration Record from (MONTH) 20, through (MONTH) 31, (YEAR) revealed no evidence that use of the boot to the left lower leg was monitored and documented. An observation was conducted on (MONTH) 4, (YEAR) at approximately 12:55 p.m. of the resident in bed, with a black boot on the left lower leg, which was laying on top of a pillow. At this time, the resident stated that the boot was for her left leg, because of her accident. Another observation was conducted on (MONTH) 5, (YEAR) at 8:51 a.m., of the resident sitting in her wheelchair. The black boot was observed to be on her left leg. An interview was conducted with a certified nursing assistant (CNA/staff #9) on (MONTH) 5, (YEAR) at 10:54 a.m. She stated the resident wears a boot on her left leg for strengthening. She stated that the resident puts it on and takes it off by herself. She also stated that the resident is supposed to remove the boot when in bed and put it back on when out of bed. Staff #9 stated she tries to ensure that the resident does this and will inform the nurse if it's not done, because there is no way for her to document it. During an interview with a certified occupational therapist (COTA/staff #118) conducted on (MONTH) 5, (YEAR) at 11:08 a.m., he stated that the resident has weight bearing limitations on her left side. He stated the boot to the left leg was for protection of the leg status [REDACTED]. An interview with a physical therapist (PT/staff #119) was conducted immediately following. Staff #119 stated that the order for the use of [REDACTED]. He stated that if the order did not specify a frequency, then the boot is to be worn at all times. An interview with an LPN (staff #73) was conducted on (MONTH) 5, (YEAR) at 11:27 a.m. She stated that the resident has a black boot on her left leg. At this time, a review of the clinical record was conducted and staff #73 stated that she could not find an order for [REDACTED].>An interview with the wound nurse (staff #48) was conducted on (MONTH) 5, (YEAR) at 11:25 a.m. She stated that there usually is an order for [REDACTED]. A review of the clinical record was conducted with the Assistant Director of Nursing (ADON/staff #61) on (MONTH) 5, (YEAR) at 1:15 p.m. She stated that she could not find an order for [REDACTED].>In a later interview with staff #61 on (MONTH) 5, (YEAR) at 1:52 p.m., she stated that she reviewed the records and found no orders for the CAM boot. Staff #61 stated if a resident uses a CAM boot, the floor nurse is expected to ensure that there is an order for [REDACTED]. During an interview with the Director of Nursing (DON/staff #66) conducted on (MONTH) 5, (YEAR) at 2:06 p.m., she stated there was no order for the use of [REDACTED]. She stated that if the resident came with a boot and there was no order for its use, the nurses are expected to communicate, document and call the physician to verify the continued use of the boot. She also said that per the therapy department, the resident still needed the boot, so the physician has been notified. Review of the policy regarding Physician order [REDACTED]. of care. The policy on Wound Management included that it the facility's policy to have a central consistent flow sheet to enable medical staff to evaluate the status of wounds. The policy also included that weekly skin assessments on all residents will be done and documented in the nurses notes. Per the policy, each wound will be measured in centimeters weekly and include drainage, odor, color and a short statement on progress (or lack of) and this will be documented on the wound flow sheet.",2020-09-01
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 the facility is not to leave medication at the bedside. She stated that she knows not to leave medication at the bedside. -Resident #144 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed an admission assessement dated (MONTH) 27, (YEAR), which documented the resident was alert and oriented times three and did not desire to self administer drugs. An observation was conducted on (MONTH) 29, (YEAR) at 9:52 a.m., of resident #144's room. At this time, one bottle of multi-vitamins with minerals was observed on the resident's bedside table. The resident stated that he purchased them and no one from the facility had said anything about them. Review of the label on the vitamin bottle revealed the following: DG Complete 100 IU (International Units) Vitamin D adults over 50 multi-vitamin with minerals. Review of the admission physician's orders [REDACTED]. An interview was conducted on (MONTH) 29, (YEAR) at 10:10 a.m., with a registered nurse (staff #45). Staff #45 reviewed the physician's orders [REDACTED]. Staff #45 stated she had not noticed the vitamin bottle in the resident's room and that it should have been removed. She stated the physician should have been notified regarding an order for [REDACTED]. Review of a facility policy on Medication Access and Storage revealed to store all drugs in locked compartments and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.",2020-09-01
40,DESERT TERRACE HEALTHCARE CENTER,35014,2509 NORTH 24TH STREET,PHOENIX,AZ,85008,2017-12-05,812,D,0,1,6GPJ11,"Based on observations, staff interview and policy review, the facility failed to ensure eating utensils were dry and ready to use, prior to being placed on resident's food trays. Findings include: An observation was conducted of the tray line on (MONTH) 30, (YEAR) at 12:05 p.m. Staff were observed placing wet eating utensils on the resident's food trays, just prior to the food trays being placed in the food cart for delivery to the unit. At this time, a dietary staff member directed the staff to make sure the utensils were not wet, and some of the wet utensils were removed off of the trays. However, further observations revealed that staff continued to place wet utensils on the food trays. An interview was conducted with a dietary staff member (staff #57) on (MONTH) 30, (YEAR) at 1:00 p.m. Staff #57 stated that he was responsible for ensuring that the utensils placed on the resident's trays were clean and dry. Staff #57 stated that the utensils had just come from the dishwasher and he missed some. Review of a policy regarding clean and dry dishware and utensils revealed documentation that all flatware, serving dishes, and cookware will be washed, rinsed, and sanitized after each use. The policy included that dishes and utensils were to air dry on the dish rack and were not to be dried with towels, and that when removing dishes, staff were to inspect them for cleanliness and dryness.",2020-09-01
41,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,578,D,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to have documentation of advanced directives for one resident (#10) and obtain physician orders once obtained, and failed to obtain physician orders in accordance with the advance directive for one resident (#171). Findings include: -Resident #10 was admitted to the facility on (MONTH) 30, (YEAR) and readmitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 3, which indicated severe cognitive impairment. Review of the clinical record on (MONTH) 5, 2019 revealed no documentation regarding advance directives for resident #10. There were also no physician orders for any advance directives. An interview was conducted with two licensed practical nurses (LPN/staff #52/staff #53) on (MONTH) 6, 2019 at 2:50 p.m. The nurses stated that they were unable to locate advance directive information for resident #10. Staff #52 stated that the nurses usually get a new order when a resident returns from the hospital, because the directive could change at anytime. Staff #52 stated that she would need to have the responsible party for the resident sign the form and that she would contact the responsible party right away. Review of the clinical record on (MONTH) 7, 2019 revealed advance directives had been obtained for resident #10. The advance directives were obtained from the resident's responsible party by telephone on (MONTH) 6, 2019 and included for a Do Not Resuscitate (DNR) status. Further review of the physician orders on (MONTH) 7, 2019 revealed there was no physician order for [REDACTED].>-Resident #171 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed an Advanced Directive form indicating the resident was a DNR status, which was signed by the resident's power of attorney on (MONTH) 2, 2019. However, review of the physician orders on (MONTH) 7, 2019 revealed there were no orders for a DNR status. An interview was conducted with two licensed practical nurses present (LPN/staff #52/staff #53) on (MONTH) 6, 2019 at 2:50 p.m. Staff #52 stated that there is an Advance Directive for a DNR on the paper chart which was signed on (MONTH) 2, 2019, but there is no physician's order at present. An interview was conducted on (MONTH) 8, 2019 at 12:17 p.m. with the Director of Nursing (DON/staff #160). She stated that Social Services interview residents or responsible parties and obtains advance directives on admission, or shortly after admission. Staff #160 stated if the resident desires a DNR status, Social Services will inform nursing so they can contact the provider to get an order in place and obtain the orange card (Prehospital Medical Care Directive). She also stated there should be a physician's order for a DNR. Review of the facility's policy regarding Advance Directives revealed the facility will respect advance directives in accordance with state law and facility policy and that the Director of Nursing or designee will notify the attending physician of advance directives. so that appropriate orders can be documented in the resident's medical record and plan of care.",2020-09-01
42,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,640,D,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a Minimum Data Set (MDS) assessment was transmitted, within 14 days after completion for one resident (#2). Findings include: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a discharge MDS assessment was completed and dated 8/6/18. Review of the MDS transmittal report revealed that the discharge MDS assessment dated [DATE] had not been transmitted. An interview was conducted on 1/08/2019 at 11:23 a.m., with the MDS Coordinator (staff #116). Staff #116 stated the MDS assessments are completed by reviewing each chart, checking history and physicals, reviewing all physician orders [REDACTED]. Staff #116 stated when a resident is a planned discharged , a MDS-return not anticipated is completed. Staff #116 stated that she will open the discharge MDS like a regular assessment and will verify there are no errors. Staff #116 said that either the Assistant Director of Nursing (staff #117) or the Director of Nursing (staff #160) will sign off when the MDS is complete. Staff #116 stated the MDS would then be ready for transmission to CMS (Centers for Medicare/Medicaid Services). Staff #116 provided the MDS transmission report and stated that the discharge MDS dated [DATE] did not get transmitted. Staff #116 stated that the facility has 20 days to transmit a completed MDS. Staff #116 stated the facility policy is to use the RAI manual to ensure MDS accuracy and transmission. An interview was conducted on 1/8/2019 at 1:01 p.m. with the Director of Nursing (staff #160), who stated the expectation for the MDS nursing staff is to ensure that each MDS is completed and transmitted to CMS, within the required timeframe. Staff #160 stated the facility uses the RAI manual for all MDS expectations. Review of the RAI manual revealed that discharge MDS assessments must be submitted within 14 days of the MDS completion date.",2020-09-01
43,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,641,D,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two residents (#'s 36 and 52). Findings include: -Resident #36 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED].#36 revealed that resident #36 had an onset of pneumonia on (MONTH) 24, (YEAR). Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) revealed documentation of an active [DIAGNOSES REDACTED]. However, review of the clinical record revealed that resident #36 had a history of [REDACTED]. An interview was conducted on 1/8/2019 at 11:23 a.m. with the MDS Coordinator (staff #116). Staff #116 stated the MDS assessments are completed by reviewing each chart, checking the history and physical, reviewing all physician orders [REDACTED]. Staff #116 stated the electronic chart is also reviewed for a 7-day look-back period, which includes all progress notes, current diagnoses, medications and treatments. Staff #116 stated that current [DIAGNOSES REDACTED]. Staff #116 stated if it was a non-active diagnoses, it would not be included on the MDS. An interview was conducted on 1/08/2019 at 1:01 p.m. with the Director of Nursing (staff #160), who stated the expectation for the MDS nursing staff is to ensure that each MDS is accurate and completed within the required timeframe. -Resident #52 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 14, (YEAR), revealed the resident did not receive an antipsychotic medication in the past seven days or since admission. However, the MDS assessment also included the following in the Antipsychotic Medication Review section: since admission the resident had received antipsychotic medications on a routine basis only, and that a Gradual Dose Reduction (GDR) had not been attempted. Review of the physician's orders [REDACTED].#52. Review of the Medication Administration Record [REDACTED]. An interview was conducted on (MONTH) 8, 2019 at 11:23 a.m., with the MDS Coordinator (staff #116). She stated the facility follows the instructions in the RAI manual to ensure MDS accuracy. She stated the information in the MDS regarding a resident's medications would come from reviewing the resident's MAR. She stated that since the resident had not received an antipsychotic medication, the Antipsychotic Medication Review section of the MDS assessment should have been coded to reflect that antipsychotics were not received. An interview was conducted on (MONTH) 8, 2019 at 1:01 p.m., with the Director of Nursing (DON/staff #160). She stated her expectation was that each MDS assessment should be accurate. She stated accuracy should be determined by both MDS nurses double checking their work. She stated that if a resident was not taking an antipsychotic, the MDS assessment should record zero days of antipsychotic use, followed by a statement that antipsychotics were not received in the Antipsychotic Medication Review section. She stated that when all three areas of documentation matched, the MDS assessment would be accurate. Review of the RAI manual revealed the following requirements: The MDS assessment must accurately reflect the resident's status; A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals; and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.",2020-09-01
44,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,689,D,1,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation and staff interviews, the facility failed to provide adequate supervision for one resident (#268) with known aggressive behaviors. Findings include: -Resident #268 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment for resident #268 dated (MONTH) 20, (YEAR), revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS also documented that the resident had physical behavioral symptoms against others that significantly interfered with the resident's care and put others at significant risk for injury. An activities note dated (MONTH) 21, (YEAR) stated the resident became agitated during bingo and began throwing bingo cards in the direction of other residents. An activities note dated (MONTH) 22, (YEAR) stated that resident #268 hit a staff member on the arm. Review of a care plan dated (MONTH) 23, (YEAR) revealed the resident exhibited behaviors of physical aggression such as hitting and kicking, during routine care. Interventions included to intervene before agitation escalates, guide resident away from the source of distress, provide one-on-one interaction, staff to re-approach the resident later or have a different staff member attempt to assist the resident, and if the resident becomes aggressive, staff should ensure her safety and give her time to calm down. A nursing note dated (MONTH) 25, (YEAR) included that resident #268 hit three staff members in the stomach and tried to kick them. Review of the behavior monitoring record for (MONTH) and (MONTH) (YEAR) revealed 4 episodes of resident #268 yelling out and 5 episodes of the resident striking out at staff. A physician's orders [REDACTED]. A nursing note dated (MONTH) 24, (YEAR) at 1:08 a.m., stated the resident was awake, roaming the halls and refusing care. The resident's pants were half on/half off and the resident was removing her clothes in the middle of the hall. A nursing note dated (MONTH) 18, (YEAR) included the resident was verbally aggressive with staff in a common area where other residents were present. The note also stated the resident tried to ram her wheelchair in the direction of another resident. Review of the resident's care plans revealed no evidence that they were updated to address the resident's aggressive behaviors toward other residents. Further review of the clinical record revealed there was no documentation that the resident was provided increased supervision, despite documentation of aggressive behaviors toward residents. A nursing note dated (MONTH) 25, (YEAR) revealed that resident #268 was extremely agitated, was screaming loudly, and swinging out, when a female resident was walking by, the resident hit her in the chest/abdomen area. The note also included that resident #268 was immediately removed from the area, staff continued to keep her away from other residents, and she began to wander in the hallway screaming loudly and speaking inaudible words. Review of the facility's investigative report regarding the incident on (MONTH) 25, (YEAR), revealed resident #268 was seen striking another resident as the resident walked by her. Per the clinical record, the resident was discharged to the hospital on (MONTH) 28, (YEAR) for continued/worsening altered mental status. An interview was conducted on (MONTH) 8, 2019 at 9:32 a.m., with a Licensed Practical Nurse (LPN/staff #52). She stated she witnessed the event between the two residents, and she was the author of the nursing note that documented the event. She stated that another resident was walking by as resident #268 was very agitated. She stated the arm of resident #268 was flailing when it struck the other resident. She stated neither resident was injured during the event.",2020-09-01
45,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,758,E,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews and staff interviews, the facility failed to ensure there was adequate monitoring for adverse side effects for three residents (#10, #52 and #171) on [MEDICAL CONDITION] medications and failed to monitor target behaviors for one resident (#52) on an antidepressant medication. Findings include: -Resident #10 was admitted on (MONTH) 30, (YEAR) and readmitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also included the resident received antipsychotic medication 7 of 7 days and antidepressant medication 6 of 7 days of the lookback period. A review of the resident's care plan regarding the use of [MEDICAL CONDITION] medications included a goal that the resident would remain free of complications related to [MEDICAL CONDITION] drugs. Interventions were to monitor for side effects and effectiveness each shift and to monitor/document/report as needed any adverse reactions of [MEDICAL CONDITION] medications such as: unsteady gait, tardive dyskinesia, shuffling gate, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, [MEDICAL CONDITION], social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting and behavioral symptoms not usual to the person. The physician orders [REDACTED]. The orders did not include to monitor for adverse effects of these medications. Review of the Pharmacist New Admission Medication Review dated (MONTH) 10, (YEAR) revealed a recommendation to the physician/prescriber which stated [MEDICATION NAME] and [MEDICATION NAME] in combination may increase the risk of serotoni[DIAGNOSES REDACTED], if either drug is increased in dose/frequency, monitor for adverse events. A review of the Nurse Practitioner hospital discharge follow up note dated (MONTH) 11, (YEAR) revealed a medication review and an assessment of major [MEDICAL CONDITION], with a plan to follow response to medications and circumstances. Further review of the clinical record revealed a form titled, Side Effects Monthly Flow Sheet for (MONTH) 2019. The form included instructions to use the form for the following medication classes: antianxiety, antidepressant, antipsychotic and sedative/hypnotic. This form also included the side effects/adverse effects of each of these drug classes, with areas to document if any adverse effects. This form was blank. In addition, there was no clinical record documentation that the resident was being monitored for adverse effects of the [MEDICAL CONDITION] medications in (MONTH) (YEAR) and (MONTH) 2019. -Resident #171 was admitted on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. The orders did not include to monitor for any adverse effects of the medications. A baseline care plan identified a focus area related to a mood problem. Interventions included to administer medications as ordered, and to monitor/document for side effects and effectiveness. Review of the clinical record revealed there was no documentation that the resident was consistently monitored for adverse side effects related to the use of [MEDICAL CONDITION] medications. An interview was conducted with Licensed Practical Nurse (LPN/staff #53) on (MONTH) 6, 2019 at 1:30 p.m. Staff #53 stated the nurses are to document on the Side Effects Monthly Flow Sheets that are placed in the book. She said that she was not sure who was responsible to place the forms in the book. She also stated that she was unable to find documentation that resident #10 and #171 were being consistently monitored for adverse effects of [MEDICAL CONDITION] medications. -Resident #52 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. An informed consent was obtained for the use of [MEDICATION NAME] on (MONTH) 10, (YEAR). Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR), revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The MDS assessment further documented that the resident had received an antidepressant for seven out of the past seven days. Review of the resident's care plans revealed there was no plan developed to address the use of an antidepressant medication. According to the Medication Administration Record [REDACTED]. However, there was no clinical record documentation from (MONTH) 9, (YEAR) through (MONTH) 6, 2019 that the resident had been monitored for any target behaviors related to depression, or that the resident was consistently monitored for adverse side effects related to an antidepressant medication. An interview was conducted on (MONTH) 7, 2019 at 9:24 a.m., with a Registered Nurse (RN/staff #104). She stated that when a resident receives an antidepressant, the nurse would be expected to verify an appropriate [DIAGNOSES REDACTED]. Staff #104 said the nurse would also be expected to monitor and document target behaviors related to antidepressant use each shift on the behavior sheets. She stated there was no behavior sheet or monitoring for resident #52, but there should have been since the resident was taking [MEDICATION NAME]. She stated the behavior sheets were normally initiated on admission and kept in the behavior binder, but she did not know the process for how the sheets were started and placed in the binder. An interview was conducted on (MONTH) 8, 2019 at 11:16 a.m., with the Director of Nursing (DON/staff #160). She stated it was the responsibility of the admitting nurse or the MDS coordinator to initiate behavior monitoring sheets and side effect monitoring sheets for residents taking antidepressants. She stated it was the responsibility of nurses who were administering antidepressant medications to monitor for and document the resident's target behaviors and side effects. She stated documentation should be done on the behavior and side effect sheets kept in the behavior binders on the units. She stated that there were no side effect monitoring sheets for resident #52 in the behavior binder, and they should have been there. She also said the facility did not have a policy for [MEDICAL CONDITION] medication administration, only a policy specifically for antipsychotic medication administration.",2020-09-01
46,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2019-01-08,880,E,0,1,ZWO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, review of the Center for Disease Control (CDC) guidelines and policy and procedures, the facility failed to implement infection control measures for one resident (#222) on contact isolation precautions and failed to ensure infection control measures were implemented regarding catheters for two residents (#41 and #321). Findings include: -Resident #222 was admitted (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Physician orders [REDACTED]. A nursing progress note dated (MONTH) 4, 2019 at 3:30 p.m. revealed the resident was placed on isolation precautions. A care plan dated (MONTH) 5, 2019 revealed the resident had [MEDICAL CONDITION]. Interventions included the following: Contact Isolation: wear gowns and masks when changing contaminated linens; educate resident, family and staff regarding preventive measures to contain the infection; place in private room with contact isolation precautions and disinfect all equipment before leaving the room. An observation was conducted on (MONTH) 5, 2019 at 11:03 a.m., outside of resident #222's room. A visitor was observed inside the resident's room and was wearing a gown that was not secured, and was slipping off her shoulders. The visitor also only had one glove on her right hand. The visitor was observed moving items on and off the bedside table with both hands. During the observation, the visitor stepped into the hallway over the threshold, two times with the unsecured gown and one glove still on, and then re-entered the room. At one point, the visitor removed the gown and one glove, and placed them into the red biohazard bag by the door and exited the room. The visitor did not wash her hands prior to leaving the room. The visitor then picked up her personal items from the top of the isolation cart which was outside of the resident's room, and proceeded to leave the building without washing her hands. An interview was conducted on (MONTH) 5, 2019 at 11:42 a.m. with a Licensed Practical Nurse (LPN/ staff #85), who stated that when a resident is placed on isolation, there is a lot of education done with staff and visitors prior to entering the isolation room. Staff #85 stated that both staff and visitors are educated to put on a gown and gloves, secure the gown, and are taught proper removal of the gown and gloves. Staff #85 stated that staff and visitors are also educated to wash their hands with soap and water prior to exiting the room, because hand sanitizer is not effective. An observation was conducted on (MONTH) 5, 2019 at 12:09 p. m. of a Certified Nursing Assistant (CNA/staff #150) who put on a gown but did not secure it and donned gloves. Staff #150 briefly spoke to resident #222, then removed the gown and gloves and placed them into the red biohazard. Staff #150 then used hand sanitizer and exited the room. Staff #150 did not wash her hands with soap and water prior to exiting the room. Immediately following the observation, staff #150 stated that because she did not touch anything in the room, the hand sanitizer was acceptable to use. An observation was conducted on (MONTH) 5, 2019 at 12:21 p.m., outside of resident #222's room. At this time, the resident's call light was on. The administrator (staff #147) was observed to walk into resident #222's room carrying a notebook, without donning a gown or gloves. Staff #147 then set the notebook on the resident's bedside table which was next to the resident and then reached over the resident to turn off the call light. Staff #147 conversed with resident #222, then picked up the notebook from the bedside table and walked out of the room, without washing his hands. Immediately following the observation, an interview was conducted with staff #147 who stated that the facility policy for entering a contact isolation room is to put on a gown and gloves, prior to entering the isolation room. Staff #147 said that before exiting the room, remove the gown and gloves, dispose of them in the red biohazard bag inside the room, and wash your hands with soap and water. Staff #147 stated that hand sanitizer would not be acceptable to use when leaving an isolation room. Staff #147 stated he did not do any of those things when he entered and exited the room. Staff #147 then proceeded to apply hand sanitizer to his hands, however, did not wash his hands with soap and water. An interview was conducted on (MONTH) 7, 2019 at 10:13 a.m. with a LPN (staff #151), who stated that when a resident is on contact isolation precautions, the person entering the room should use hand sanitizer prior to applying a gown and gloves, and tie the gown around their neck and waist to secure the gown. Staff #151 said that before exiting the room, the gown and gloves should be removed and placed into the red biohazard bag inside the room, then wash their hands with soap and water. Staff #151 stated that soap and water will ensure the [MEDICAL CONDITION] spores are killed, as hand sanitizer is not effective. An interview was conducted on (MONTH) 8, 2019 at 8:39 a.m. with the Director of Nursing (staff #160), who stated when a resident is on isolation precautions, an isolation cart is set up outside of the resident's room. Staff #160 stated for contact isolation precautions, all people who enter the room, including staff and visitors are to put on a gown and gloves, prior to entering the room every time they enter. Staff #160 said that prior to leaving the room, the person should remove the gown and gloves and dispose of them in the designated biohazard trash bag. Staff #160 stated the person should then wash their hands with soap and water and exit the room, without touching anything else in the room. Review of the facility's Infection Control policy revealed the purpose is to minimize as far as possible, the risks of harm to staff, residents, volunteers, family members and visitors, which may arise through pathogens being passed from one person to another. Staff and residents are most likely sources of infectious agents and are also the most common susceptible hosts. Other people visiting the premises may be at risk of both infection and transmission. The facility ensures effective implementation of infection control. Hand washing and hand care are considered the most important measures in infection control. Effective infection control is central to providing high quality support for residents and a safe work environment for the facility's employees, board members and visitors. Infection control is integral to resident support, not an additional set of practices. Risks of infections are regularly assessed, identified, and managed and mechanisms are put in place for compliance with infection control procedures. Review of a policy regarding Transmission-Based Precautions revealed it is our policy to take appropriate precautions to prevent transmission of infectious agents. Transmission-based precautions are additional controls based on a particular infectious agent and the agent's mode of transmission. These precautions are to be used in adjunct with standard precautions. The policy further included an order for [REDACTED]. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning personal protective equipment (PPE) upon entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. [MEDICAL CONDITION], norovirus and other intestinal tract pathogens). Review of the CDC guidelines revealed that [MEDICAL CONDITION] is a spore forming bacterium that causes inflammation of the colon known as [MEDICAL CONDITION]. [MEDICAL CONDITION] spores are shed in feces and transferred to patients mainly via the hands of people who have touched a contaminated surface or item. For the prevention of transmission of [MEDICAL CONDITION] in healthcare settings, use contact precautions for patients with known or suspected [MEDICAL CONDITION]. The guidelines included to use gloves and gowns when entering patient rooms and during care and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. The guidelines also stated that before exiting the patient room, discard gowns and gloves, and wash hands with soap and water to contain the [MEDICAL CONDITION] pathogens. -Resident #41 was admitted (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 22, (YEAR) revealed the resident had an indwelling catheter for [MEDICAL CONDITION] bladder. The goal included the resident will have no signs or symptoms of a UTI through the next review date. Interventions included the following: -position tubing below the level of the bladder. -monitor and document for pain/discomfort due to the catheter -monitor/record/report to MD for signs or symptoms of UTI including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever and chills. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR) revealed the resident had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. This MDS also revealed the use of an indwelling catheter. Review of the physician's orders [REDACTED]. During a random observation conducted on (MONTH) 6, 2019 at 8:31 a.m., resident #41 was in bed and the catheter bag was hanging on the bed rail, and approximately 5 inches of the catheter tubing was on the floor. Another observation was conducted on (MONTH) 6, 2019 at 2:49 p.m. of the resident in bed. The catheter bag was observed hanging on the bed rail and approximately 3-4 inches of the catheter tubing was on the floor. An interview was conducted on (MONTH) 7, 2019 at 10:13 a.m. with a Licensed Practical Nurse (LPN/staff #151), who stated that when a resident has a catheter, it is never acceptable for the catheter bag or tubing to be on the floor for infection control prevention. An interview was conducted on (MONTH) 7, 2019 at 1:56 p.m., with a Certified Nursing Assistant (CNA/staff #2). Staff #2 stated that the catheter tubing comes with a clip so it can be secured so it does not drag on the floor. Staff #2 stated that if the tubing drags on the floor, the entire tubing would have to be replaced by the nurse, because the tubing would be contaminated, as it would pick up germs from the floor, and those germs should not be transferred to the resident from the catheter tubing. An interview was conducted on (MONTH) 8, 2019 at 8:39 a.m. with the Director of Nursing (staff #160), who stated that catheter tubing should not be dragging on the floor for infection control purposes. -Resident #321 was admitted on (MONTH) 30, (YEAR), with the [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An observation was conducted at 11:25 a.m. on (MONTH) 5, 2019, of the resident lying in bed. The resident's catheter bag was hanging under the bed facing the door, and the catheter tubing and the catheter bag was observed touching the floor. Another observation was conducted at 12:01 p.m. on (MONTH) 6, 2019, of a certified nursing assistant (CNA/staff #171) pushing the resident in the wheelchair down the hallway to the dining room. During the transport, approximately 4 inches of the catheter tubing was observed dragging on the floor. At 12:30 p.m. on (MONTH) 6, 2019, the resident was observed in the dining room eating lunch. The catheter tubing was observed resting on the floor under the wheelchair. At 12:55 p.m. on (MONTH) 6, 2019, staff #171 was observed pushing the resident in the wheelchair down the hall from the dining room to the resident's room. The catheter tubing was again dragging on the floor. Following the observation, an interview was conducted with staff #171. He stated that he did not see an issue with the catheter tubing dragging on the floor. He stated there was no way he could secure the tubing higher and prevent it from dragging on the floor. He then stated that he could tuck the tubing in the Foley bag and proceeded to tuck the tubing in the bag. An interview was conducted at 10:13 a.m. on (MONTH) 7, 2019, with a Licensed Practical Nurse (LPN/staff #151). She stated that the urinary catheter tubing or the Foley bag should never touch the floor. An interview was conducted with the Director of Nursing (DON/staff #160), who stated that all Foley drainage bags need to have a privacy bag and that the urinary catheter tubing should not be dragging on the ground. Review of policy and procedure for Catheter Care Urinary revealed the main goal is to prevent catheter-associated urinary tract infection. Under infection control, the policy included Be sure the catheter tubing and drainage bag are kept off the floor.",2020-09-01
47,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2018-06-28,622,D,1,0,KWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of hospital documentation, staff interviews and review of facility policies and procedures, the facility failed to ensure there was documentation in one resident's (#2) clinical record regarding the basis for the transfer. The sample size was three. Findings include: Resident #2 was admitted to the facility on (MONTH) 15, (YEAR) with [DIAGNOSES REDACTED]. Nursing Note dated (MONTH) 15, (YEAR) documented Arrived from (name of hospital) at 3:15 p.m .Alert and oriented x 3 but slow to speak appears exhausted .Oxygen two liters - not on home oxygen . Review of a Social Services Note dated (MONTH) 18, (YEAR) at 2:03 p.m. documented .requesting that patient be transferred to (another skilled nursing facility) to continue her skilled related to family's dissatisfaction with her care. Writer obtained telephone order for discharge . Review of a Physician Telephone Order dated (MONTH) 18, (YEAR) at 6:18 p.m. documented Send to ER (emergency room ). There was no documentation on the telephone order as to the reason for the transfer and the order was not signed by the resident's primary physician at the facility. Review of the clinical record revealed no documentation regarding the basis for the transfer to the hospital. Review of hospital documentation dated (MONTH) 18, (YEAR) at 10:30 p.m. documented .per her primary care physician .who saw the patient today, patient was somnolent and hypoventilating this afternoon and hypoxic (83% on room air) . An interview was conducted with the medical records clerk, staff #76 on (MONTH) 27, (YEAR) at 11:38 a.m. The medical records clerk stated that the resident did not get transferred to the other skilled nursing facility because of insurance purposes but that she thought the resident's family took the resident to the hospital. An interview was conducted with the DON (director of nursing), staff #64 on (MONTH) 27, (YEAR) at 2:00 p.m. The DON stated that she did not think the resident had a change of condition but that she did not have anything to back that up because the agency nurse did not document why the resident was discharged . An interview was conducted with the resident's primary physician on (MONTH) 27, (YEAR) at 4:00 p.m. The physician stated that he was the resident's primary physician while she resided at the facility but did not give an order to send the resident to the hospital. An interview was conducted with the DON, staff #64 on (MONTH) 27, (YEAR) at 4:05 p.m. The DON stated that the resident also had a concierge physician who must have gave the order to transfer the resident to the hospital as the telephone order did not indicate which physician gave the order and it was not signed by a physician. The DON further stated that the licensed nurse did not document the reason for discharge to the hospital. Another interview was conducted with the DON, staff #64 on (MONTH) 28, (YEAR) at 9:10 a.m. The DON stated that the nurse who got the order to transfer the resident to the hospital was an agency nurse. The DON stated that she noticed there was no documentation in the clinical record so she called the agency to ask the agency nurse to document as to why the resident was sent to the hospital. The DON stated that the agency nurse stated that she could not remember. An interview was conducted with an RN (registered nurse), staff #92 on (MONTH) 28, (YEAR) at 12:28 p.m. The RN stated that if she had to transfer a resident to the hospital that she would write a basic summary of what was going on with the resident, who was notified such as the physician and family, and document that in the resident's clinical record. An interview was conducted with a LPN (licensed practical nurse), staff #93 on (MONTH) 28, (YEAR) at 12:35 p.m. The LPN stated that if she transferred a resident to the hospital that she would document the reason as to why the resident was being transferred, who was notified, who gave the order and any other pertinent information. The LPN further stated that she would document that in the resident's clinical record. Review of the facility's policy Emergency Transfer or Discharge documented .Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: .Prepare a transfer form to send with the resident .",2020-09-01
48,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2018-06-28,689,G,1,0,KWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of facility policies and procedures, the facilty failed to ensure that one resident (#1) was transferred appropriately to prevent a fracture to her humerus. The sample size was three. Findings include: Resident #1 was admitted to the facility on (MONTH) 19, 2012 with [DIAGNOSES REDACTED]. Review of an ADL (activities of daily living) care plan dated (MONTH) 13, (YEAR) revealed Resident requires extensive assist with ADLs with two staff members for transfers .due to debility, due [MEDICAL CONDITION] and right sided sensory impairment. A goal documented was Resident will .have daily needs met by staff. Approaches documented were Two staff members for all transfers. Patient and her daughters refuse gait belt use. They have been educated but continue to state their refusal . Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), section G Functional Status revealed the resident required the extensive assistance of 2 for transfers and support. Nursing Note dated (MONTH) 23, (YEAR) documented Resident was being transferred by CNA (certified nursing assistant) from bed to wheelchair. When resident's legs touched the front wheel of the wheelchair and CNA was unable to complete transfer safely that's when CNA lowered resident gently to the floor and called for help. Nursing Note dated (MONTH) 23, (YEAR) documented Resident x-rays came back abnormal for RUE (right upper extremity). Orders were received and transcribed. Family is aware of transportation to (name of hospital) emergency room for further evaluation . An Accident/Incident Report dated (MONTH) 23, (YEAR) by the CNA who transferred the resident when she fell , staff #91, documented We were pivoting to sit in chair. Then she said oh. I looked down and seen her left foot slide behind her small front wheel. I could not hold her up and get her right foot in the right place so I slowly slid down my leg to a soft sit then held her up till nurse came and helped. I only held her under her arms. Got her feet in right place. I lifted her up and nurse had her legs. We sat her in the chair. Have never had a transfer go this way . A hospital History and Physical dated (MONTH) 23, (YEAR) documented .she had a fall while she was being lifted from the bed on her right side, complaining or right hip pain, right arm pain, about 7 out of 10 .Humerus fracture . Review of a nurse practitioner progress note dated (MONTH) 29, (YEAR) documented .Her right side is her weak side affected [MEDICAL CONDITION] when purposely moved with transfers or care, the area remains painful for patient .[MEDICATION NAME] increased to BID (twice a day) . An interview was conducted with a CNA, staff #41 on (MONTH) 28, (YEAR) at 9:02 a.m. The CNA stated that if she is unsure how a resident should be transferred she asks the nurse or physical therapist prior to transferring the resident. The CNA stated that the licensed nurse documents on the Report Sheet how a resident should be transferred. The CNA stated that if a new staff person or agency staff is working we always tell them how a resident should be transferred. An interview was conducted with a CNA, staff #21 on (MONTH) 28, (YEAR) at 9:10 a.m. The CNA stated that when a new resident is admitted we get report on how to care for them. The CNA stated that he always checks with the nurse first to see how a resident should be transferred. The CNA further stated that he would never transfer a resident without checking with the nurse first because you could do more harm than good. An interview was conducted with the DON (director of nursing), staff #64 on (MONTH) 28, (YEAR) at 9:15 a.m. The DON stated that the CNA who transferred the resident when she fell was an agency CNA but that she had been familiar with the residents. The DON stated that she thought the resident required the assistance of one person for transfers. When the resident's care plan was reviewed with the DON, the DON acknowledged that it was the assistance of two for transfers but stated that the facility usually used a mechanical lift if the resident required the assistance of two for transfers. The DON further stated that the MDS coordinator develops the care plan and then refers the information to the licensed nurse on the unit. An interview was conducted with the MDS coordinator, staff #15 on (MONTH) 28, (YEAR) at 9:30 a.m. The MDS coordinator stated that she completed the MDS and the care plan prior to the resident's fall and the resident was assessed to require two staff for transfers because of her [MEDICAL CONDITION]. The MDS coordinator further stated as far as I know she should have had two CNA's to transfer her at the time of the fall. An interview was conducted with the CNA, staff #91, who transferred the resident at the time of the fall on (MONTH) 28, (YEAR) at 10:50 a.m. The CNA stated that she worked at the facility as an agency CNA quite a few times. The CNA stated that she asked and was told that the resident was weight bearing and a one person transfer. The CNA stated that she always checked with facility staff first before she transferred a resident. The CNA stated that she did not want the resident to fall so she lowered her to the floor. The CNA stated she found out later that the resident was not feeling good that day. The CNA further stated the resident did not fall, she was an assist to sit. Another interview was conducted with the DON, staff #64 on (MONTH) 28, (YEAR) at 1:00 p.m. The DON stated that the facility did not have a specific policy regarding safe transfers but that she would expect staff to transfer residents safely and follow the care plan. A review of the facilty's policy Managing Falls and Fall Risk documented Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling .",2020-09-01
49,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,241,D,0,1,VEV011,"Based on observation, staff interviews, and policy and procedures, the facility failed to promote care for residents in a manner that enhances each resident's dignity and respect, by failing to offer residents condiments with their meals and by failing to promptly clean a resident after a beverage spill. Findings include: A dining observation was conducted on (MONTH) 3, (YEAR) at 11:45 a.m., on the secured dementia unit. Prior to the start of the lunch meal, one resident was observed to spill a can of soda on her clothing and on the table where she was seated. The resident was observed to call out I need some help over here, please. One CNA (Certified Nursing Assistant) responded to the resident's call for help and proceeded to wipe up the soda spill from the table. However; the CNA neglected to clean or offer to change the resident's wet clothing. The resident ate her meal in wet clothing. In addition, during this meal observation no condiments, including salt and pepper were offered to the residents. An interview was conducted on (MONTH) 4, (YEAR) at 12:40 p.m., with a LPN (Licensed Practical Nurse/staff #177). She stated that salt and pepper and other condiments are provided to residents if they ask for it. She stated that if a resident was unable to request any condiments and was eating good, then the food must be alright and the condiments would not be offered. Another interview was conducted on (MONTH) 4, (YEAR) at 12:45 p.m., with a CNA (staff #224). She stated that she had not cleaned the resident after the soda spill, because it was a crazy day. She stated that she should have cleaned and changed the resident right after the spill. An interview was conducted on (MONTH) 4, (YEAR) at 2:30 p.m., with the DON (Director of Nursing/staff #161). She stated that all residents should have been offered condiments for their meal. She also stated that the resident who spilled the soda should have been cleaned and changed, since she would want clean, dry clothing on for her meal. A facility policy titled Condiments, Food Baskets and Food Items at the Table included, Individuals who are able should be allowed to self-select items such as condiments, bread and crackers. Condiments placed on the tables for meal service will be monitored for diet compliance to prescribed physician prescribed diets .by designated facility staff during meal service. The facility was unable to provide a written policy regarding the care of residents during a meal.",2020-09-01
50,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,279,D,0,1,VEV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that a comprehensive care plan was developed, as indicated in Section V. of the MDS (Minimum Data Set) assessment for one resident (#76). Findings include: Resident #76 was admitted on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A review of Section V. of the admission (Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR), revealed the care area for activities of daily living triggered and a care plan would be developed to address the resident's needs. However, the clinical record did not include any documented evidence that an activities of daily living care plan had been developed. An interview was conducted on (MONTH) 6, (YEAR), with MDS staff #234, who following a review and comparison of the MDS assessment and care plans, stated that an activities of daily living care plan should have been developed as indicated in Section V. of the MDS assessment. An interview was conducted on (MONTH) 6, (YEAR) at 12:13 p.m., with the ADON (Assistant Director of Nursing/staff #178), who following a review of the clinical record stated that the expectation was that care plans would be developed as indicated. Staff #178 also stated that the facility did not have a policy regarding the development of comprehensive care plans based on Section V. of the MDS assessment.",2020-09-01
51,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,314,E,0,1,VEV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that pressure ulcer care and services were consistently provided for one resident (#24). Findings include: Resident #24 was readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. The admission nursing evaluation dated (MONTH) 16, (YEAR), included that the resident's left heel had a round black area, which measured 4 by 4 cm (centimeters) and that it was possibly a deep tissue injury. A pressure ulcer care plan was developed on (MONTH) 16, (YEAR), and included documentation that an unstageable pressure ulcer was present on the resident's left heel. A Braden Risk assessment dated (MONTH) 16, (YEAR), identified that the resident was a high risk for the development of a pressure ulcer. The resident's score was a 12 and according to the Braden risk assessment key, a score of 10 to 12 indicated a high risk. Review of the clinical record revealed there were no specific admission treatment orders for the unstageable pressure ulcer to the resident's left heel. A history and physical dated (MONTH) 22, (YEAR), included that eschar was present on the resident's left heel. A physician's orders [REDACTED]. The (MONTH) (YEAR), TAR included the physician's orders [REDACTED]. The next pressure ulcer assessment was not completed until 13 days later on (MONTH) 29, (YEAR). The documentation included that an unstageable pressure ulcer was present on the resident's left heel, which measured 2.5 by 3 cm and to continue the skin prep every shift and prn. Review of a nurse's note dated (MONTH) 6, (YEAR), revealed the resident had an unstageable pressure ulcer to the left heel, which measured 2 x 4 cm with 100% eschar. A review of the (MONTH) (YEAR), TARs revealed that the skin prep order which was to be done every shift had been transcribed to be done nightly and prn, and not every shift as physician ordered. Further review revealed that the skin prep was only applied three times from (MONTH) 1 through 7, by the night shift. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. The next pressure ulcer assessment was not completed until 21 days later on (MONTH) 19, (YEAR), which included that an unstageable pressure ulcer was present on the resident's left heel, which measured 2 by 3.5 cm with slough/eschar present. The new recommendation was to apply Santyl everyday and prn to the slough/eschar. A physician's orders [REDACTED]. The next pressure ulcer assessment was dated (MONTH) 26, (YEAR), and included that the resident had a pressure injury to the left heel, which was unstageable and measured 2.4 by 3.7 cm with slough present. The recommendation was to continue with the same treatment. On (MONTH) 26, (YEAR), another physician's orders [REDACTED]. Review of the (MONTH) (YEAR), TAR revealed there was no documented evidence that the prescribed Santyl treatment had been provided on (MONTH) 29, as scheduled. The next pressure ulcer assessment was not completed until 28 days later on (MONTH) 23, (YEAR). The documentation included that an unstageable pressure injury was present on the resident's left heel and measured 2 by 3 cm, with slough present. The recommendation was to continue with the current treatment plan. A review of the (MONTH) (YEAR), TAR revealed the transcription of the Santyl order and to apply it every two days. However, according to the (MONTH) (YEAR), TAR, the Santyl treatment had been provided daily instead of every two days as physician ordered, except on (MONTH) 11, and 29, which were blank. An interview was conducted on (MONTH) 5, (YEAR), with the DON (Director of Nursing/staff #161). She stated that she provides the monthly pressure ulcer assessments, but the nursing staff were responsible to do the required weekly skin assessments, which would include a complete evaluation of any pressure ulcers which were present. Staff #161 stated she was not aware that the weekly wound assessments had not been provided by the licensed staff. Another interview was conducted on (MONTH) 6, (YEAR), with staff #161. She stated that the (MONTH) and (MONTH) treatment orders were not always administered as physician ordered. She also stated that the TARs were suppose to be signed when the prescribed treatment was administered. A facility policy titled, Pressure Ulcer Risk Assessment included that the purpose was to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. The policy included that pressure ulcers are a serious skin condition for the resident and to routinely assess and document the condition of the resident's skin, per the facility's wound and skin care program. Skin assessments are to be completed weekly or more frequently if indicated. Per the policy, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps identify those initial approaches and interventions. In addition, the policy included that the admission evaluation may identify pre-existing signs (such as a purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION], or induration) suggesting that deep tissue damage has already occurred and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable stage 3 or 4 pressure ulcer or progression of a stage 1 pressure ulcer to and ulcer with eschar or exudate within days of admission. The policy also included that the following should be recorded in the resident's clinical record: 5. The condition of the resident's skin 9. Observations of anything unusual exhibited by the resident. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin noted.",2020-09-01
52,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,334,D,0,1,VEV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and policy review, the facility failed to ensure that the Pneumococcal vaccine was offered to one resident (#166). Findings include: Resident #166 was admitted (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) recapitulation of physician orders [REDACTED]. However, review of the clinical record revealed no documented evidence that the pneumococcal vaccine was offered to the resident or that the resident refused the vaccine, or that the vaccine was contraindicated. An interview was conducted on (MONTH) 6, (YEAR) at 2:45 p.m., with the Assistant Director of Nursing (staff #178). She was unable to locate any documented evidence that the pneumococcal vaccine had been offered. A facility policy titled, Pneumococcal Vaccine included all residents will be offered the Pneumococcal vaccine to aid in preventing pneumonia/Pneumococcal infection. The policy also included: 1. Prior to admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series., and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 3. Before receiving a Pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of Pneumococcal vaccine.",2020-09-01
53,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,364,D,0,1,VEV011,"Based on observations and staff interviews, the facility failed to ensure that residents were assisted with their meals in a timely manner, in order to maintain food at preferable temperatures. Findings include: A dinning observation was conducted on (MONTH) 3, (YEAR) at 11:45 a.m. on the Kalmanovitz secured dementia unit. During this observation, two residents were seated in their wheelchairs at the same table. Once the noon meal arrived on the unit, the food was served to both of the residents and the plate covers were removed. At this time, neither resident was observed to attempt to feed themselves, nor did staff attempt to feed either resident. After 15 minutes, a CNA (Certified Nursing Assistant/staff #224) attempted to assist one of the residents with her meal. The resident was observed to not want to eat the meal. After 5 minutes, the CNA moved to the second resident and attempted to feed this resident. However, this resident also did not want to eat her food. Further observations revealed that the CNA, nor any other staff member was observed to offer to re-heat the resident's food. An interview was conducted with staff #224 immediately following this observation. Although the lunch meal had sat uncovered for 15-20 minutes, staff #224 stated that she thought the food would still be warm, because she could feel the warmth from the food, while she cut the noodles up with a spoon. Another interview was conducted on (MONTH) 4, (YEAR) at 2:30 p.m., with the DON (Director of Nursing/staff #161). She stated that the residents' food should have remained covered until staff were ready to assist the residents with their meals. She also stated that the meal could have been re-heated if needed.",2020-09-01
54,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,371,D,0,1,VEV011,"Based on observation, staff interviews and policy review, the facility failed to ensure that staff did not touch ready to eat food with bare hands. Findings include: A dining observation was conducted on (MONTH) 3, (YEAR) at 11:45 a.m. on the Kalmanovitz secured dementia unit. During this observation, a CNA (Certified Nursing Assistant/staff #185) was observed to touch a resident's muffin, with her bare hands. An interview was conducted on (MONTH) 4, (YEAR) at 12:30 p.m., with the CN[NAME] Although the CNA was unable to recall if she had touched any resident's food with her bare hands, she stated that would be a sanitary problem. Another interview was conducted on (MONTH) 4, (YEAR) at 2:30 p.m., with the Director of Nursing (staff #161) who stated that staff should not handle ready to eat food with their hands and that utensils should have been used. A facility policy titled, Assistance with Meals included: 7. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling.",2020-09-01
55,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,431,E,0,1,VEV011,"Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that medications were properly stored, and that expired medication and laboratory supplies were not expired and available for resident use. The facility also failed to ensure that the medication refrigerator temperatures were consistently monitored. Findings include: A medication storage observation was conducted on (MONTH) 3, (YEAR), on all of the nursing units and the following concerns were identified: Kalmanovitz secured dementia unit: In the Medication storage room, there was an unlocked medication refrigerator which contained a locked plastic narcotic box. However, the narcotic box was not affixed to the inside of the medication refrigerator. Further observations revealed that the plastic narcotic box did not fully close, and the opening was large enough to withdraw medications from the box, without unlocking it. Inside the plastic narcotic box were a total of 23 vials of Lorazepam (an anti-anxiety medication). At this time, the medication refrigerator temperature log for (MONTH) (YEAR) was reviewed and revealed that there was no documentation that the temperature of the refrigerator was monitored on one day. An interview was conducted on (MONTH) 4, (YEAR) at 12:45 p.m., with a LPN (Licensed Practical Nurse/staff #177). She stated that she had contacted the maintaince department and had the narcotic box permanently secured. At this time, another observation of the narcotic box was conducted. Inside of the unlocked refrigerator was a locked plastic narcotic box. The narcotic box was now attached to a shelf in the refrigerator. However, the shelf was able to be easily removed, along with the narcotic box. Rich unit: In the medication storage room there were eight yellow cap laboratory tubes, which had an expiration date of (MONTH) (YEAR). In addition, the medication refrigerator temperature logs were reviewed and revealed the following: in (MONTH) (YEAR), there were four days with no evidence that the temperature had been monitored; in (MONTH) (YEAR), there were two days with no documented evidence that the temperature had been monitored; and in (MONTH) (YEAR), there were two days with no documented evidence that the temperature had been monitored. Following this observation, an interview was conducted with a LPN (Licensed Practical Nurse/staff #6). She stated that the laboratory test tubes were occasionally used when blood was needed to be drawn. Staff #6 stated that the night shift nurses were responsible to monitor and document the medication refrigerator temperatures. She stated that the day shift nurses will now need to double check that it was done. Bregman unit: On the Medication cart, there was one vial of Lantus Insulin with an opened date of (MONTH) 26, (YEAR). Per the manufacturer's instructions, the insulin would expire 28 days after the date of opening. There were also two opened sets of Insulin Control Solution, which had an expiration date of (MONTH) (YEAR). In addition, there was an unlocked medication refrigerator which was located inside the locked medication storage room. Inside of the refrigerator was a locked narcotic box, however, it was not permanently affixed to the refrigerator. The narcotic box contained a box of 15 tablets of Dronabinol (a controlled drug used to treat nausea and vomiting associated with chemotherapy). The medication refrigerator temperature logs were also reviewed and revealed the following: in (MONTH) (YEAR), there was one day without a recorded temperature; in (MONTH) (YEAR), there were six days without a recorded temperature and in (MONTH) (YEAR), there were four days without a recorded temperature. Following this observation an interview was conducted with a LPN (staff #106), who stated that it was the night shifts responsibility to check weekly for expired medications and supplies. Golding unit: The medication refrigerator temperature logs were reviewed and revealed the following: in (MONTH) (YEAR), there were eight days without a recorded temperature; in (MONTH) (YEAR), there were two days without a recorded temperature and in (MONTH) (YEAR), there were two days without a recorded temperature. An interview was conducted on (MONTH) 4, (YEAR), with the DON (Director of Nursing/staff #161). She stated that she was not aware that the refrigerated narcotic boxes were not permanently affixed. She stated that the boxes need to be secured and that locking them to a removal shelf did not ensure that they were permanently affixed. The DON also stated that both the laboratory provider and the nursing staff were responsible to ensure that expired items were not available. According to the DON, the night shift licensed staff were responsible to check the medication refrigerator temperatures nightly, and the medication carts for expired medications and medical supplies. Per the DON, any expired medication or medical item, should be discarded and replaced. A facility policy titled, Storage of Medications included The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy also included the following: 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Another facility policy titled, Controlled Substances included The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances. The policy also included the following: 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. The container must remain locked at all times, except when it is accessed to obtain medications for residents.",2020-09-01
56,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2016-10-06,441,D,0,1,VEV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure that dietary staff used proper handwashing techniques and failed to ensure proper infection control practices were implemented during a pressure ulcer treatment for one resident (#24). Findings include: -Observations were conducted on (MONTH) 5, (YEAR) of multiple dietary staff members washing their hands in the kitchen sinks. The handwashing sinks were equipped with faucet rods in the center of the faucet spigot. The purpose of the faucet rods were to turn the water on and off. To turn on the water, the faucet rod had to be moved and the rod had to be held onto, in order to keep the water flowing. If you let go of the rod, the water turned off. Multiple observations revealed that dietary staff touched the faucet rods with their soiled hands to turn on the water, then let go of the faucet rod and lathered their hands with soap, then they had to touch the faucet rod again with their clean hands to start the flow of water, in order to rinse their hands. An interview was conducted with the dietician (staff #233) on (MONTH) 5, (YEAR) at 11:20 a.m. The dietician stated that the faucet rod was contaminated, unless it was facility procedure to clean the faucet rods after each use. An interview was conducted with the food service assistant manager (staff #63) on (MONTH) 5, (YEAR) at 12:00 p.m. The food service assistant manager did not recognize a problem with this handwashing procedure. A review of the facility's policy on Hand Washing revealed for staff to wash hands following proper hand washing procedures. Instructions on how to wash hands included to turn on the faucet using a paper towel to avoid contaminating the faucet, wet hands and scrub with soap and additional water as needed, rinse thoroughly, dry hands with a paper towel and turn the faucet off with a paper towel. -Resident #24 was readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed documentation that the resident had an unstageable pressure ulcer on the left heel A pressure ulcer treatment observation was conducted on (MONTH) 4, (YEAR) at 1:15 p.m., with a RN (registered nurse/staff #222). At this time, staff #222 was observed to gather the treatment supplies, enter the resident's room, donn gloves and place all of the treatment supplies, including a tube of Santyl and various dressings, on the resident's bedside table. However, staff #222 was not observed to wash or disinfect her hands prior to this. A clean barrier also had not been placed on the bedside table. Staff #22 then raised the head of the resident's bed and changed her gloves. Staff #222 then removed the old dressing and changed her gloves. However, staff #222 was not observed to wash or disinfect her hands after the removal of the soiled dressing. Staff #222 then proceeded to wash the pressure ulcer with soap and water, measured the wound, removed her gloves and washed her hands. However, she was only observed to rinse her hands under the water for five seconds and did not use any soap. She then touched the automatic paper towel dispenser twice, with her clean hands, thereby, coming into contact with a potentially contaminated surface (the paper towel dispenser). Once her hands were dry, staff #222 was observed to donn gloves and apply the Santyl ointment with her gloved finger to the pressure ulcer and then placed a dressing on the wound. An interview was conducted on (MONTH) 4, (YEAR) at 2:15 p.m., with staff #222. She stated that she had washed her hands prior to gathering the treatment supplies, but agreed that she had not washed her hands prior to donning gloves at the start of the treatment. Staff #222 also stated that she should have cleaned the bedside table surface or placed a barrier on it. In regards to handwashing, staff #222 stated that she should have washed her hands every time she changed her gloves and that she should have washed her hands with soap and water for 30 seconds. An interview was conducted on (MONTH) 4, (YEAR) with the DON (Director of Nursing/staff #161), who stated that the RN should have washed or disinfected her hands, prior to the start of the pressure ulcer treatment and should have washed her hands with soap and water for 30 seconds, and she should not have touched the paper towel dispenser with her hands after washing. Staff #161 also stated that the resident's bedside table should have been wiped down or a paper towel placed on it, in order to provide a clean work surface. A facility policy titled, Handwashing/Hand Hygiene included This facility considers hand hygiene the primary means to prevent the spread of infections. The policy also included the following: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc. m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. In addition, the policy included a section for proper hand washing. It included the following: 1. Vigorously lather hands with soap and rub together creating friction to all surfaces for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. The handwashing/hand hygiene policy also included a section titled, Applying and Removing Gloves and the following was included: 1. Perform hand hygiene before applying non-sterile gloves.",2020-09-01
57,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,154,E,0,1,PP4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure three residents and/or representatives (#94, #195 and #230) were informed of the risks and benefits of [MEDICAL CONDITION] medications, prior to administering. Findings include: -Resident #94 was admitted (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 1, (YEAR) included that the resident exhibited intrusive behaviors and was difficult to redirect related to [DIAGNOSES REDACTED]. Interventions included for medications to be administered as ordered by the provider. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. The MDS also included the resident received an anti-depressant. The physician's orders [REDACTED]. However, review of the clinical record revealed no evidence that the resident was informed of the risks and benefits of the Trazadone and the [MEDICATION NAME]. In an interview conducted with a Licensed Practical Nurse (LPN/staff #131) on (MONTH) 19, (YEAR) at 9:30 a.m., she stated that before a resident is administered [MEDICAL CONDITION] medications, the risks and benefits should be explained to the resident. Staff #131 stated that an informed consent which includes the risks and benefits of the medication should be signed by the resident or resident representative before administration. During an interview conducted on (MONTH) 19, (YEAR) at 12:11 p.m. with the Director of Nursing (DON/staff 64), she stated that she was unable to locate an informed consent for these medications for this resident. -Resident #195 was admitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated (MONTH) 3, (YEAR) revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. A care plan dated (MONTH) 2, (YEAR) included the resident was at risk for side effects and adverse reactions due to the use of an antidepressant medication. An approach included to involve family in resident care. A physician's orders [REDACTED]. However, there was no clinical record documentation that the risks and benefits of Trazadone were discussed with the resident/resident representative, prior to administration. An interview was conducted with staff #64 on (MONTH) 19, (YEAR) at 8:24 a.m. She stated that she was unable to locate an informed consent for the Trazadone. -Resident #230 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 1, (YEAR) included the resident was at risk for side effects and adverse reactions due to the use of antidepressant medications. An approach included to involve the family in resident care. Review of the MDS assessment dated (MONTH) 8, (YEAR) revealed a BIMS score of 8, which indicated the resident had moderate cognitive impairment. The MDS also included the resident was administered antipsychotic and antidepressant medications. Further review of the clinical record revealed that a consent form was signed by the resident's family member dated (MONTH) 1, (YEAR). However, the consent form did not include the name of any medications or any information regarding the risks and benefits of the medications. An interview was conducted with a Licensed Practical Nurse (LPN/staff #128) on (MONTH) 19, (YEAR) at 9:16 a.m. She stated that prior to administering [MEDICAL CONDITION] medications, an informed consent containing the name of the medication and the risks and benefits of the medication needs to be signed by the resident/resident representative. An interview was conducted with staff #64 on (MONTH) 19, (YEAR) at 9:27 a.m. She stated that an informed consent containing the risks and benefits of the medication must be obtained prior to administering the medication. She stated that if a resident is unable to sign the informed consent, then the resident's responsible person would be contacted to obtain the informed consent. A policy regarding Antipsychotic Medication Use did not address the need to obtain informed consent for antipsychotic medications or of the need to inform residents/resident representative of the risks and benefits, prior to administration.",2020-09-01
58,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,278,D,0,1,PP4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one resident (#195). Findings include: Resident #195 was admitted (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR) revealed the resident was administered an antipsychotic medication for 7 days during the look back period. However, review of the (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. The MDS further included that the resident was administered a hypnotic medication on 5 days, during the look back period. However, review of the (MONTH) 27 through (MONTH) 3, (YEAR) MARs revealed the resident received the hypnotic medication for 3 days during the look back period. In addition, the MDS included that the resident was not administered an anticoagulant medication. However, review of the (MONTH) 27 through (MONTH) 3, (YEAR) MARs revealed the resident was administered an anticoagulant medication for 7 days. The MDS further included the resident was administered an antibiotic medication for 7 days. However, review of the (MONTH) 27 through (MONTH) 3, (YEAR) MARs revealed the resident was administered an antibiotic medication for 5 days during the look back period. An interview was conducted with the MDS coordinator/Assistant Director of Nursing (ADON/staff #8) on (MONTH) 19, (YEAR) at 8:49 a.m. She stated that when coding medications administered on the MDS, the MAR indicated [REDACTED]. Staff #8 stated that the correct coding for the MDS assessment dated (MONTH) 3, (YEAR), should have included that an anticoagulant medication was administered for 7 days, an antipsychotic medication was administered for 6 days, an antibiotic medication was administered for 5 days, and a hypnotic medication was administered for 3 days. She stated that the expectation is that the MDS assessment is accurate. Review of the RAI manual revealed to review the resident's medical record for documentation that certain medications were administered to the resident during the 7 day look-back period and to record the number of days that the select medications were administered to the resident during this time.",2020-09-01
59,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,281,D,0,1,PP4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure an order was clarified with the physician regarding the frequency for administering a narcotic pain medication to one resident (#257). Findings include: Resident #257 was admitted (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order did not include a frequency for administration. Review of the Medication Administration Record [REDACTED]. However, the MAR indicated [REDACTED]. Review of the clinical record revealed there was no order for the [MEDICATION NAME] to be administered every four hours PRN. An interview was conducted on (MONTH) 18, (YEAR) at 9:28 a.m., with a licensed practical nurse (staff #141). She stated the order for [MEDICATION NAME] did not have a frequency and should have been clarified with the physician. Staff #141 stated that physician's orders [REDACTED]. An interview was conducted on (MONTH) 18, (YEAR) at 9:51 a.m., with the Assistant Director of Nursing (staff #8). Staff #8 stated medication orders should include the frequency. She stated the expectation is for nurses to call the physician to clarify an order. Staff #8 stated the [MEDICATION NAME] order did not have a frequency and the order was not clarified with the physician. During an interview conducted (MONTH) 19, (YEAR) at 11:23 a.m. with the Director of Nursing (staff #64), staff #64 stated medication orders should include the medication frequency, and if the frequency is not written, the nurse is to clarify the order with the physician. Review of the facility's policy regarding Administering Medications revealed that medications must be administered in accordance with the orders, including any required time frame.",2020-09-01
60,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,371,E,0,1,PP4811,"Based on observations, facility documentation, staff interviews and policy and procedures, the facility failed to ensure that food and kitchenware were stored in a clean and sanitary manner, and failed to ensure sanitation levels for the dishwashing machine were consistently monitored. Findings include: Regarding the food storage: An observation of the kitchen was conducted at 11:00 a.m. on (MONTH) 16, (YEAR) and the following was observed: -A head of romaine lettuce was stored uncovered on a wheeled cart. The lettuce was in contact with the surface of the cart. -In the dry storage room there were multiple tea bags stored on a food rack. The tea bags were uncovered and in direct contact with the rack. In an interview with the assistant food service manager (staff #105) at 11:05 a.m. on (MONTH) 16, (YEAR), he stated that these items should not be stored this way. The Food Storage policy included that sufficient storage facilities are provided to keep foods safe. The policy also included food is stored in an area that is clean, dry, and free from contaminants and that food should be stored in covered containers or wrapped carefully and securely. Regarding the storage of kitchenware: An observation of the kitchen was conducted at 10:35 a.m. on (MONTH) 18, (YEAR) and the following was observed: -A tray with multiple ready-to-use bowls was stored near the dish room. The bowls were observed to be wet and when handled, the water dripped to the floor. -Multiple ready-to-use plastic cups which were stacked on top of each other were observed to be wet and when handled, water dripped onto the floor. -Multiple ready-to-use plates were stored on a rack with food debris on them. The food debris fell to the floor when the plates were lifted. -Two small pans stored ready-to-use had dried food debris on them. -A large rack had stuck-on debris on it and was stored ready-to-use. -Two metal bowl grill covers stored ready-to-use had blackened debris on them. An interview was conducted with staff #105 at 10:45 a.m. on (MONTH) 18, (YEAR). He stated that ready-to-use dishes should be stored clean. Staff #105 stated that the large rack is used as a cooling rack and that it should have been cleaned better before it was put away. He stated the metal bowls are used to cover hamburgers that are cooked on the grill and did not know what was on them. An interview was conducted with the dishwasher (staff #73) at 11:00 a.m. on (MONTH) 18, (YEAR). He stated that he makes sure that dishes are dry and clean before putting them away. The policy regarding Clean Equipment and Utensils included that clean equipment and utensils will be handled to prevent contamination. Clean equipment will be stored in a clean and dry location in a way that protects them from splashes, dust or other contamination. The policy further included that glasses and cups will be stored in an inverted position, and stored utensils should be covered or inverted wherever possible. Regarding the dishwashing machine sanitation monitoring: Review of the dishwashing machine sanitation monitoring log for (MONTH) (YEAR) revealed kitchen staff were checking the dishwashing sanitation levels twice a day, once in the morning and once in the evening. Further review of the log revealed no documentation that the sanitation level was checked on the evening of (MONTH) 17, and on the morning of (MONTH) 18. At this time, a copy of the log was requested. When the log was provided, the missing information regarding the checking of the sanitation levels had been filled in for (MONTH) 17 and 18. The initials of a staff member (identified as staff #73) were documented for the evening check on (MONTH) 17. An interview was conducted with staff #105 at 10:45 a.m. on (MONTH) 18, (YEAR). Staff #105 stated a dishwasher (staff #69) had checked the dishmachine this morning, but did not document it. He stated that staff #69 wrote in the information for today on the log after it was identified. He stated that another dishwasher (staff #73) had filled in the information for the evening of (MONTH) 17. During an interview with a dishwasher (staff #73) at 11:00 a.m. on (MONTH) 18, (YEAR), she stated that she did not work the evening shift on (MONTH) 17, (YEAR) and did not know why her initials were on the log. An interview with staff #69 was conducted at 11:25 a.m. on (MONTH) 18, (YEAR). He stated that he had checked the dishwashing machine sanitation this morning, but had not documented it on the log, until the missing documentation had been identified. Review of the policy regarding the Dishwashing Machine Temperature Log revealed that the dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The policy included that the staff will be trained to record dishwashing machine temperatures for the wash and rinse cycles in the morning and in the evening, and that the dietary manager will spot check this log to assure temperatures are appropriate and staff are actually monitoring the dishwashing temperatures.",2020-09-01
61,HANDMAKER HOME FOR THE AGING,35016,2221 NORTH ROSEMONT BOULEVARD,TUCSON,AZ,85712,2017-10-19,500,D,1,1,PP4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and facility documentation, the facility failed to ensure that a urology appointment was scheduled in a timely manner for one resident (#173). Findings include: Resident #173 was admitted (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. An interim care plan dated (MONTH) 19, (YEAR) revealed that the resident had a urinary catheter in place. A goal included the resident would be free of complications. Review of an Appointment/Transportation form dated (MONTH) 26, (YEAR) revealed the resident went to a follow up nephrology appointment. At the bottom of this form were progress notes from the nephrologist provider. The notes included for the resident to have a urology evaluation to assess bladder function and possibly remove the urinary catheter. A physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 26, (YEAR) revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The resident was also coded as having an indwelling urinary catheter. Review of the clinical record revealed no documentation of an attempt to schedule the urology appointment or that an appointment had been scheduled from (MONTH) 26-May 11. A nursing note dated (MONTH) 12, (YEAR) included that a family member voiced concerns about the resident's care. The note included that a nurse practitioner (NP) was present and wrote an order for [REDACTED].>A NP order dated (MONTH) 12, (YEAR) included for a urology consult related to [MEDICAL CONDITION]. Review of an Appointment/Transportation form dated (MONTH) 18, (YEAR) revealed the resident went to the urologist appointment. At the bottom of this form were progress notes from the urology provider. The notes included the resident had acute [MEDICAL CONDITION] requiring Foley catheter. The catheter was exchanged in the office today. Will need to come back in one month for a voiding trial attempt. Clinical record documentation showed that the resident was discharged from the facility on (MONTH) 18, (YEAR). During an interview conducted on (MONTH) 18, (YEAR) at 12:10 p.m. with the transportation coordinator (staff #156), staff #156 stated that the appointment may have been delayed because the resident was a new patient. Staff #156 stated she remembered the urologist wanted more information before scheduling the appointment. However, she was unable to provide any documentation of any attempts to schedule the urology consult during the time frame of (MONTH) 26-May 11. An interview was conducted with the Director of Nursing (DON/staff #64) on (MONTH) 18, (YEAR) at 12:15 p.m. She stated that there should be documentation if the appointment was delayed. She also stated they do not have a policy regarding appointments, but provided a protocol for setting up appointments. Review of the protocol for Setting up Appointments included that physician's orders [REDACTED]. The appointment form should be completed with the resident's name, date of birth, the doctor's name, address, and phone number and signed and dated by the nurse taking the order. The protocol also included to call the doctor's office to determine if the resident is an established patient or new patient and to input the appointment on the appointment calendar and print a copy for the nurses, so they are aware of the daily appointments.",2020-09-01
62,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,600,G,1,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, resident and staff interviews, facility documents and policy and procedures, the facility failed to ensure one resident (#8) was free from neglect which resulted in harm, failed to ensure one resident (#284) was free from verbal abuse by a staff member and failed to ensure that one resident (#283) was free from physical abuse by another resident (#11). The resident census was 41. Findings include: -Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have severe cognitive impairment. The functional assessment of the MDS indicated the resident had no impairment with range of motion to her extremities. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. The resident was placed on Alert Charting, the care plan was updated and a Fall Risk Assessment was completed. The physician and responsible party were notified. Review of the CNA task documentation revealed it was updated on 11/15/18 to reflect that resident #8 required the assistance of two staff with transfers. A physician hospital progress note dated 11/16/2018 included the resident was admitted due to being transferred from the wheelchair to standing, and while standing fell out of their grasp. Patient reports the staff person lost their balance while standing, and fell on to the patient. The hospital course included the resident had a humeral head fracture status [REDACTED]. The fall care plan was updated on 11/18/18 to reflect that the resident had a witnessed fall with major injury (right humeral head fracture) on 11/14/18. An observation was conducted on 1/23/19 at 8:46 a.m. of the resident in bed. With the assistance of a Spanish-speaking Certified Nursing Assistant, the resident was asked to move her right arm. The resident demonstrated severe limited ability with range of motion to the right shoulder, right elbow and right wrist. The resident was able to move all fingers on the right hand. An interview was conducted on 1/25/19 at 8:54 a.m. with a CNA (staff #19), who was observed with a gait belt around her waist. Staff #19 stated she always has it with her and it is required to be used for all resident assisted transfers. Staff #19 stated that she checks the Kardex and the Task List to see what specific care is needed for residents or she asks the therapist or nurse. Staff #19 stated if she doesn't feel comfortable transferring a resident, she will ask for help. Staff #19 stated that she remembered they were transferring resident #8 with one person and that she had transferred her by herself more than once, because there was nothing on the Kardex or on the task list to tell her that the resident needed to be transferred with two people. She stated that she doesn't have access to the care plan. An interview was conducted on 1/25/19 at 9:18 a.m. with the ADON (staff #29), who stated that ever since she had been working at the facility (8/08/17), she felt resident #8 was a two person transfer, but it was not determined for her to be a two person transfer until her first fall in (MONTH) (YEAR). Staff #29 stated when she was investigating the (MONTH) fall, the information regarding the need for two persons for transfers was not on the Kardex/Task list, so it was added then. Staff #29 stated she doesn't think the CNA's have access to the care plans, but she wasn't sure. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated that staff are trained on physical, emotional, mental, sexual, financial and verbal abuse and neglect. Staff #40 stated that staff are made aware of what is included in the various types of abuse and that it was just reviewed along with resident rights at the all staff meeting. Staff #40 stated the leadership team will make a determination on whether or not an incident is abuse/neglect. Staff #40 stated neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not being provided. Staff #40 stated that the CNA (staff #67) was terminated, because of not following the resident's care plan and our policy for transfers. Another interview was conducted on 1/25/19 with ADON (staff #29), who stated she convened the IDT Fall team the day after the fall. She said the appropriate people (physician, responsible party) were notified and the resident was sent out to the hospital. Staff #29 further stated that based on the definition of neglect (as discussed above), she would now consider what occurred as neglect. An interview was conducted on 1/25/19 with the DON (staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed, she would now consider what occurred as neglect. An interview was conducted on 1/25/19 at 11:45 a.m., with the CNA (staff #67). Staff #67 stated that he was provided training by the facility on how to do transfers and how to obtain information regarding transfer needs of residents from the computer system. Staff #67 stated the facility policy was to use a gait belt for all transfers and he used a gait belt for all transfers, except for one incident. Staff #67 stated the incident was when resident #8 fell . He said that he had taken the gait belt out of his pocket to use the restroom and didn't put it back and forgot about it. Staff #67 stated that Prior to that day we always used two people to transfer her, but that day I didn't call for help because I was just trying to get her laid down before the end of my shift and I had things to do. -Resident #284 was admitted on (MONTH) 16, 2019, with [DIAGNOSES REDACTED]. Review of the care plan initiated on (MONTH) 17, 2019, revealed the resident was on antidepressant medication related to depression. Interventions included redirection and activities of choice for crying, self-isolation or verbalization of sadness. Review of an activity of daily living (ADL) care plan revealed resident #284 has an ADL self-care performance deficit related to impaired mobility. Interventions included for PT/OT evaluation and treatment as per physicians orders and to encourage resident to participate to the fullest extent possible with each interaction. Review of the nurse's notes dated (MONTH) 19, 2019, revealed the resident was alert and oriented x 4, and has a right leg and left arm in an immobilizer. Per the note, the resident was extensive assist of one person for bed mobility and toileting, and a two-person extensive assist for transfers. The admission Minimum Data Set (MDS) assessment dated (MONTH) 23, 2019, revealed the resident scored a 15 on the Brief Interview for Mental Status (BIM's), indicating the resident was cognitively intact. The MDS also revealed the resident did not have any behaviors. Review of the facility's investigation dated (MONTH) 23, 2019, revealed that on (MONTH) 18, 2019, resident #284 was very upset about her therapy that day. She reported that the therapy staff (#68 and #21) were yelling and cussing at her. The resident reported that she wanted to work with physical therapy (PT), as she had already received a shower from occupational therapy (OT). She stated that when she went to the therapy gym, the therapist (Certified Occupational therapy assistant/COTA/staff #68) told her If you get your butt down here we can work. Resident #284 further reported that the therapists were yelling at her and told her that it took 30 minutes to get her out of bed and walk her and that was her therapy for the day. She stated it was not correct that it took her 30 minutes to get her out of bed. The resident stated that one of the therapists called her a name (B word), but she wasn't sure which one. She said that made her angry and she called the therapist the same name. Further review of the investigative report revealed a statement by the physical therapy assistant (PTA/staff #21). Staff #21 explained that it took 30 minutes for the resident to get out of bed, take a shower and walk 25 feet. After the shower, resident #284 came to the therapy gym and was upset, so she told the resident to sit down and she would explain it to her. Staff #21 reported that as she was explaining the issue regarding the therapy minutes, the resident started to escalate, so she backed off. Staff #21 stated that there were two other therapists in the room, one was an Occupational Therapist (OT/staff #23) and the other was staff #68 (COTA). She reported at that point, staff #68 tried to explain the situation to the resident. Staff #21's statement included that none of the therapists were yelling at the resident. Continued review of the investigative report revealed a statement from staff #23. Staff #23 said when resident #284 entered the gym, she was upset because it took 35 minutes to get her out of bed. Per staff #23, that time was included as part of her therapy and the resident did not understand that. Staff #23 reported that she saw staff #21 back down, when resident #284 started yelling and swearing. Staff #23 stated at that point, staff #68 started to jump in and started yelling If you want therapy get out of bed. Staff #23 stated that resident #284 and staff #68 were yelling at each other. She said that she did not hear anyone say the B word. Staff #23's statement also included that she could see how it was aggressive from the resident's point of view and she wouldn't talk to a patient like that. The investigative report also included a statement by a Certified Nursing Assistant (CNA/staff #51), who was present during the incident. Staff #51 reported that staff #21 was explaining to the resident about her physical therapy minutes and the resident was upset saying that it did not take her 30 minutes to get out of bed. Staff #51 reported that staff #68 was yelling at the resident, as she was trying to get the resident back to her room. Staff #51 stated the resident was strolling away when staff #68 kept at it and told the resident If you don't like it you can always go home. Staff #51 reported that she did not hear any cuss words from anyone. Per the report, a statement from staff #68 revealed that she tried to calm resident #284 down by trying to explain some items to her. Staff #68 reported the resident started wheeling out of the gym and she was trying to explain things to her, so she kept saying loudly Ma'am Ma'am. She stated that she did not think her actions were uncalled for. Review of staff #68's personal employee file revealed that staff #68 had a disciplinary warning on (MONTH) 13, (YEAR). Staff #68 was observed by a staff member talking to another staff member about a resident during a smoking break. It was reported that staff #68 was cussing and using profanity about a resident in front of other residents and a family member, who were a few feet away. Additional documentation via email included that based on their investigation the B word was never used. However, it was determined that staff #68 did yell at the resident even after the resident turned around to wheel herself out of the gym. Due to the previous warnings and this incident, staff #68 lacked the ability to provide good customer service and has demonstrated a pattern of behaviors, as a result staff #68 was terminated. The investigative report concluded that no staff witnessed staff #21 or staff #68 cussing at the resident, therefore the allegation was unsubstantiated. However, despite witnesses reporting that staff #68 was yelling at the resident, even as the resident was attempting to leave the area, the facility did not substantiate that verbal abuse had occurred. During an interview conducted with resident #284 on (MONTH) 23, 2019 at 8:28 a.m., she stated that on (MONTH) 18, 2019 she went to the physical therapy gym to talk to staff about her therapy. She said that a physical therapy assistant (PTA/staff #21) and a certified occupational therapy assistant (COTA/staff #68) were very rude to her. She stated that staff #21 and #68 were yelling at her and staff #68, who has never worked with her before continued to yell at her. She stated that staff #68 was yelling saying If you don't like it you can leave even as the Certified Nursing Assistant CNA (staff #51) was pushing her wheelchair out of the therapy gym. An interview was conducted on (MONTH) 25, 2019 at 8:38 a.m. with staff #21. She stated that on (MONTH) 18, 2019, she was working with resident #284. She stated that they used 30 minutes of therapy time getting the resident up from bed, giving her a shower and they walked the resident. She said the resident came to the therapy gym wanting the remaining minutes of her therapy later that day. Staff #21 said that she tried to explain to the resident that her 30 minutes of therapy was completed, as it had been used up when they got her up from bed to the shower and did some walking. She stated the resident was not happy when she heard this and started arguing in a loud voice, almost yelling. At this point, staff #21 stated that she backed down and said they could talk about it later and the resident was satisfied with that explanation. Staff #21 said that staff #68 was sitting in the corner of the room and tried to reiterate what she had just said, but by this time resident #284 and staff #68 were both yelling at each other. Staff #21 stated the resident was yelling and staff #68 was also yelling back at her. Staff #21 stated that staff #68 could have handled the situation differently and she felt that staff #68 was aggravating the situation further. She stated staff #68 has a tendency to get frustrated and escalates easily. An interview was conducted on (MONTH) 25, 2019, at 9:37 a.m. with the Director of Nursing (DON/staff #53), who stated that they conducted employee interviews during the investigation and based on the employee interviews they determined that it was not abuse, since there were no cuss words used. Staff #53 stated that during their investigation it was determined that only staff #68 was yelling. She stated that they fired staff #68, because she was yelling at a resident and did not provide good customer service. An interview was conducted with staff #51 on (MONTH) 25, 2019 at 11:09 a.m. Staff #51 stated that resident #284 went to the therapy room to speak to staff #21 to see if she was going to get therapy that day. Staff #21 told resident #284 that she already had her therapy for 30 minutes this morning. Staff #51 stated that staff #21 was telling the resident that it took her 30 minutes to get the resident out of bed to the shower, which was her total therapy time for the day. She said that is when staff #68 who was sitting in the far corner intervened and said that resident #284 only has 30 minutes allotted to her and she has used it all. Staff #51 stated that resident #284 turned around to leave and staff #68 started yelling at the resident stating she only gets 30 minutes and that's how much her insurance pays and if the resident does not like it she can leave. Staff #51 stated that there were no swear words used, but staff #68 was yelling at the resident. She stated that staff #68 should have let the other therapist finish her conversation with the resident and not interfere and it would have been easier to explain rather than start yelling. -Resident #11 was admitted on (MONTH) 29, 2003, with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 21, (YEAR), revealed the Brief Interview for Mental Status (BIMS) was not conducted, however, the resident was assessed to have moderate cognitive impairment. The MDS also included the resident had difficulty focusing, was short-tempered and gets restless at times. Review of a care plan revealed that resident #11 displays behaviors of physical aggression. -Resident #283 was admitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 8, (YEAR), revealed a BIMS interview was not attempted as the resident was rarely/never understood. The MDS included that resident #11 had moderate cognitive impairment. A nurse's weekly skin check and wound assessment dated (MONTH) 12, (YEAR) included resident was involved in a resident to resident altercation in which he was struck on the arm. No bruising, laceration, open skin or injury observed from residents altercation . Review of the facility's investigative report revealed that on (MONTH) 12, (YEAR) at approximately 7:00 p.m., resident #11 had been sitting next to resident #283 after dinner at the nurse's station. Resident #283 was talking/mumbling to himself quietly as he does most of the time. Staff observed resident #11 reach over and swing at resident #283's face. The first swing did not make contact, but resident #11 swung again immediately and resident #283 put his forearm in front of his face, so resident #11 made contact with resident #283's shoulder/upper arm. This incident was witnessed by facility staff who separated the residents just as resident #11 made contact with the second swing. An interview was conducted on (MONTH) 23, 2019 at 2:05 p.m., with a CNA (staff #3). She stated the residents were roommates and were seated in wheelchairs side by side at the nurses station. She said that resident #283 was talking to himself like he usually does and resident #11 thought he was talking about him. Staff #3 said that resident #11 is not very verbal and gave resident #283 an agitated look and then tried hitting him. She said when resident #11 missed, he swung again and this time he was able to punch resident #283 on his left arm. She stated that he did not hit him hard. Staff #3 stated they were quick in separating both residents and no injuries were noted on either resident. Staff #3 also stated that resident #11 has exhibited some aggressive behaviors in the past, but can easily be redirected and will calm down in a few minutes if removed from the situation. An interview was conducted on (MONTH) 24, 2019 at 9:52 a.m., with a Registered Nurse (staff #44). She stated that both resident's were sitting at the nurses station when she heard one of the CNA's yell no and that's when she turned and saw the CNA's in between the two residents. She said there were no injuries and they made sure both residents were safe. She said they kept them separated and placed them in separate rooms and did frequent checks (every 15 minutes for an hour then frequently). Staff #44 stated they notified the Administrator and the Director of Nursing. An interview was conducted on (MONTH) 25, 2019 at 9:38 a.m., with the Administrator (staff #40). He stated that abuse is covered in orientation and in staff meetings and is discussed on a weekly basis. He stated when there is a resident to resident altercation, employees should make sure the resident is safe and separate them from the situation. During an interview conducted on (MONTH) 25, 2019 with the Director of Nursing (staff #53), she said when there is a resident to resident altercation, staff should notify the nurse or charge nurse. She stated that staff are aware that they are mandated reporters of any kind of abuse. Review of the facility's Abuse policy revealed the facility will strive to prevent the abuse of all residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. We care for residents with a [DIAGNOSES REDACTED]. The policy included that by definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Potential abusers can be residents, employees or family members. The policy also included that If abuse is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.",2020-09-01
63,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,607,D,0,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to identify an incident of neglect involving a staff member and a resident (#8), and by failing to report the incident of neglect to the State Agency and Adult Protective Services (APS). The resident census was 41. Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. The resident was placed on Alert Charting, the care plan was updated and a Fall Risk Assessment was completed. The physician and responsible party were notified. A physician hospital progress note dated 11/16/2018 included the resident was admitted due to being transferred from the wheelchair to standing, and while standing fell out of their grasp. Patient reports the staff person lost their balance while standing, and fell on to the patient. The hospital course included the resident had a humeral head fracture status [REDACTED]. Further review of the investigative documentation revealed the facility had not identified this incident as neglect, therefore, did not notify the State Agency and APS. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated the types of abuse staff are trained on include physical, emotional, mental, sexual, financial, verbal and neglect. Regarding allegations of abuse/neglect, he stated they initiate an investigation and the leadership team will make a determination on whether or not it is abuse. Staff #40 stated neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not provided. He stated the CNA (staff #67) was terminated, because he did not follow the resident's care plan and our policy regarding transfers. Staff #40 also stated that staff members have been educated that they have to call the State Agency, along with other agencies within 2 hours of becoming aware of the incident. An interview was conducted on 1/25/19 at 9:38 a.m. with staff #29, who stated that based on the definition of neglect as discussed (above), she would now consider what occurred as neglect. An interview was conducted on 1/25/19 with the Director of Nursing (DON/staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed (above) she would now consider what occurred as neglect. An interview was conducted on 1/25/19 at 11:45 a.m., with the CNA (staff #67) who transferred the resident. He stated the facility policy was to use a gait belt for all transfers. He said that he used a gait belt for all transfers, except for one incident when resident #8 fell . Staff #67 stated he had taken the gait belt out of his pocket to use the restroom and didn't put it back and forgot about it. Staff #67 stated that Prior to that day we always used two people to transfer her, but that day I didn't call for help because I was just trying to get her laid down before the end of my shift and I had things to do. Review of the facility's Abuse policy revealed the facility will strive to prevent the abuse of all residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. We care for residents with a [DIAGNOSES REDACTED]. The policy included that by definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Potential abusers can be residents, employees or family members. The policy included that if abuse is witnessed or suspected, reporting and an investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: a. Adult Protective Services b. Ombudsman 3. State Survey Agency d. Law Enforcement when applicable e. Facility Director of Nursing (DON) 3. DON will notify the following: a. Physician b. Responsible Party c. Corporate Clinical Team 4. ED will begin investigation immediately and complete within 5 days using the Abuse Investigation Packet. Suspected abuse will be reported in accordance with timeframes and standards required by the State Agency. If an employee is suspected of being the abuser, they will be suspended until the investigation is complete. If the investigation finds that abuse is substantiated and the abuser is an employee, they will be immediately terminated and licensure reporting as applicable will be done. The policy further included that If abuse is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.",2020-09-01
64,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,608,D,0,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and policy and procedures, the facility failed to report a suspicion of a crime (neglect) to law enforcement involving a staff member and a resident (#8). Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. Further review of the investigative documentation revealed the facility had not identified this incident as neglect and therefore, did not notify law enforcement. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated that staff are trained on physical, emotional, mental, sexual, financial and verbal abuse and neglect. Staff #40 stated the leadership team will make a determination on whether or not an incident is abuse/neglect. Staff #40 stated neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not being provided. Staff #40 stated that the CNA (staff #67) was terminated, because of not following the resident's care plan and our policy for transfers. He further stated that staff members have been educated that the facility has to call the State Agency, along with other agencies, including law enforcement when appropriate, within the required time frames. An interview was conducted on 1/25/19 at 9:38 a.m. with staff #29, who stated that based on the definition of neglect as discussed (above), she would now consider what occurred as neglect. An interview was conducted on 1/25/19 with the DON (staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed, she would now consider what occurred as neglect. An interview was conducted on 1/25/19 at 11:45 a.m., with the CNA (staff #67) who transferred the resident. He stated the facility policy was to use a gait belt for all transfers. He said that he used a gait belt for all transfers, except for one incident when resident #8 fell . Staff #67 stated he had taken the gait belt out of his pocket to use the restroom and didn't put it back and forgot about it. Staff #67 stated that Prior to that day we always used two people to transfer her, but that day I didn't call for help because I was just trying to get her laid down before the end of my shift and I had things to do. Review of the facility's Abuse policy revealed that the facility will strive to prevent the abuse of all residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. The policy included that by definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Potential abusers can be residents, employees or family members. The policy included that if abuse is witnessed or suspected, reporting and an investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: a. Adult Protective Services b. Ombudsman 3. State Survey Agency d. Law Enforcement when applicable e. Facility Director of Nursing (DON) 3. DON will notify the following: a. Physician b. Responsible Party c. Corporate Clinical Team 4. ED will begin investigation immediately and complete within 5 days using the Abuse Investigation Packet. Suspected abuse will be reported in accordance with timeframes and standards required by the State Agency. If an employee is suspected of being the abuser, they will be suspended until the investigation is complete. If the investigation finds that abuse is substantiated and the abuser is an employee, they will be immediately terminated and licensure reporting as applicable will be done. The policy further included that If abuse is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.",2020-09-01
65,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,609,D,0,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, facility documentation and policy and procedures, the facility failed to report an incident of neglect involving one resident (#8) to the State Agency and to Adult Protective Services (APS). The resident census was 41. Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. The physician and responsible party were notified. However, the State Agency and APS were not notified of the incident of neglect within two hours. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated that neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not provided. He stated that staff members have been educated that they have to call the State Agency, along with other agencies within two hours of becoming aware of the incident. An interview was conducted on 1/25/19 with the Director of Nursing (DON/staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed, she would now consider what occurred as neglect. Review of the facility's Abuse policy revealed that if abuse is witnessed or suspected, reporting and an investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: a. Adult Protective Services b. Ombudsman 3. State Survey Agency d. Law Enforcement when applicable e. Facility Director of Nursing (DON) 3. DON will notify the following: a. Physician b. Responsible Party c. Corporate Clinical Team 4. ED will begin investigation immediately and complete within 5 days using the Abuse Investigation Packet. Suspected abuse will be reported in accordance with timeframes and standards required by the State Agency.",2020-09-01
66,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2019-01-25,689,E,0,1,NNTV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, facility documents and policy and procedure, the facility failed to ensure safe water temperatures were maintained in eight resident rooms. The facility census was 41. Findings include: During an observation conducted on 1/22/19 at 2:35 p.m., the water temperature of the restroom sink in room [ROOM NUMBER]-1 was checked and was 135 degrees Fahrenheit (F). This resident was able to use the restroom sink. During an observation conducted on 1/22/19 at 2:58 p.m., the water temperature in room [ROOM NUMBER]-1 was 130 degrees F. This resident was able to use the restroom. At this time, a family member stated sometimes the water feels a little hot and we are just careful. Additional water temperatures were taken on 1/22/19 at 3:43 p.m. and the following was found: -room [ROOM NUMBER]: water temperature was 126.6 degrees F -room [ROOM NUMBER]: water temperature was 126.2 degrees F -room [ROOM NUMBER]: water temperature was 130 degrees F -room [ROOM NUMBER]: water temperature was 135 degrees F -room [ROOM NUMBER]: water temperature was 134 degrees F -room [ROOM NUMBER]: water temperature was 131.5 degrees F On 1/22/19 at 4:15 p.m., the Environmental Services manager (staff #5) tested the water temperatures and the following was observed: -room [ROOM NUMBER]: water temperature was 122 degrees F -room [ROOM NUMBER]: water temperature was 132 degrees F -room [ROOM NUMBER]: water temperature was 136 degrees F -room [ROOM NUMBER]: water temperature was 118 degrees F -room [ROOM NUMBER]: water temperature was 140 degrees F -room [ROOM NUMBER]: water temperature was 124 degrees F During this observation, an interview was conducted with staff #5, who stated that water temperatures are checked weekly and documented and there have not been any problems. He stated the water should be run for 3-5 minutes before checking the temperatures. The facility immediately turned down the water temperatures at least twice and monitored the water temperatures every hour throughout the night. Facility water temperature logs were reviewed with the following results: -January (YEAR): all temperatures were either 101, 102 or 103 degrees F. -February (YEAR) through (MONTH) (YEAR): all temperatures were either 101, 102 or 103 degrees F. -August (YEAR): all temperatures were either 103 or 104 degrees F. -September (YEAR) through (MONTH) (YEAR): all temperatures were either 101, 102 or 103 degrees F. Review of the facility temperature log for (MONTH) 2019 revealed the water temperatures were checked on 1/21/19 and all temperatures in every room were either 101, 102 or 103 degrees F. In an interview conducted on 1/23/19 at 8:00 a.m. with the Executive Director (staff #40), he stated that he did not know why the water temperatures were so consistent on previous temperature checks. He said the facility has monitored the water temperatures throughout the night and have made adjustments to the temperature settings to get them back in the required ranges. He stated that he takes this very seriously and understands residents could be easily burned with high water temperatures. Staff #40 further stated he has made sure the team checking the temperatures are using good thermometers (new ones were purchased) and are following the correct procedures to check the temperatures accurately. Follow-up water temperatures were conducted on 1/23/19 at 11:20 a.m. with the following results: -room [ROOM NUMBER]: water temperature was 113 degrees F -room [ROOM NUMBER]: water temperature was 109.2 degrees F -room [ROOM NUMBER]: water temperature was 110.2 degrees F -room [ROOM NUMBER]: water temperature 103.2 degrees F -room [ROOM NUMBER]: water temperature 104.2 degrees F -room [ROOM NUMBER]: water temperature 96.5 degrees F -Shower 1: water temperature 98 degrees F Follow up water temperatures were taken on 1/25/19 at 8:05 a.m. and revealed the following: -room [ROOM NUMBER]: water temperature was 110.9 degrees F -room [ROOM NUMBER]: water temperature was 105.9 degrees F -room [ROOM NUMBER]: water temperature was 104.9 degrees F -room [ROOM NUMBER]: water temperature was 106.6 degrees F -Shower 2: water temperature was 104.3 degrees F Review of the facility policy titled Accidents and Supervision - Water Temperatures (undated), revealed the purpose of recording water temperatures is to assure that the facility is remaining free from [MEDICAL CONDITION] scalds, and that issues are addressed in a prompt and consistent manner. The policy described the process which included: the dial thermometer should be calibrated on a regular basis; insert the step of the thermometer under the running water, while also holding your hand under the water to see how the water feels on skin and test water at various locations throughout the facility. The policy further included that patient water temperatures should be between 105 F and 115 F, and that State law should be followed with temperatures between 95 F to 120 F. Results of testing should be recorded, discrepancies noted, water setting adjusted as needed, and retest as necessary.",2020-09-01
67,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,241,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy review, the facility failed to promote care for residents in a manner that maintains each residents dignity, by having one resident (#151) who was in their bed and their brief and lower extremities were exposed and were visible to others in the hallway. Findings include: Resident #151 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated (MONTH) 15, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated that the resident had moderate cognitive impairment. A review of the admission nursing evaluation revealed the resident had bilateral weakness to the lower extremities. During an observation conducted on (MONTH) 19, (YEAR) at 6:30 a.m., resident #151 was observed inside the room sleeping. The resident was lying on his bed, with his lower legs and brief exposed. The privacy curtains were not pulled and the resident's door was wide open. The resident was visible from the hallway. Another observation was conducted on (MONTH) 19, (YEAR) at 7:35 a.m. The resident was in bed with his lower legs and brief exposed. The door was open and the resident was visible from the hallway. A later observation was conducted at 10:06 a.m. of the resident lying in bed asleep, with the door open. The resident was uncovered and his belly, lower legs and brief were exposed and he was visible from the hallway. This resident's room was directly across from the activity room. During this observation, there was an activity taking place in the activity room. Multiple staff, residents and visitors were observed passing by the resident's room. At 10:11 a.m., a certified nursing assistant (CNA/staff #7) entered the resident's room, but then quickly exited. The resident remained uncovered and his belly, lower legs and brief were still exposed. At 10:21 a.m., staff #7 looked inside the resident's room, but did not notice that the resident was still exposed. At 11:04 a.m., staff #7 entered the resident's room and placed a blanket over the resident covering his belly, legs and brief. In an interview with a CNA (staff #27) conducted on (MONTH) 20, (YEAR) at 2:49 p.m., she stated that she checks residents frequently and when she sees a resident with exposed body parts or brief, she will immediately enter the room and cover the resident. An interview with a licensed practical nurse (LPN/staff #60) was conducted on (MONTH) 21, (YEAR) at 11:04 a.m. She stated that when she sees a resident who is exposed, she will enter the room and cover the exposed area. In an interview with the Director of Nursing (DON/staff #6) conducted on (MONTH) 21, (YEAR) at 4:31 p.m., she stated that when a resident's body parts and undergarments are exposed, she expects staff to cover the resident immediately. A facility policy on Quality of Life-Dignity included that Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. It also included that staff shall promote, maintain, and protect resident privacy, including bodily privacy.",2020-09-01
68,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,250,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documents and policy review, the facility failed to provide medically-related social services to maintain the highest practicable physical, mental, and psychosocial well-being of one resident (#144). Findings include: Resident #144 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. Physician admission orders [REDACTED]. A care plan initiated on (MONTH) 1, (YEAR) included for the use of antianxiety medications related to an anxiety disorder. Interventions included to administer anxiety medications as ordered and to monitor and document side effects and effectiveness. A social service intervention included to educate the resident/family regarding the risks/benefits and side effects and/or toxic symptoms of antianxiety medication. Another care plan included the resident exhibited behavior problems related to hitting staff, throwing food, and poor safety awareness. Interventions included to administer medication as ordered after non pharmacological interventions are tried and ineffective, monitor side effects, approach resident calmly and provide activities. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) revealed the resident had a Basic Interview for Mental Status score of 13, which indicated the resident was cognitively intact. The mood section indicated the resident had not exhibited any symptoms of depression since arrival. Review of the behavior section revealed the resident had not exhibited any behaviors since admission. Nursing progress notes for (MONTH) 6 and 7, (YEAR) documented the resident complained of increased anxiety and requested the Alprazolam. Review of the Daily Skilled Notes from (MONTH) 8, 9 and 10, (YEAR) included the resident was experiencing confusion and anxiety, and received Alprazolam as ordered. A MAR note dated (MONTH) 10, (YEAR) documented the resident was trying to stand and remove her clothing and was yelling. The resident was medicated with Alprazolam for behaviors. A MAR note dated (MONTH) 11, (YEAR) at 1:08 a.m. included the resident stated that she was trying to leave and find her husband and was nervous, and was medicated with Alprazolam. Review of a fall report dated (MONTH) 11, (YEAR) at 7:34 a.m., the resident had been yelling and trying to get out of her chair. The report indicated the resident got away from the Licensed Practical Nurse, took off the tab alarm and jumped out of her chair onto the floor. The report also included the resident commented about not wanting to live anymore. A physician's orders [REDACTED]. Review of the MAR and a MAR note revealed the resident received the increased one time dose of Alprazolam. Further review of the MAR note dated (MONTH) 11, (YEAR) at 8:59 a.m. revealed the one time dose of Alprazolam was not effective. No additional interventions were documented. Review of the Alert Charting note dated (MONTH) 12, (YEAR) at 1:57 a.m. revealed the resident continuously attempted to get up unassisted during waking hours, was occasionally combative, and self propelled herself in her wheelchair into the medication cart, treatment cart, snack cart and attempted to open them. The note also indicated the resident self propelled herself into other resident's rooms and the resident remained intermittently argumentative. Despite the resident's behaviors, there was no clinical record documentation from social services regarding any services that were provided or interventions which were implemented to address the social service needs of the resident. A physician's orders [REDACTED]. A care plan was developed on (MONTH) 12, (YEAR) for feelings of loss of control and not wanting to live anymore. Interventions included to administer psychotropic medications as ordered, monitor for ineffective coping ability (e.g. verbalization of inability to cope, decreased problem solving, increased confusion, social withdrawal, insomnia, destructive behaviors toward self or others), psychiatrist to evaluate, and social service to visit and offer support as needed. Review of the MAR notes for (MONTH) 13 and 14 revealed the administered doses of Alprazolam were not effective. Review of physician progress notes [REDACTED]. Further review of the physician's orders [REDACTED]. Additional orders included to monitor the resident for target symptoms/behaviors every shift, which included yelling out and to monitor for side effects associated with the use of antianxiety medication. According to the Medication Administration Record (MAR), the resident received the Alprazolam for increased anxiety from one to four times each day between (MONTH) 1, and (MONTH) 20, (YEAR), with the exception of (MONTH) 12, when she did not receive any Alprazolam. Further review of the clinical record revealed that as of (MONTH) 20, (YEAR), the resident had not yet been evaluated by a psychiatrist as ordered on (MONTH) 12, (YEAR). In addition, there were still no social services notes addressing the resident's needs. In an interview conducted with the Director of Nursing (DON/staff #6) on (MONTH) 20, (YEAR), the DON stated that depending on what type of consult and the circumstances, the Social Worker will contact the physician to come out and see the resident. She further stated that the delay in getting this consult is not within the expected time frame and the consult should have been completed sooner. In an interview conducted with the Social Worker (staff #21) on (MONTH) 20, (YEAR) at 2:25 p.m., staff #21 stated that he called and requested for the psychiatrist to see the resident, but he won't see her until tomorrow. He stated that he did not know about her comment (of not wanting to live) and did not see any immediacy in getting the consult any faster. He stated that usually our psychiatrist comes once each month to see residents and if a consult is ordered, then it is requested. He stated he initially emailed the doctor and then talked with him by phone and they did not see any reason for him to see her any faster. He stated he does not have any social services notes regarding this resident. Shortly after the above interview the clinical record was reviewed. A social services progress note dated (MONTH) 20, (YEAR) at 2:51 p.m. now included that the social worker met with the resident regarding her previous statements of not wanting to live anymore and the resident indicated that she felt trapped in her body, due to Parkinson's disease. The note included the resident had been seeing a psychiatrist in the community prior to admission to the facility, and agreed to social services involvement. The note also included that the resident did not currently have any suicidal ideations. Review of a physician progress notes [REDACTED]. The resident states that the worst her suicidality becomes is when she has random thoughts to wheel herself in her wheelchair into traffic, but states she would never do that. Per the note, the resident also described feeling down, due to being away from home, family and her dogs, and due to having insomnia, Parkinson's disease, chronic pain and anxiety. The physician initiated treatment included for Remeron at bedtime for sleep, depression and anxiety. Review of a policy titled, Social Services revealed that the facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The policy identified factors that have a potentially negative affect on the resident's dignity and sense of control that included disability or loss of function, the presence of a progressive, chronic, or disabling condition and behavioral problems (anxiety, confusion, depressed mood, anger, fear, wandering, psychotic episodes). The responsibilities of the social services department included obtaining pertinent social data, identifying social and emotional needs, assisting in providing corrective actions by developing and maintaining care plans, maintaining regular progress and follow-up notes, maintaining appropriate documentation of referrals and providing social services data summaries and making supportive visits to the resident.",2020-09-01
69,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,278,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure one resident's (#136) Minimum Data Set (MDS) assessment was accurate. Findings include: Resident #136 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A pressure ulcer assessment dated (MONTH) 26, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. The pressure ulcer care plan dated (MONTH) 27, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. Review of the physician wound care note dated (MONTH) 28, (YEAR) also revealed that the resident had a stage III pressure ulcer located on the sacrum. However, review of the admission MDS assessment dated (MONTH) 1, (YEAR) revealed in Section I. that the resident was coded as having an active [DIAGNOSES REDACTED]. In an interview with the Director of Nursing (DON/staff #6) conducted on (MONTH) 22, (YEAR) at 9:00 a.m., she stated that Section I. of the MDS admission assessment was an error and the resident's pressure ulcer wound was a stage III. In an interview with the MDS Coordinator (staff #55) conducted on (MONTH) 22, (YEAR) at 9:31 a.m., he stated that he bases the MDS entries on therapy documentation, the certified nursing assistant (CNA) notes regarding activities of daily living, the daily assessments of the nurses and physician documentation. He stated that when there are discrepancies on the documentation regarding the stages and locations of pressure ulcers, he will verify it with the physician and the nurse, and will go with what the physician said and documents. He stated that he should have checked and clarified Section I. of the MDS to ensure that the stage of the pressure ulcer matched. Review of the RAI manual for the MDS revealed .the importance of accurately completing and submitting the MDS assessment cannot be over-emphasized. The MDS assessment is the basis for the development of an individualized care plan .",2020-09-01
70,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,281,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure an interim care plan was developed to address one resident's (#43) needs related to contact isolation. Findings include: Resident #43 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A review of the Infection Surveillance Report dated (MONTH) 1, (YEAR) revealed Pt (patient) arrived to facility with infection .Type of isolation precautions:[MEDICAL CONDITION]-Contact . A physician's orders [REDACTED]. A nurses note dated (MONTH) 2, (YEAR) revealed Resident on isolation precautions related to DX (diagnosis):[MEDICAL CONDITION] of abdominal wound. Resident continues with PO (by mouth) antibiotics this shift without noted signs/symptoms of adverse or side effect. The admission Minimum Data Set assessment dated (MONTH) 8, (YEAR) also identified that the resident was on isolation. However, review of the clinical record revealed there was no interim care plan that was developed to address the residents needs related to contact isolation. During an interview conducted at 9:05 a.m. on (MONTH) 22, (YEAR), a LPN (Licensed Practical Nurse/staff #2) stated the admitting nurse was responsible for the development of the interim care plan. She stated that she would expect the need for contact isolation to be included in the interim care plan, when the resident has a [DIAGNOSES REDACTED]. During an interview conducted at 9:17 a.m. on (MONTH) 22, (YEAR), the DON (Director of Nursing/staff #6) also stated the nurse admitting the resident was responsible for developing the interim care plan. A review of the Care Plans - Preliminary policy and procedure revealed, A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. The policy also stated To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission.",2020-09-01
71,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,314,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#136) pressure ulcer was accurately identified and documented. Findings include: Resident #136 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. According to a hospital physician progress notes [REDACTED]. Review of the admission nursing evaluation dated (MONTH) 25, (YEAR) revealed the resident had a wound on the sacrum. However, there was no clinical record documentation of any description of the wound or any measurements. Review of the admission orders [REDACTED]. There were orders to apply EPC (Endothelial Progenitor Cell) to gluteal cleft/coccyx three times a day for skin impairment, however, there was no documentation that this order was clarified with the physician, in order to determine if this treatment was for the sacral pressure ulcer. An initial care plan dated (MONTH) 25, (YEAR) included that the resident had skin breakdown to the sacrum. Interventions included for weekly skin checks and to notify the charge nurse of skin issues. Review of the pressure ulcer assessment documentation dated (MONTH) 26, (YEAR), revealed the resident had a stage III pressure ulcer to the sacrum, which measured 2.1 cm x 2.0 cm x 0.2 cm. Per the documentation, the treatment included for the use of [MEDICATION NAME]. However, there were no wound treatment orders for the use of [MEDICATION NAME]. A physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR (Treatment Administration Record) revealed the above order to the coccyx. However, there was no clinical record documentation that this order was clarified with the physician, in order to determine if the treatment order was for the sacral pressure ulcer or if it was a new wound to the coccyx which had developed. A pressure ulcer care plan dated (MONTH) 27, (YEAR) included the resident had a stage III pressure ulcer to the sacrum. Interventions included monitoring, documenting any changes in skin status and reporting to physician as needed. Review of the physician wound care notes dated (MONTH) 28, (YEAR) revealed the resident had an acute unhealed stage III pressure ulcer located on the sacrum, which measured 2.1 cm in length x 2 cm in width x 0.2 cm in depth. The plan included to cleanse the wound with NS or water, apply alginate with [MEDICATION NAME] and an island dressing, and to change the dressing every day and as needed. However, a physician's orders [REDACTED]. Further review of the (MONTH) (YEAR) TAR revealed this order was included for the coccyx. According to the weekly pressure ulcer report dated (MONTH) 29, (YEAR), the resident had a stage III pressure ulcer to the coccyx, which measured 2.1 cm x 2.0 cm x 0.2 cm. The documentation did not indicate whether this was a new pressure ulcer to the coccyx, or if it was the same wound to the sacrum which was present upon admission. Review of the Minimum Data Set (MDS) admission assessment dated (MONTH) 1, (YEAR), revealed in Section I. that the resident had a stage II pressure ulcer to the sacral area. However, in Section M. under skin conditions, the resident was assessed to have one unhealed stage III pressure ulcer that was present upon admission. The weekly pressure ulcer report dated (MONTH) 5, (YEAR) included the resident had a stage III pressure ulcer to the coccyx, which measured 2.0 cm x 2.0 cm x 0.2 cm. In an interview with a licensed practical nurse (LPN/staff #60) conducted on (MONTH) 21, (YEAR) at 11:04 a.m., she stated that wound care, treatment, measurement and documentation are done by a wound care nurse. She further stated that the floor nurses only apply barrier creams and ointments to wounds. An interview with another LPN (staff #24) was conducted on (MONTH) 21, (YEAR) at 4:48 p.m. The Director of Nursing (DON/staff #6) was also present during the interview. Staff #24 stated that she was the treatment nurse during the time when the resident was admitted and that the resident only had a stage III pressure ulcer to the coccyx. She stated that the resident did not have any pressure ulcer on the sacrum. In another interview with staff #24 on (MONTH) 22, (YEAR) at 9:00 a.m., she stated that when conducting a treatment, she documents what she sees. She said when the site of the wound is different from the physician's documentation, she will clarify it with the physician. Staff #6 was also present during the interview stated that she could not tell if the resident had two pressure ulcers, one on the sacrum and one on the coccyx, or if the physician and/or nurse just made a mistake in identifying the location of the wound. An interview with the wound care physician (staff #79) was conducted on (MONTH) 22, (YEAR) at 9:46 a.m. She stated that the resident only had one pressure ulcer and it's location and stage is whatever her documentation indicated. The policy regarding Wound Management included a comprehensive wound management program with a goal to promote the highest level of functioning and well-being of residents and to minimize the number of residents that develop in house acquired pressure ulcers. All residents with wounds receive treatment and services consistent with the resident's goals of treatment. The policy included that pressure ulcers are to be assessed weekly and that nursing staff shall describe and document a full assessment of the pressure sore, including the location, stage, length, width, depth and the presence of exudate or necrotic tissue.",2020-09-01
72,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2016-09-22,514,D,0,1,BZVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to maintain clinical records that were accurately documented, by failing to ensure a physician's orders [REDACTED].#5). Findings include: Resident #5 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Discharge orders from the hospital dated (MONTH) 9, (YEAR) included an order for [REDACTED]. However, review of the current physician's orders [REDACTED].>Review of the MAR (medication administration record) for (MONTH) and (MONTH) (YEAR) also revealed the order for [MEDICATION NAME] 27.5 mcg. In an interview with a Licensed Practical Nurse (LPN/staff #35) on (MONTH) 21, (YEAR) at 12:55 p.m., she reviewed the orders and acknowledged that the order for [MEDICATION NAME] 27.5 mcg was incorrect. In an interview on (MONTH) 21, (YEAR) at 1:00 p.m., the Clinical Operations Director (staff #76) reviewed the resident's chart regarding the original admission orders [REDACTED]. She stated somehow the order must have been entered incorrectly into the electronic clinical record. In an interview with the corporate resource nurse (staff #77) on (MONTH) 22, (YEAR) at 8:12 a.m., she stated that the night nurse is responsible for checking the electronic chart to ensure new orders are put in correctly. In addition, she stated that either herself and/or the Director of Nursing, review new orders in an audit report to ensure orders are transcribed correctly.",2020-09-01
73,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2017-10-25,156,D,1,1,DB1811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, and policy review, the facility failed to provide two residents (#s 13 and 18) with Notifications of Medicare Non-Coverage (NOMNC), prior to discharge. Findings include: -Resident #18 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of the Admission Record dated (MONTH) 21, (YEAR) revealed the resident's primary payer source was Medicare [NAME] Review of an undated and unsigned Case Management Activity note revealed DC (discharge) to group Home .will get house cleaned on 6/8 and wants to be home on that day to make sure all goes well. Review of the Physical Therapy Discharge Summary dated (MONTH) 7, (YEAR) revealed the resident's discharge destination was a group home, and the reason for discharge was Highest Practical Level Achieved. A review of the Occupational Therapy Discharge Summary dated (MONTH) 7, (YEAR) revealed the resident's discharge destination was a group home, and the reason for discharge was Highest Practical Level Achieved. Review of the clinical record revealed no documented evidence that a Notice of Medicare Non-Coverage was provided to the resident, prior to being discharged to the community on (MONTH) 8, (YEAR). -Resident #13 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A review of the Admission Record dated (MONTH) 15, (YEAR) revealed the resident's primary payer source was Medicare [NAME] Review of an unsigned and undated Case Management/Interdisciplinary Discharge Plan-Tier Two Active Inpatient Plan revealed Resident wants to return home on date/week of 6/5 for family reunion. Review of the Physical Therapy Discharge Summary dated (MONTH) 6, (YEAR) revealed the resident's discharge destination was Home, and the reason for discharge was Highest Practical Level Achieved. A review of the Occupational Therapy Discharge Summary dated (MONTH) 6, (YEAR) revealed the resident's discharge destination was Home, and the reason for discharge was Highest Practical Level Achieved. Review of the clinical record revealed no documented evidence that a Notice of Medicare Non-Coverage was provided to the resident, prior to being discharged to the community on (MONTH) 7, (YEAR). During an interview conducted at 12:35 p.m. on (MONTH) 25, (YEAR), the Administrator stated he was responsible for providing the Notice of Medicare Non-Coverage letters to the residents, prior to discharge. He stated that he had not provided these residents with the NOMNC letters, because the residents had told him they wished to go home and indicated the dates they wished to leave. During the survey, the facility provided undated Business Office Manager Auditor notes which included the following: .also discussed with .administrator, the importance of ensuring NOMNCs are done for all residents even if the resident chooses to leave on their own . Review of the facility's policy regarding Medicare Denial Notices revealed under the section Notice of Medicare Non Coverage that for residents currently under the Medicare A benefit in the facility, when the facility determined that Medicare A is no longer the appropriate payer for the resident or the resident is planning on discharging from the facility, the CMS NOMNC (Notice of Medicare Non Coverage) is to be issued to the resident and/or the appropriate Responsible Party two days before the resident is to come off Medicare A or be discharged . Once signed and dated appropriately, this is to be uploaded into the EHR (electronic health record).",2020-09-01
74,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2017-10-25,281,D,1,1,DB1811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that medications were administered as physician ordered for two residents (#143 and #145). Findings include: -Resident #143 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. -[MEDICATION NAME] 325 mg (milligrams) by mouth every six hours PRN (as needed) for a pain level of 1-2. -[MEDICATION NAME] 325 mg two tablets by mouth every six hours PRN for a pain level of 3-4. -[MEDICATION NAME] (non steroidal anti [MEDICAL CONDITION]) 500 mg by mouth every 12 hours PRN for pain level of 5-6. -[MEDICATION NAME] (narcotic) 5-325 mg two tablets by mouth every four hours PRN for a pain level of 7-10. However, a review of the (MONTH) (YEAR) MAR (Medication Administration Record) revealed the resident had been administered [MEDICATION NAME] twice for a pain level of seven on (MONTH) 19, and once on (MONTH) 20 for a pain level of 7. Per the physician's orders [REDACTED]. An interview was conducted on (MONTH) 24, (YEAR) at 1:45 p.m., with the ADON (Assistant Director of Nursing/staff #55). Following a review of the physician's orders [REDACTED].#55 stated that the [MEDICATION NAME] was administered for a pain level of seven, which was not as ordered. He stated the physician's orders [REDACTED]. -Resident #145 was admitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. -Tylenol 325 mg two tablets by mouth every four hours PRN for a pain level of 1-5. -[MEDICATION NAME] (narcotic) 15 mg by mouth every four hours PRN for a pain level of 6-10. A review of the (MONTH) (YEAR) MAR indicated [REDACTED]. There was no clinical record documentation that the physician was notified or additional orders were obtained. An interview was conducted on (MONTH) 24, (YEAR) at 10:20 a.m., with a LPN (Licensed Practical Nurse/staff #2). Following a review of the physician's orders [REDACTED].#2 stated that Tylenol was administered outside of the physician's prescribed pain scale parameters. Staff #2 stated that the physician's orders [REDACTED]. An interview was conducted on (MONTH) 24, (YEAR) at 10:30 a.m., with the DON (Director of Nursing/staff #5). Following a review of the physician's orders [REDACTED]. Staff #5 stated that if a resident requests a medication which is outside of the pain parameters, the physician should be notified and new orders obtained and documented. A facility policy titled, Administering Pain Medications included the following: 6. Administer pain medications as ordered.",2020-09-01
75,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2017-10-25,322,D,0,1,DB1811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#83) with a feeding tube was provided the appropriate treatment and services. Findings include: Resident #83 was admitted on (MONTH) 1, (YEAR) and readmitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had a percutaneous endoscopic gastrostomy (PEG) tube. A care plan dated (MONTH) 5, (YEAR) included the resident had a feeding tube related to poor nutritional intake. A goal included the resident would be free of aspiration. Interventions were for the nurse to check tube placement per facility protocol, and flush the PEG tube with water. Review of a Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR) revealed the resident had severe cognitive impairment, was unable to speak, and had a feeding tube. A medication administration observation was conducted on (MONTH) 23, (YEAR) at 9:00 a.m., with a Registered Nurse (staff #4). During the observation, the nurse crushed nine medications together and mixed them with 60 cc of water in a cup. Without first checking placement of the PEG tube, the nurse then flushed the resident's PEG tube with 30 cc of water using a 60 cc syringe, by pushing the plunger on the syringe to administer the water, instead of using the gravity flow method. The nurse then drew up the medications which had been mixed with water into the syringe, and pushed the plunger on the syringe to administer the medications into the PEG tube, instead of using the gravity flow method. Next, the nurse flushed the PEG tube with 30 cc of water using a 60 cc syringe and pushed the plunger on the syringe to administer the water, instead of using the gravity flow method. Following the observation, an interview was conducted with staff #4, who stated that she had checked the placement of the tube by looking at a black line on the PEG tube. She stated that if the line is not visible, the PEG tube is not correctly placed and the tube cannot be used. Staff #4 stated that she did not need to use a stethoscope to check for correct placement of the tube, because the night shift nurse does that. Staff #4 also stated that the medications are usually pushed into the tube by depressing the plunger on the 60 cc syringe, and she was not sure if the gravity flow method was suppose to be use. She stated that she had mixed all of the medications together in the same cup, instead of giving them separately to prevent the resident from being disturbed. Staff #4 further stated that she was unsure what the facility policies were regarding medication administration through a PEG tube. An interview was conducted on (MONTH) 24, (YEAR) at 11:00 a.m., with the Director of Nursing (DON/staff #5). The DON stated that nurses are supposed to check the placement of the PEG tube, prior to flushing the tube. Staff #5 stated that this is done by injecting air into the tube, and at the same time, using a stethoscope to listen for air being injected into the stomach. The DON stated that the medications provided through a PEG tube are to be given separately and should not be mixed altogether. The DON further stated the nurses are supposed to remove the plunger from the 60 cc syringe, add the crushed medications which have been mixed with water, and allow the medications to flow by gravity into the PEG tube. The DON stated the nurses are not to administer the medications by depressing the plunger on the syringe. A facility policy for administering medications through an enteral (PEG) tube contained the following guidelines: The nurse is not to mix medications together prior to administering medications through an enteral tube, the nurse is to administer each medication separately; the nurse is to confirm placement of the feeding tube prior to flushing the tube; and that medications are to be administered by gravity flow.",2020-09-01
76,HAVEN OF SCOTTSDALE,35059,3293 NORTH DRINKWATER BOULEVARD,SCOTTSDALE,AZ,85251,2017-10-25,371,E,1,1,DB1811,"> Based on observation, staff interview, review of the temperature logs and facility documentation, the facility failed to ensure one nourishment refrigerator temperatures were maintained at or below 41 degrees F. Findings include: During an observation conducted at 12:10 p.m. on (MONTH) 24, (YEAR), the nourishment refrigerator was observed to contain food and snacks for the residents. Review of the Refrigerator Temperature Log Audit for (MONTH) (YEAR) revealed the temperatures were to be checked daily. The log included that the temperature range should be between 35-46 degrees F, instead of at or below 41 degrees F, as required. Per the documentation, there were 12 of 24 days with documented temperatures between 42 to 46 degrees F. During an interview conducted at 1:00 p.m. on (MONTH) 24, (YEAR), the Dietary Manager (staff #35) stated the temperature range for the nourishment refrigerator should be between 35 and 41 degrees F. She stated this log was incorrect and was not the dietary refrigerator log which should be used. She stated she was not aware that the temperatures were often above 41 degrees F. Staff #35 stated that when the temperatures were not within the appropriate range, the food should have been discarded. She also said that snacks for residents are stored in the snack/nourishment refrigerator. Review of a facility's guideline regarding Resident Food Stored in Nourishment Refrigerators revealed that all nourishment refrigerators have a working thermometer and that the temperatures are to be maintained between 36-41 degrees F.",2020-09-01
77,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2020-01-08,609,D,1,0,DWKV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of policies and procedures, and review of the State Agency data base, the facility failed to ensure that alleged violations involving abuse or mistreatment for [REDACTED].#1, 2, 3, 4) were reported to APS (Adult Protective Services) and failed to ensure that the results of investigation of alleged violations involving abuse or mistreatment for [REDACTED].#1, 3, 4, 5) were reported to the State Agency. The deficient practice could result in additional allegations of abuse or mistreatment not being reported to APS, and additional results of investigations of abuse or mistreatment not being reported to the State Agency. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. A Health Status Note dated (MONTH) 16, 2019 at 1:00 a.m. included that during a smoke break, a peer (resident #5) had grabbed the cigarette supply and that resident #1 had observed resident #5 grab the cigarettes. The note included that resident #1 tried to take the cigarettes from resident #5, and resident #5 then grabbed the sweater of resident #1, who slid to the floor. The note included that there were no injuries. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. The note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #5 was admitted on (MONTH) 31, 2019 with [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 9, 2019 included that resident #5 had a BIMS score of 7 which indicated that resident #5 had severe cognitive impairment. The assessment included that resident #5 had verbal and physical behavioral symptoms directed towards others, no functional limitations in range of motion and used a wheelchair. An Incident Note dated (MONTH) 15, 2019 at 11:34 p.m. included that during a smoke break, resident #5 had grabbed all of the cigarettes, which caused an argument with a peer. The note included that resident #5 grabbed the peer by her sweater, which caused the peer to slide to the floor, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that on (MONTH) 15, 2019 at 7:10 p.m. as residents were headed to a smoke break, and when resident #1 noticed that resident #5 had the box of (resident) cigarettes, resident #1 became angry and confronted resident #5, and resident #5 grabbed the sweater of resident #1. The report included that when resident #5 grabbed the sweater of resident #1, this caused resident #1 to fall to the ground. The report included that the AZDHS (Arizona Department of Health Services), Phoenix Police, local Ombudsman and responsible parties were notified of the incident. Review of the facility investigation did not reveal a fax receipt, and review of the State Agency data base did not reveal any documented evidence that the facility sent a summary report of the incident on (MONTH) 15, 2019 to AZDHS. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. The note included that resident #2 said that the other resident hit her on the cheek and pulled her hair, and that the other resident was trying to take her pet birds away from her when she grabbed the other resident by the arm. The note included that there were no injuries. An investigative report dated (MONTH) 24, 2019 included that on (MONTH) 21, 2019 at 3:00 p.m. resident #1 entered resident #2's room and was observing pet birds that resident #2 keeps on her dresser, and resident #1 attempted to remove the birds in their cage from the room. The report included that resident #2 grabbed resident #1's arm, and resident #1 retaliated by pulling resident #2's hair and slapping her across the face. Staff separated the resident's and there were no injuries. The report included that the AZDHS (Arizona Department of Health Services), Phoenix Police, local Ombudsman and responsible parties were notified. However, there was no documentation that APS had been notified of the incident on (MONTH) 21, 2019. Review of the facility investigation revealed a form titled Desert Haven Care Center State Report File Folder. The form included multiple entries where staff recorded that the incident was reported on (MONTH) 21, 2019 to AZDHS, the Phoenix PD (Police Department), the resident's responsible party, and the State Ombudsman. However, the form did not include a space to record that APS had been notified of the incident. -Resident #4 was admitted on (MONTH) 8, 2019 with [DIAGNOSES REDACTED]. An Admission MDS assessment dated (MONTH) 20, 2019 included that resident #4 had a BIMS score of 3, which indicated that the resident had severely impaired cognition, difficulty focusing attention and physical behaviors directed at others. An Incident Note dated (MONTH) 7, 2019 at 10:36 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. -Resident #3 was admitted on (MONTH) 6, 2014 with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated (MONTH) 9, 2019 included that the resident had speech that was unclear or slurred, and that he usually understands others. The assessment included that the resident had a BIMS score of 9, which indicated that the resident had moderately impaired cognition, and verbal behavioral symptoms directed at others. An Incident Note dated (MONTH) 17, 2019 at 10:31 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that on (MONTH) 17, 2019 residents #4 and #3 were in the unit dining room, and began to have a verbal altercation, and that resident #4 reached over and hit resident #3 on the right arm. The report included that the residents were immediately separated and there were no injuries. Review of the facility investigation revealed a State Report File Folder form, which included that the incident was reported on (MONTH) 17, 2019 to AZDHS, the Phoenix PD (Police Department), the resident's responsible party, and the State Ombudsman. However, there was no documentation on the form that APS had been notified of the incident. Also, review of the facility investigation did not reveal a fax receipt, and review of the State Agency data base did not reveal any documented evidence that the facility sent a summary report of the incident to AZDHS. The following interviews were interviews conducted on (MONTH) 6, 2020 with the Director of Nursing/staff #120: -At 1:45 p.m. the Director stated that he tries to save fax receipts when he sends the 5 day summary report of the investigation to AZDHS. However, the fax machine had broken down and he was unable to print fax receipts. The Director also stated that the facility does report allegations of abuse to APS, and notifications to APS are sometimes done by the nurse on duty. However, the Director examined the Report File Folder forms, and stated that APS was not listed on the form to be notified of an allegation, which may have resulted in the nurse not notifying APS. -At 2:25 p.m. the Director stated that he had phoned APS to determine if APS had received reports of the incidents on (MONTH) 17, 2019 and (MONTH) 21, 2019, and stated that APS had never received notification of the incidents A policy and procedure titled Abuse Investigations included a statement that all allegations/signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management. The policy included that the Administrator of designee will review and if incidents meet the elements of reporting within 2 hours, will ensure appropriate Regulatory Agencies, Law enforcement, Medical Director and Representative are notified. The policy also included that the Administrator or designee will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the local police department, the Ombudsman and others as may be required by State or local laws, within 5 days of the incident.",2020-09-01
78,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2020-01-08,610,D,1,0,DWKV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures, the facility failed to ensure that an allegation of resident to resident abuse for two residents (#1, 2) was thoroughly investigated. The deficient practice could result in additional allegations of abuse not being thoroughly investigated by the facility. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. The note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. The note included that resident #2 stated that the other resident hit her on the cheek and pulled her hair, and that the other resident was trying to take her pet birds away from her when she grabbed the other resident by the arm. The note included that there were no injuries. An investigative report dated (MONTH) 24, 2019 included that on (MONTH) 21, 2019 at 3:00 p.m. two CNA's (Certified Nursing Assistants) witnessed an altercation, and that the staff stated that resident #1 entered resident #2's room (located on the Magnolia Unit) and was observing pet birds that resident #2 keeps on her dresser, and resident #1 attempted to remove the birds in their cage from the room. The report included that resident #2 grabbed resident #1's arm, and resident #1 retaliated by pulling resident #2's hair and slapping her across the face. The report included that the staff who were present immediately separated the resident's, the residents were assessed for injuries, and there were no injuries present. Review of the facility investigation, did not incude any direct witness statements, or reveal the names of the two CNA's who witnessed the altercation, or identify the staff who separated residents #1 and #2. The following interviews were conducted on (MONTH) 7, 2020 with the following staff who were assigned to the Magnolia Unit on (MONTH) 21, 2019 when the incident occurred: -At 10:00 a.m. a CNA/staff #86 stated that when the incident occurred she was not present on the unit at that time because she was on a break and that she believed that two other CNA's (staff #173, and #71) and a nurse (staff #21) remained on the unit while she was on break. -At 10:09 a.m. a CNA/staff #143 stated that she did not witness what actually happened because she was in another room with another CNA (staff #71) providing care to a resident. Staff #143 stated she heard a commotion and when she went out of the room saw resident #1 placing resident #2's pet birds in the hallway, the two resident's were arguing and she helped to separate them. Staff #143 stated that another CNA was supposed to be monitoring the hallway while she and staff #71 were in another room providing care, and she did not know the location of the nurse at the time of the incident. -At 10:22 a.m. a CNA/staff #71 stated she did not observe what happened because she was assisting staff #143 to provide care in another room when the incident occurred. Staff #71 stated that there should have been a nurse and at least one of possibly two CNA's on the unit when she was in another room providing care. -At 11:35 a.m. an LPN/staff #21 stated that when the incident occurred she was off the unit on a break and did not witness the incident. The following interviews were conducted on (MONTH) 7, 2020 with the Director of Nursing/staff #120: -At 9:00 a.m. the Director identified 3 CNA's who were assigned to work on the Magnolia Unit on (MONTH) 21, 2019 at the time of the incident, and stated that witness statements had not been obtained from the CNA's. -At 10:26 a.m. the Director identified a nurse who was assigned to work on the Magnolia Unit on (MONTH) 21, 2019 at the time of the incident, and stated that witness statements had not been obtained for this investigation. A policy and procedure titled Abuse Investigations included a statement that all allegations/signs of resident abuse, neglect and injuries of unknown source shall be thoroughly investigated by facility management, and that the Administrator or his/her designee will appoint a member of management to investigate the alleged incident. The policy included that the individual conducting the investigation will, as a minimum interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident and the witness reports will be obtained in writing.",2020-09-01
79,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2020-01-08,689,E,1,0,DWKV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures, the facility failed to ensure that multiple residents with aggressive behaviors (#1, 2, 4, 5) were provided adequate supervision to prevent the residents from behaving in a physically aggressive manner towards other residents. The deficient practice could result in multiple residents behaving aggressively towards other residents. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A written care plan initiated on (MONTH) 25, 2019 and updated on (MONTH) 8, 2019 included that resident #1 had a history of [REDACTED]. A Behavioral Plan dated (MONTH) 9, 2019 included that on admission the resident had a history of [REDACTED]. The behavioral plan included that currently, the resident makes false accusations of peers taking her belongings, and has a history of physical altercations with peers. The behavioral plan listed multiple interventions included to monitor resident #1 for her peer's safety, listen to her concerns and to remove peers for their safety. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. Review of the MAR (Medication Administration Record) for (MONTH) 2019 revealed that resident #1 had the following behaviors which were documented in sections of the record for daily behavioral monitoring: -Verbally abusive behaviors were recorded on (MONTH) 1, 3, 5, 9, 10, 12 and 15, 2019. -Angry outbursts were recorded on (MONTH) 3, 5, 9, 10, and 12, 2019. -Delusions were recorded on (MONTH) 1, 4, 6, 7, 8, 11, 14, and 15, 2019. -False accusations were recorded on (MONTH) 8, 10, and 15, 2019. A Health Status Note dated (MONTH) 16, 2019 at 1:00 a.m. included that during a smoke break, a peer (resident #5) had grabbed the cigarette supply and that resident #1 had observed resident #5 grab the cigarettes. The note included that resident #1 tried to take the cigarettes from resident #5, and resident #5 then grabbed the sweater of resident #1, who slid to the floor. The note included that there were no injuries. Review of the MAR for (MONTH) 2019 revealed that resident #1 had following behaviors which were documented in daily behavioral monitoring: -Verbally abusive behaviors were recorded on (MONTH) 5, 6, 8, 12, 14, 15, 17, 19, 20, and 21, 2019. -Angry outbursts were recorded on (MONTH) 8, 12, 14, 16, 17, 20, and 21, 2019. -Delusions were recorded on (MONTH) 1-5, 8, 9, 12, 14, 15, 16, and 18-21, 2019. -False accusations were recorded on (MONTH) 8, 9, and 19-21, 2019. -Combativeness was recorded on (MONTH) 17, 2019. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. This note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #5 was admitted on (MONTH) 31, 2019 with [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 9, 2019 included that resident #5 had a BIMS score of 7 which indicated that resident #5 had severe cognitive impairment. The assessment included that resident #5 had verbal and physical behavioral symptoms directed towards others, no functional limitations in range of motion and used a wheelchair. A psychiatric evaluation dated (MONTH) 10, 2019 included that resident #5 had displayed intermittent irritability, impulsivity, agitation, demanding behavior and verbal aggression. A plan of care for resident #5 for impaired cognitive function related to dementia, had multiple interventions listed including to cue, re-orient and supervise the resident as needed. A plan of care of care for a history and [DIAGNOSES REDACTED]. Review of the MAR for (MONTH) 2019 revealed that resident #5 had demanding and verbally abusive behaviors recorded in daily behavioral monitoring for (MONTH) 1-5, 7, 8. 11. and 13-15, 2019. An Incident Note dated (MONTH) 15, 2019 at 11:34 p.m. included that during a smoke break, resident #5 had grabbed all of the cigarettes, which caused an argument with a peer. The note included that resident #5 grabbed the peer by her sweater, which caused the peer to slide to the floor, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that (MONTH) 15, 2019 at 7:10 p.m. as residents were headed to a smoke break, and when resident #1 noticed that resident #5 had the box of (resident) cigarettes, resident #1 became angry and confronted resident #5, and resident #5 grabbed the sweater of resident #1, The report included that when resident #5 grabbed the sweater of resident #1, this caused resident #1 to fall to the ground. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A written plan of care for resident #2 included a plan for impaired cognitive function related to dementia, that had multiple interventions including to cue, reorient and supervise the resident as needed. A Behavior Note dated (MONTH) 4, 2019 at 10:16 a.m. included that resident #2 was worried that resident #1 was getting into her closet when she was out out of her room. A Health Status Note dated (MONTH) 8, 2019 at 5:18 p.m. included that resident #2 had complained that resident #1 had been in her room and was afraid that resident #1 would take her possessions. The note included that staff would monitor the resident for any changes and safety. A Behavioral Plan dated (MONTH) 9, 2019 included that resident #2 grabs at other residents, and that she appears to be targeting a specific peer, and takes the peers belongings. The plan included to monitor and redirect her away from a specific peer. A Behavior Note dated (MONTH) 15, 2019 at 9:02 a.m. included that resident #2 and #1 had an argument and were redirected away from each other to de-escalate the argument. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. The note included that resident #2 stated that the other resident hit her on the cheek and pulled her hair, and that the other resident was trying to take her pet birds away from her when she grabbed the other resident by the arm. The note included that there were no injuries. An investigative report dated (MONTH) 24, 2019 included that on (MONTH) 21, 2019 at 3:00 p.m. resident #1 entered resident #2's room and was observing pet birds that resident #2 keeps on her dresser, and resident #1 attempted to remove the birds in their cage from the room. The report included that resident #2 grabbed resident #1's arm, and resident #1 retaliated by pulling resident #2's hair and slapping her across the face. Staff separated the resident's and there were no injuries. During an interview with an LPN (Licensed Practical Nurse/staff #72) conducted on (MONTH) 6, 2020 at 2:45 p.m. the LPN stated that the staff circulate about the unit continuously to monitor resident's behavior and for safety. The LPN stated that the unit is usually staffed with 1-2 nurses and 3 CNA's (Certified Nursing Assistants). The following interviews were conducted on (MONTH) 7, 2020 with the following staff regarding the incident that occurred on (MONTH) 21, 2019: -At 10:00 a.m. a CNA/staff #86 stated that when the incident occurred she was not present on the unit at that time because she was on a break and that she believed that two other CNA's (staff #173, and #71) and a nurse (staff #21) remained on the unit while she was on break. -At 10:09 a.m. a CNA/staff #143 stated that she did not witness what actually happened because she was in another room with another CNA (staff #71) providing care to a resident. Staff #143 stated she heard a commotion and when she went out of the room saw resident #1 placing resident #2's pet birds in the hallway, the two resident's were arguing and she helped to separate them. Staff #143 stated that another CNA was supposed to be monitoring the hallway while she and staff #71 were in another room providing care, and she did not know the location of the nurse at the time of the incident. -At 10:22 a.m. a CNA/staff #71 stated she did not observe what happened because she was assisting staff #143 to provide care in another room when the incident occurred. Staff #71 stated that there should have been a nurse and at least one of possibly tow CNA's on the unit when she was in another room providing care. -At 11:35 a.m. an LPN/staff #21 stated that when the incident occurred she was off the unit on a break and did not witness the incident. The following interviews were conducted on (MONTH) 7, 2020 with the Director of Nursing/staff #120: -At 11:50 a.m. the Director stated that there should always be a staff present in the hallway on the unit and that the staff have scheduled break times to ensure there is staff coverage on the unit. The Director stated that there may have been a miscommunication which resulted in the nurse and a CNA being off the unit at the same when the incident occurred n (MONTH) 21, 2019. -At 1:30 p.m. the Director stated that one staff is assigned to assist the resident's with smoke breaks, and that one staff is sufficient to provide safety for the residents while they smoke. The Director stated that on (MONTH) 15, 2019 when the incident occurred between resident #1 and resident #5 during the smoke break, there was one staff present, however she was unable to reach the resident's quickly enough to prevent resident #5 from grabbing resident #1. -At 3:05 p.m. the Director stated that resident #5 was very compulsive about smoking from the time she was admitted and that interventions were not effective. The Director stated that resident #5 had grabbed a box of resident cigarettes, and resident #1 tried to take it from her to protect the cigarettes and that's when resident #5 pushed down resident #1. -Resident #4 was admitted on (MONTH) 8, 2019 with [DIAGNOSES REDACTED]. An Admission MDS assessment dated (MONTH) 20, 2019 included that resident #4 had a BIMS score of 3, which indicated that the resident had severely impaired cognition, difficulty focusing attention and physical behaviors directed at others. Review of the clinical record did not reveal that a written plan of care for physical behaviors directed at other residents had been initiated. An Incident Note dated (MONTH) 7, 2019 at 10:36 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. -Resident #3 was admitted on (MONTH) 6, 2014 with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated (MONTH) 9, 2019 included that the resident had speech that was unclear or slurred, and that he usually understands others. The assessment included that the resident had a BIMS score of 9, which indicated that the resident had moderately impaired cognition, and verbal behavioral symptoms directed at others. A written plan of care included that resident #3 has a [DIAGNOSES REDACTED]. The plan of care included a goal that the resident would refrain from verbally or physically abusive behavior and listed multiple interventions including to intervene by speaking calmly and professionally and in a soft tome of voice. The plan of care also included a that the resident had a communication problem related to weak voice and that he whispers, and listed multiple interventions including to allow the resident adequate time to respond. An Incident Note dated (MONTH) 17, 2019 at 10:31 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that on (MONTH) 17, 2019 residents #4 and #3 were in the unit dining room, and began to have a verbal altercation, and that resident #5 reached over and hit resident #3 on the right arm. The report included that the residents were immediately separated and there were no injuries. During an interview conducted on (MONTH) 8, 2020 at 10:00 a.m. with the Director of Nursing/staff #120, he stated that resident #4 had never behaved aggressively towards another resident before this incident. The Director stated that sometimes resident #3 says things under his breath that are insulting to other residents, and that may have been why resident #4 struck resident #3. The Director stated that there was a CNA in the dining room at the time of the incident. A policy and procedure titled Problematic Behavior Management-Clinical Guideline included a statement that as part of the initial assessment, the staff and physician will identify individuals with a history of impaired cognition, problematic behavior, or mental illness, and that nursing staff will document the nature, duration, and associated features of any changes over time in behavior, cognition, or mood. The policy included that if the resident is being treated for [REDACTED].",2020-09-01
80,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,154,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident's (#88) representative was informed of the risks and benefits of an antipsychotic medication, prior to administering. Findings include: Resident #88 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) and the quarterly MDS assessment dated (MONTH) 7, (YEAR), revealed the resident was rarely or never understood. Review of the clinical record revealed a physician's orders [REDACTED]. Review of the medication administration records for (MONTH) and (MONTH) (YEAR) and for (MONTH) and (MONTH) (YEAR) revealed the [MEDICATION NAME] was administered as ordered. Further review of the clinical record revealed no documentation that the resident's representative was informed of the risks and benefits of [MEDICATION NAME], nor had informed consent been obtained. During an interview conducted on (MONTH) 1, (YEAR) at 10:12 a.m., a Licensed Practical Nurse (staff #54) stated an antipsychotic medication should not be administered before obtaining consent. During an interview conducted on (MONTH) 1, (YEAR) at 10:43 a.m., the acting Director of Nursing (staff #1) stated before administering an antipsychotic medication, a consent is obtained from either the resident or the responsible person explaining the medication and the side effects. Staff #1 further stated there should have been consent for the [MEDICATION NAME]. Review of the policy titled, Antipsychotic Medication Use included the physician and staff will gather and document information to clarify a resident's symptoms and risks. However, the policy did not address the need to inform the resident/representative of the risks and benefits of an antipsychotic medication, prior to administering.",2020-09-01
81,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,225,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident and staff interviews, and policy and procedures, the facility failed to ensure resident to resident altercations involving two residents (#57 and #97) were investigated and reported to the State agency. Findings include: Resident #57 was admitted to the facility in (MONTH) 2014, with [DIAGNOSES REDACTED]. The resident resided in the secured Behavioral Unit. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of resident #57's Nurse's Notes dated (MONTH) 27, (YEAR) and (MONTH) 12, (YEAR) revealed resident #57 reported to staff that she was hit on the arm by resident #97 and no physical injury had occurred. Resident #97 was admitted to the facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. The resident resided in the secured Behavioral Unit and was discharged in (MONTH) (YEAR). Review of the quarterly MDS assessment dated (MONTH) 18, (YEAR) revealed a BIMS score of 13, which indicated the resident was cognitively intact. In an interview on (MONTH) 31, (YEAR) at 9:19 a.m., resident #57 said yes that she was abused by a former roommate, who had hit her on the left arm multiple times. The resident stated these incidents had occurred sometime in the spring of last year and were reported to staff. Resident #57 stated staff had moved the roommate to the other side of the room and at a later date, resident #57 had changed rooms. Resident #57 further stated that the roommate was no longer in the facility and there were no further incidents. During interviews on (MONTH) 1, (YEAR) at 11:27 a.m. and on (MONTH) 2, 2012 at 10:12 a.m. with the Interim Director of Nursing (staff #1/former unit manager of the Behavioral Unit where residents #57 and #97 resided), investigations regarding the incidents were requested. Staff #1 stated the allegations had occurred between residents #57 and #97 in the spring of (YEAR). Staff #1 stated that management staff and the physician had discussed the incidents and had met with both residents. Staff #1 confirmed an investigation of these reported altercations was not done and stated the incidents were not reported to the State agencies as required. The facility's Abuse Investigations policy and procedures identified that All allegations/signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management .The Administrator or Designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident.",2020-09-01
82,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,226,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy and procedures, the facility failed to implement their policy regarding an allegation of abuse for one resident (#57), and failed to ensure that two direct care staff's (staff #2 and #63) licenses were verified with the licensing board. Findings include: -Resident #57 was admitted to the facility in (MONTH) 2014, with [DIAGNOSES REDACTED]. The resident resided in the secured Behavioral Unit. Review of resident #57's Nurse's Notes dated (MONTH) 27, (YEAR) and (MONTH) 12, (YEAR) revealed resident #57 reported to staff that she was hit on the arm by another resident (#97). In an interview on (MONTH) 31, (YEAR) at 9:19 a.m., resident #57 said yes that she was abused by a former roommate, who had hit her on the left arm multiple times. The resident stated these incidents had occurred sometime in the spring of last year and were reported to staff. During interviews on (MONTH) 1, (YEAR) at 11:27 a.m. and on (MONTH) 2, 2012 at 10:12 a.m. with the Interim Director of Nursing (staff #1/former unit manager of the Behavioral Unit where residents #57 and #97 resided), investigations regarding the incidents were requested. Staff #1 stated the allegations had occurred in the spring of (YEAR). Staff #1 confirmed an investigation of these reported altercations was not done and stated the incidents were not reported to the State agencies as required. The facility's Abuse Investigations policy and procedures identified that All allegations/signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management .The Administrator or Designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. -Review of the personnel file for staff #2 (Licensed Practical Nurse) revealed a hire date of (MONTH) 10, (YEAR). Further review revealed no documentation that staff #2's license had been verified with the licensing board. Review of the personnel file for staff #63 (Registered Nurse) revealed a hire date of (MONTH) 15, (YEAR). Further review revealed no documentation that staff #63's license had been verified with the licensing board. During an interview conducted on (MONTH) 1, (YEAR) at 2:07 p.m., administrative staff (#110) stated she did not know that verification of licenses was required. Staff #110 stated she thought having a copy of the license would meet the requirement. During an interview conducted on (MONTH) 3, (YEAR) with the Director of Nursing (staff #129), staff #129 stated that the New Hire Packet Check Off List was their policy for verifying licenses. Review of the New Hire Packet Check Off List revealed to verify the license.",2020-09-01
83,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,241,D,0,1,TPN311,"Based on observations, staff interviews and a review of policy, the facility failed to maintain an environment that enhanced each resident's dignity and respect. Findings include: A random observation was conducted on (MONTH) 1, (YEAR) at 12:30 p.m., on the secured male behavioral unit. During this observation, the lunch meal cart was observed to be positioned by the main dining room door and across from the assisted dining room. While conducting observations, a CNA (Certified Nursing Assistant/staff #123) was heard to tell the other CNA's to pull the Feeders trays. The same CNA was again heard to tell the other CNA's to take the Feeders trays into the assisted dining room. An interview was conducted on (MONTH) 1, (YEAR) at 1:50 p.m., with staff #123, who acknowledged that she had referred to the residents as, Feeders. Staff #123 stated that she probably should not have referred to those residents who required assistance with their meals as Feeders, because it was not appropriate. She said she could have called them, Assisted residents. A interview was conducted on (MONTH) 2, (YEAR) at 2:10 p.m., with the Director of Nursing (staff #129). He stated that referring to the residents as, Feeders would be a dignity issue and that they should be referred to as assisted residents. On (MONTH) 2, (YEAR), an interview was conducted with the Administrator (staff #48), who stated that calling a resident a Feeder, is not dignified and that he had just provided an inservice regarding dignity approximately six months ago. A facility policy titled, Assistance with Meals included the following: 3. Residents Requiring Full Assistance: Residents who can not feed themselves will be fed with attention to safety, comfort and dignity, for example: c. Avoiding the use of labels when referring to residents (e.g., feeders).",2020-09-01
84,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,248,E,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure that an individualized activities program was implemented for one resident (#71). Findings include: Resident #71 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. The resident resided on the male behavioral unit. According to the annual Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR), the resident had severe cognitive impairment. Under the activity section, the documentation included that it was important to the resident to have books, newspapers and magazines available and to listen to music and to go outside for fresh air. A quarterly activities assessment dated (MONTH) 18, (YEAR), identified that the resident's favorite activities were one to one visits, coffee socials, music and conversing with family and friends. An activities care plan was developed and included as goals the following: -Resident will accept one to one visits at least twice a week. -Resident will attend group activity of interest once a week. The interventions included: -Invite to scheduled activities. -Offer to assist/escort the resident to activity functions. -Provide one to one visits twice weekly: conversation, outdoor leisure. -Socials 1-2 times weekly; cognitive games 1-2 times weekly; bingo 1-2 times monthly; education programs 1-2 times monthly; and exercise 1-2 times monthly. A review of the (MONTH) (YEAR) activity calendar revealed that 1:1 visits and coffee chats were scheduled daily, Bingo and a music program were scheduled weekly, and that fitness programs were scheduled several times a week. Review of the resident's one to one visit records from (MONTH) (YEAR) through (MONTH) (YEAR), revealed the following: July: five one to one visits were provided. August: seven one to one visits were provided. September: three one to one visits were provided. December: two one to one visits were provided January (YEAR): three one to one visits were provided. Further review of the activity records from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: August: The resident attended only one group activity during the month. October: The resident attended two group activities during the month. November: The resident attended only one group activity during the month. December: The resident did not attend any group activities during the month. January (YEAR): The resident did not attend any group activities during the month. During multiple resident observations, the resident was observed either in his room or sleeping in his wheelchair and was not involved in any 1:1 visits, group activities or any other type of activities. An interview was conducted on (MONTH) 2, (YEAR) at 9:10 a.m., with the Activity Director (staff #109). She stated the resident was supposed to have 1:1 visits on Wednesdays and Saturdays and that those visits should last approximately 15 to 30 minutes. Staff #109 stated the 1:1 visits would consist of sensory activities, hand massages and reading a book about horses to the resident, since he use to keep horses. Following a review of the resident's activities records, she stated that she had not followed up with the activities staff to ensure that the 1:1 visits and invitations to other activities had been provided. She also stated the activities department was short a full time activities assistant and that she needed another part time employee. On (MONTH) 1, (YEAR) at 11:00 a.m., an interview was conducted with the Director of Nursing (staff #129), who stated that the facility did not had a written policy regarding 1:1 visits. At this time, he stated that if the resident's care plan indicated 1:1 visits as an intervention, then that should be provided and that would act as the facility policy. On (MONTH) 3, (YEAR) at 8:15 a.m., another interview was conducted with staff #109. She stated that the activities assistants keep the documentation for the month's attendance and provide them to her at the end of each month, so she can file them. Staff #109 stated that although she had looked over the activity records, she had not noticed that the activities were not provided as planned. Staff #109 stated if not documented then it was not done. Staff #109 further stated the activity program is a work in progress. An interview was conducted on (MONTH) 3, (YEAR) at 8:30 a.m., with an activity assistant (staff #93). She stated that she provides activities on the unit where the resident resides. She stated that she keeps the activity attendance records for each resident until the end of the month and then turns them in to the Activities Director. At this time, she stated that she may not have recorded all the activities that the resident was involved in. Review of the Activity Assessment policy revealed the following: In order to promote the physical, mental and psychosocial well-being of residents, an activity assessment is conducted and maintained for each resident. The assessment will be conducted to help develop an activities plan that reflects the choices and interests of the resident.",2020-09-01
85,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,253,E,0,1,TPN311,"Based on observations and staff interviews, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior. Findings include: During the initial tour conducted on (MONTH) 30, (YEAR) at 10:46 a.m., the following was observed: -There was a strong urine odor in the hallway upon entering the Oak unit. -In multiple resident rooms, there were portable oxygen concentrators which had filters that were visible from the outside. The filters had a grayish dust like build up on them. -On all three units, the flooring in multiple resident rooms were stained with a brownish residue. -Multiple ceiling vents throughout the facility were dirty with a gray residue on the vent blades. Additional observations were conducted on (MONTH) 30, (YEAR) at 2:46 p.m. and revealed the following: -In room #7, there was a slight urine odor and there was a full urinal on the bed. -In room #8's bathroom, the flooring had several scuff marks and the floor boards were separated from the wall and there were several small holes in floor at the doorway. -In room #14, there was chipped paint on the walls and the floor boards had a dust build up and were stained. -In room #17, the bathroom door had a walnut sized hole, with jagged edges. The bathroom sink faucet was loose and moved freely. The sink vanity had multiple small gaps in the caulking, and the toilet ran continuously. -In room # 22's bathroom, one wall contained multiple small gouges and scrapes, and the bathroom door had small gouges with rough edges along the hinge side. -In room #26, the bathroom wall contained small gouges and peeling paint. The floor had missing tiles. The cove base was separating from the wall creating moderate sized gaps. There were multiple small gaps between the floor tile with an accumulation of gray/brownish dirt and debris in the gaps. Several window blinds were bent or had broken slats. -The window blinds in room #27 had several bent or broken slats. There was a hole in the bathroom wall over the toilet with exposed pipe, and there were small holes in the wall and unpainted surfaces from the removal of a dispenser, which was approximately 12 inches x 8 inches. The wood door had multiple small gouges and scrapes in the veneer. There was a hole in the wall at the head of the bed, which was approximately 3 x 1.5 inches. -In room #29, a closet drawer was missing, a section of the bathroom baseboard was missing and there was a large dark colored stain on the floor. -In room #31, there were multiple dark discolorations on the floor. -In room #32, there was floor tile that was missing which was approximately a 6 x 6 inch area. -In room #33, the bathroom walls were missing paint and the paint on the bathroom door frames paint were chipped. The window sill was missing approximately a 1 inch x 6 inch section of drywall, exposing the metal mesh. -In room #34, the bathroom door frame was rusted with a dark reddish/brown residue. The ceiling vent was stained with a dark reddish discoloration. -In room #39, the wall next to the bed was missing paint and the bathroom water faucet was missing a knob. -In room #42, the lower portion of the bathroom door frames had a dark reddish brown residue and there was extensive drywall deterioration around the sink and floor level. -In room #47, the ceiling was missing paint in several areas. An environmental tour was conducted on (MONTH) 1, (YEAR) at 11:30 a.m. with the Administrator (staff #48) and the maintenance/housekeeping supervisor (staff #41) present. Both staff were aware of the flooring issues, but both stated that they were not aware of the condition of the resident's rooms.",2020-09-01
86,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,279,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure that comprehensive care plans regarding ADLs (Activities of Daily Living) were developed for two residents (#40 and #88). Findings include: -Resident #40 was admitted on (MONTH) 26, 2013, with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 16, (YEAR), revealed in Section G, Functional Status that the resident required supervision-oversight/cueing with ADLS. An annual MDS assessment dated (MONTH) 18, (YEAR), included the resident now required limited to extensive assistance with ADLs. However, no care plan was developed regarding the resident's ADL needs. An interview was conducted on (MONTH) 1, (YEAR) at 12:50 p.m. with the MDS staff (staff #121), who stated that the MDS assessment was coded to reflect the resident's increased level assistance needed. A second interview was conducted in (MONTH) 1, (YEAR) at 1:30 p.m. with staff #121. Following a review of the (MONTH) 18, (YEAR) MDS assessment, staff #121 stated that although Section V. of the MDS assessment (CAA: Care Area Assessment) did not automatically trigger for initiation of an ADL care plan, she should have developed an ADL care plan, based on the documentation of the resident's increased level of assistance. -Resident #88 was admitted (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A admission MDS assessment dated (MONTH) 7, (YEAR), assessed the resident as requiring extensive assistance to total dependence, with ADLs. However, in Section V., the care area for ADLs did not trigger. A quarterly MDS assessment dated (MONTH) 7, (YEAR), also assessed the resident as requiring extensive assistance to total dependence, with ADLs. Review of the clinical record revealed no care plan was developed based on the resident's ADL needs. During an interview conducted on (MONTH) 1, (YEAR) at 10:48 a.m., the MDS coordinator (staff #121) stated she was unable to state why Section V. did not trigger for ADLs for care planning. Staff #121 stated ADLs should have triggered and ADLs should be care planned. During an interview conducted on (MONTH) 1, (YEAR) at 12:35 p.m., the Director of Nursing (staff #129) stated he would expect an ADL care plan be developed for this resident. A facility policy titled, Care Area Assessments included that Care Area Assessments will be used to help analyze data obtained from the MDS and to develop individualized care plans. The policy also included the following: 3. The IDT (Interdisciplinary Team) will employ tools and resources during the CAA process, including evidenced-based research and clinical practice guidelines, along with sound clinical decision making and problem-solving. Another facility policy titled, Care Plans Goals and Objectives included Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence.",2020-09-01
87,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,280,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff interviews and a review of facility policy, the facility failed to ensure that a comprehensive care plan was revised for one resident (#61). Findings Include: Resident #61 was admitted on (MONTH) 20, 2011, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that the resident previously had been on a 960 cc (centimeter) fluid restriction, however, it had been discontinued on (MONTH) 24, (YEAR). Review of the current physician's orders [REDACTED]. However, according to a care plan for potential complications related to [MEDICAL TREATMENT], one of the interventions included for a 960 cc daily fluid restriction. An interview was conducted on (MONTH) 3, (YEAR) at 9:30 a.m., with the Assistant Director of Nursing (staff #45), who stated that care plans were suppose to be updated at the time of the care conference (the resident's last quarterly care plan conference was in (MONTH) (YEAR)). Another interview was conducted on (MONTH) 3, (YEAR) at 9:37 a.m., with the Director of Nursing (staff #129), who confirmed that the 960 cc fluid restriction was still included as a current intervention on the care plan. Staff #129 stated that licensed staff were responsible to update care plans whenever necessary, and that all of the resident's care plans were suppose to be reviewed and revised at the time of the resident's care conference. He stated that the care plan should have been revised to reflect the discontinuation of the fluid restriction. A facility policy titled, Care Plan Goals and Objectives included the following: 2 .Care plans will be modified accordingly and that 5. Goals and objectives are reviewed and/or revised .at least quarterly.",2020-09-01
88,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,314,E,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, staff interviews, and policy review, the facility failed to consistently and thoroughly assess pressure ulcers for three residents (#22, #45 and #89). Finding include: -Resident #45 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was admitted with an unstageable pressure ulcer to the left heel. The wound measured 5.9 cm x 6.3 cm, with a black wound bed, with moderate drainage and no tunneling or undermining. An admission MDS (Minimum Data Set) assessment dated (MONTH) 20, (YEAR) included the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS also included that the resident was admitted with an unstageable pressure ulcer. Further review of the clinical record including the weekly wound reviews revealed the left heel pressure ulcer was assessed weekly from (MONTH) (YEAR) through (MONTH) (YEAR). A care plan dated (MONTH) (YEAR) included the resident had a pressure ulcer. An intervention included for weekly treatment documentation to include measurement of each area of skin breakdown (width, length, depth, type of tissue and exudate). According to the weekly pressure ulcer log dated (MONTH) 3, (YEAR), the left heel pressure ulcer was identified as a stage 3 and measured 4.5 cm x 4.3 cm. The next wound assessment which included measurements was not completed until (MONTH) 30, (YEAR). Per the wound note dated (MONTH) 30, the left heel measured 4.3 cm x 4.2 cm., however, there was no description of the wound bed. Continued review of the clinical record revealed the next thorough wound assessment was completed on (MONTH) 20, (YEAR). Per the Pressure Injury Log dated (MONTH) 20, the left heel wound was a stage 3 and measured 5 x 5 x 0.2 cm, and the wound bed was pink. There were no additional wound assessments which included the measurements of the pressure ulcer to the left heel, nor a description of the wound bed until (MONTH) 25. According to the Wound Weekly Observation Tool dated (MONTH) 25, (YEAR), the left heel was a stage 3 and measured 4.8 x 4.8 x 0.4 cm depth. The wound bed was described as having 50% [MEDICATION NAME] tissue and 50% slough. The wound edges were well defined and the wound was improving. A pressure ulcer treatment observation was conducted on (MONTH) 1, (YEAR) at 7:30 a.m., with the wound nurse (staff #25) present. The wound measured 4.5 x 4.4 cm, with no measurable depth. The wound edges were well approximated and the wound bed was brownish in appearance. -Resident #89 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the Nursing Admission Screening assessment dated (MONTH) 13, (YEAR), revealed no documentation that the resident had a pressure ulcer to the left ankle. Review of an admission MDS assessment dated (MONTH) 20, (YEAR) revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. The MDS also assessed the resident to have no pressure ulcers upon admission. A health status note dated (MONTH) 27, (YEAR) revealed that during a daily foot/leg assessment, the resident was noted to have an open area on the left ankle. The area was assessed by the wound nurse and identified as a stage 2 pressure ulcer. The note did not include any measurements or a description of the wound bed. A physician's orders [REDACTED]. Review of the Treatment Records revealed wound care was provided to the left ankle through (MONTH) (YEAR). Per the (MONTH) (YEAR) Treatment Record, the wound treatment to the left ankle was changed on (MONTH) 3, to three times a week. The wound care was provided through (MONTH) 13. A care plan identified that the resident was at risk for developing a pressure ulcer. A goal included that the resident would have intact skin. The care plan did not include that the resident had a pressure ulcer to the left ankle. Review of the clinical record revealed there were no thorough assessments of the left ankle wound which included measurements and a description of the wound bed from (MONTH) 27, (YEAR) through (MONTH) 15, (YEAR). Clinical record documentation revealed that on (MONTH) 13, (YEAR) orders were received to admit the resident to hospice care. The resident expired on (MONTH) 15, (YEAR). In an interview with the wound nurse (staff #25) on (MONTH) 1, (YEAR) at 11:20 a.m., she stated that during (MONTH) and (MONTH) there was no appointed wound nurse. She said that during that time, she was a floor nurse and she was responsible for administering treatment for [REDACTED]. She stated that she took over the wound nurse position in (MONTH) and the procedure now is to perform weekly assessments on wounds and document them in the electronic charting system. In an interview with the interim Director of Nursing (DON/staff #1) on (MONTH) 1, (YEAR) at 12:31 p.m., she stated that there were no wound assessments performed during the time period when there was no wound nurse. She stated that the floor nurses were responsible for administering treatments, but not doing a full wound assessment. She also stated that there were weekly wound meetings to discuss if the wounds were improving or if there were any concerns or changes, but measurements were not necessarily part of the discussion. -Resident #22 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. The admission wound note dated (MONTH) 3, (YEAR) included the resident had a stage IV pressure ulcer on the sacrum. The documentation included the wound measurements and a description of the wound bed. Physician orders [REDACTED]. Review of the Braden Scale assessment dated (MONTH) 5, (YEAR) revealed the resident was at moderate risk for the development of pressure ulcers. Review of the admission MDS assessment dated (MONTH) 10, (YEAR) revealed a Brief Interview for Mental Status score of 11, which indicated that the resident had moderate cognitive impairment. The MDS also included the resident required the assistance of two persons with bed mobility and transfers, and was admitted with a stage IV pressure ulcer to the sacrum. Review of the clinical record revealed the sacrum wound was assessed on (MONTH) 10, (YEAR), per the Wound Care/Skin Integrity Evaluation. The sacral wound was identified as a full thickness, stage IV pressure ulcer. The documentation included measurements and a description of the wound bed. Further review of the clinical record revealed there were no additional assessments of the sacral wound which included measurements until (MONTH) 30. A nurse's note dated (MONTH) 30, (YEAR) documented that the measurements of the sacrum pressure ulcer, however, there was no description of the wound bed. A comprehensive care plan identified that the resident had a stage IV pressure ulcer. The goals included that the pressure ulcer would show signs of healing, there would be no signs of infection, and the skin will remain intact. Interventions included performing treatments as ordered and monitoring for effectiveness. The care plan did not address completing weekly wound assessments. Per the nurse's notes dated (MONTH) 3 and 4, (YEAR), the documentation included a description of the sacral wound bed and measurements. The next assessment of the sacral pressure ulcer was not completed until (MONTH) 16, (YEAR). A nurse's note dated (MONTH) 16, included a description of the sacral wound, however, there were no measurements of the length and width of the wound. Continued review of the clinical record revealed there were no other assessments of the sacral pressure ulcer from (MONTH) 17, through (MONTH) 30, which included the measurements and a description of the wound bed. The next thorough wound assessment was completed by the wound care physician on (MONTH) 10, (YEAR). The assessment included the resident had a stage IV pressure ulcer to the sacrum. The wound measurements and a description of the wound bed were also included. The next thorough wound assessment was done on (MONTH) 17, (YEAR) and was completed by the wound nurse. The next thorough wound assessment was completed eight days later on (MONTH) 25, (YEAR). Per the documentation, the wound was measured and included a description of the wound bed. An interview was conducted with resident #22 on (MONTH) 2, (YEAR) at 9:15 a.m. and the resident declined a wound care observation. An interview was conducted with the wound nurse (LPN/staff #25) on (MONTH) 2, (YEAR) at 9:56 a.m. She stated that she just started doing treatments in (MONTH) for this resident. She stated the wound doctor comes once a month to see the resident. Staff #25 stated that each resident should have a skin assessment on admission and for pressure ulcers, the wound assessments and documentation should be done weekly by the wound nurse, and the weekly skin assessments should be documented by the floor nurses. She stated the missing documentation for the wounds is related to the fact that they did not have a wound nurse for several months. Review of the Pressure Ulcer Risk Assessment policy revealed that nurses should conduct skin assessments at least weekly to identify changes, and document them in the resident's medical record. A policy titled, Pressure Ulcer Treatment included that the purpose was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The pressure ulcer treatment program should focus on assessing the resident and the pressure ulcer. Per the policy, the following should be recorded in the medical record: all assessment data (i.e. color, size, pain, drainage etc.) when inspecting the wound. The policy did not address how often pressure ulcer assessments should be completed.",2020-09-01
89,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,323,D,0,1,TPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy and procedures, the facility failed to ensure the environment was free from accident hazards, by failing to ensure a physical restraint was properly applied to one resident (#71) and by having resident door frames with exposed sharp edges. Findings include: -Resident #71 was admitted on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. The resident resided on the behavioral unit. A review of the clinical record revealed a physician's orders [REDACTED]. A fall risk care plan included an intervention for the use of a lap buddy when in a wheelchair for poor safety awareness. The care plan also included to check the lap buddy for positioning and placement every shift. According to the CNA (Certified Nursing Assistant) care sheet, a lap buddy was to be used for this resident. The (MONTH) (YEAR) TAR (Treatment Administration Record) included the physician's orders [REDACTED]. An observation of the resident was conducted on (MONTH) 30, (YEAR) at 1:27 p.m. At this time, the resident was observed sleeping in a wheelchair, with a waist restraint on. The device was a non self-releasing cloth belt. The belt went around the front of the resident's waist and criss crossed behind the resident. The belt then went around the back of the wheelchair and one end was tied to the other end, which was then looped over the back rung of the wheelchair. An interview was conducted on (MONTH) 2, (YEAR) at 10:30 a.m., with the ADON (Licensed Practical Nurse/Assistant Director of Nursing/staff #45). She stated that she had also observed the resident on (MONTH) 30, with the non self-releasing waist restraint on. Staff #45 stated that after her observation, she replaced the non self-releasing waist restraint with a lap buddy. She stated that she had spoken with the staff on duty and they had reported that the night shift had gotten the resident up, and had put the non self-releasing waist restraint on the resident. She confirmed that the non self-releasing waist restraint was incorrectly applied and that the resident should have had a lap buddy applied. An interview was conducted on (MONTH) 2, (YEAR), with a LPN (staff #126). She stated that although the CNAs were responsible to apply the physician ordered devices, the nurses were responsible to ensure that they are being applied. A facility policy titled, Use of Restraints included the following: 9. Restraints shall only be used upon written order of a physician . 12. The following safety guidelines shall be implemented and documented while a resident is in restraints: a. Restraints shall be used in such a way as not to cause physical injury to the resident and to ensure the least possible discomfort to the resident. b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. -An observation was conducted on (MONTH) 30, (YEAR) at approximately 2:46 p.m., of the bathroom in room #33 and #42. The bathroom metal door framing was observed to have extensive deterioration of the door frames, which had disintegrated through on the lower portions, exposing sharp metal edges. An environmental tour was conducted on (MONTH) 1, (YEAR) at 11:30 a.m., with the Administrator (staff #49) and the maintenance/housekeeping supervisor (staff #48). They both stated that they were not aware of the extensive deterioration of the door frames in the rooms. The Administrator stated the rooms identified would be prioritized, due to safety concerns.",2020-09-01
90,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,364,D,0,1,TPN311,"Based on observations, staff interviews and a review of facility policy, the facility failed to ensure that food was served at the proper temperature. Findings include: A lunch observation was conducted on (MONTH) 30, (YEAR), in the main dining room. During this observation the following issues were observed: -After the meal cart arrived in the dining room, 5 residents were served their meal. These residents sat with their covered food plate in front of them for 15 to 35 minutes, before a staff member assisted them to eat their meal. A second dining observation (breakfast) was conducted on (MONTH) 1, (YEAR), in the main dining room. The following issues were identified: -The breakfast meal was scheduled to be served at 7:30 a.m., however, the food cart was not delivered from the kitchen until 7:45 a.m. -The first meal tray was served to a resident at 7:55 a.m., which was 10 minutes after the food cart had arrived from the kitchen. -At this time, four residents were identified to require feeding assistance. The first resident was assisted with her breakfast at 8:10 a.m. and the second resident was assisted with his meal at 8:20 a.m. Although the breakfast plates were covered, the trays had been sitting on the residents' table from approximately 7:55 a.m. -At 8:30 a.m., a CNA (Certified Nursing Assistant) was observed to prepare to feed the third and fourth resident their breakfast. Although the breakfast plates were covered, they had been sitting on the dining room table since 7:55 a.m. At this time, the breakfast food temperature was obtained by the dietary manager. The pureed biscuits and gravy was at 79 degrees F. (Fahrenheit) and the oatmeal was at 113 degrees F. The dietary manager then instructed that another breakfast meal be provided to those residents. An interview was conducted on (MONTH) 1, (YEAR) at 8:40 a.m. with the dietary manager (staff #112). He stated that the covered foods would only stay hot for approximately 20 minutes after it was served. He stated that at the temperatures obtained, the food would not be considered hot and should not be served to a resident. He stated that the residents should be assisted with their meals when it comes out of the kitchen. Another interview was immediately conducted with a CNA (Certified Nursing Assistant/staff #32), who was preparing to assist the third and fourth resident with their meals. She stated that staff were not assigned to assist certain tables or residents, and that she had seen the residents sitting with the covered plates on the tables, while she was serving the beverages. The CNA stated that she should have realized that their food was getting cold and she should have obtained hot food for those residents. A facility policy titled, Assistance with Meals included the following: 5. For all residents, hot foods shall be held at a temperature of 136 degrees or above until served .Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement.",2020-09-01
91,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,371,E,0,1,TPN311,"Based on observations, staff interviews and policy review, the facility failed to ensure that ready to eat foods were handled properly, that food and beverages were properly labeled and that the nourishment refrigerator temperatures were consistently obtained and documented. Findings include: -A lunch observation was conducted in the main dining room on (MONTH) 30, (YEAR). During this observation a CNA (Certified Nursing Assistant) was observed to donn gloves, remove a resident's meal tray from the rack, carry the tray to the resident's table and place the food items in front of the resident. The CNA was then observed to butter the resident's bread, with the same gloves on. With the same gloves on, the CNA was then observed to reposition the meal cart in the dining room and removed another resident's meal tray from the rack. Again, the CNA removed the food items and placed them in front of the resident. The CNA then proceeded to butter the resident's bread, with the same gloves on. The CNA was not observed to change her gloves after touching the non-food items or in between assisting residents. An interview was conducted on (MONTH) 1, (YEAR) at 8:40 a.m., with a CNA (staff #32). She stated that gloves were suppose to be changed after touching a non-food item, like the meal cart and were suppose to be worn when handling food. A facility policy titled, Handling Ready to Eat Foods included Nursing staff and other dinning assistive personnel shall provide ready to eat foods while assuring sanitation guidelines are followed. The policy also included the following: 2. If a resident requires assistance with opening and handling of an item the associate assisting shall: a. Wash their hands. b. Caution to only touch the wrapper and avoid touching the food item. c. Wear gloves as appropriate if food item must be handled. d. Gloves shall be changed between service to each resident. 5. As gloves are changed between each resident the associate shall; a. Wash their hands. b. Use a hand sanitizer as indicated by the manufacturer's label. -An observation of three resident nourishment refrigerators was conducted on (MONTH) 31, (YEAR) at 2:15 p.m., with the Kitchen Manager (staff #112 ) present. The nourishment refrigerators contained unlabeled and undated beverages and foods. In addition, review of the refrigerator temperature logs revealed that the refrigerator temperatures were to be maintained between 38-41 degrees F, and if the temperatures were not in range, it was staff's responsibility to correct the issue (i.e. change temperature or write a work order.) Further review of the temperature logs from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: -August: There were seven days with no documentation that the temperature was checked. The documentation included that on (MONTH) 13, a temperature reading of 50 degrees was documented and a note indicated that the unit needed defrosting. However, there was no documentation that the refrigerator was defrosted and there were no follow up temperatures which were recorded on (MONTH) 14, 15, or 16 to confirm that the temperatures were at the appropriate temperature. -September: There were five days with no documentation that the temperatures were checked. -October: There were five days with no temperatures documented. -November: There were eight days with no temperatures documented. -December: There were seven days with no temperatures documented. -January: There were five days with no temperatures documented. During the six month time frame, the documentation on the temperature logs showed that the refrigerator required adjustments or defrosting eight times to maintain safe operating temperatures. An interview was conducted on (MONTH) 31, (YEAR) at 2:18 p.m. with the Kitchen Manager (staff #112) who stated it was the floor nurses responsibility to monitor and record the refrigerator temperatures. Another interview was conducted on (MONTH) 31, (YEAR) at 2:31 p.m. with a LPN (Licensed Practical Nurse/staff #45) ). Staff #45 stated that the temperatures were to be checked and recorded by the night nurses and the Unit Managers review the logs to ensure compliance, and follow up on any pending work orders. Staff #45 stated that the Unit Manager position was eliminated a few months earlier and the task was not reassigned to anyone specifically to ensure it was being done. On (MONTH) 31, (YEAR) at 2:51 p.m., an interview was conducted with the acting DON (Director of Nursing/staff #31), who stated there were so many other problems to resolve that she missed it. Review of the Facility Nourishment Refrigerator Policy revealed the refrigerator temperatures were to be at or below 41 degrees F and at or above 38 degrees F, to prevent the spread of food borne illness. The policy included the following procedure: The night nurses (11 p.m.-7 a.m shift on weekends or 7 p.m.-7 a.m. shift on weekdays) will read the thermometer in the refrigerator and record the temperature on the refrigerator log nightly. Any temperature not in the range of 38-41 degrees F, must be reported to maintenance on a work order form and food thrown away.",2020-09-01
92,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,431,E,0,1,TPN311,"Based on observations, staff interviews, facility documentation, and policy review, the facility failed to ensure expired medications were not available for use and failed to consistently monitor and document medication refrigerator temperatures on the Oak unit. Findings include: -During a medication storage observation conducted on (MONTH) 2, (YEAR) at 2 p.m., three expired medications were found in the medication room on the Magnolia unit as follows: Calcitrate one bottle with an expiration date of (MONTH) of (YEAR), Vitamin B1 one bottle with an expiration date of (MONTH) of (YEAR), and Loperamide one bottle with an expiration date of (MONTH) (YEAR). An interview was conducted with a Licensed Practical Nurse (LPN/staff #27) on the Magnolia unit on (MONTH) 2, (YEAR) at 2:00 p.m. She stated that the nurses are the ones who check the medications to make sure they are not expired. She stated that she thought the night nurses do the medication room checks to ensure medications are not expired. Review of the facility's policy regarding the Storage of Medications revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. -Review of the temperature logs for the medication refrigerator on the Oak unit revealed the following: No temperatures were recorded for nine days in (MONTH) (YEAR), for six days in (MONTH) (YEAR), for nine days in (MONTH) (YEAR), for ten days in (MONTH) (YEAR), for twenty days in (MONTH) (YEAR), and for fourteen days in (MONTH) (YEAR). An interview was conducted with an LPN (staff #28) on (MONTH) 2, (YEAR) at 1:45 p.m. He stated that the refrigerator temperatures are to be checked every night and recorded by night shift. An interview was conducted with a unit manager (Registered Nurse/staff #1) on (MONTH) 2, (YEAR) at 3:03 p.m. She stated that for the medication refrigerators, they keep a log of what the temperature is, and if a temperature is out of range, they have to document what their corrective action is. She stated they will notify maintenance right away, change the temperatures, and then check the temperatures again. She stated the temperatures are to be checked every night and recorded on the temperature log. Review of the facility's Refrigerator log policy and procedure revealed to maintain the medication refrigerators between 36 and 46 degrees Farenheit. Per the policy, the night shift nurses (working from 11 p.m. - 7 a.m.) will read the thermometer in the refrigerator and record it on the nightly refrigerator log.",2020-09-01
93,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,441,D,0,1,TPN311,"Based on observation, staff interviews, and policy review, the facility failed to ensure proper handwashing techniques were followed during a pressure ulcer treatment. Findings include: A pressure ulcer treatment observation was conducted on (MONTH) 1, (YEAR) at 7:30 a.m., with the wound nurse (staff #25). Prior to beginning the wound treatment, the nurse was not observed to wash her hands or use sanitizer gel. Following the wound treatment, the nurse removed her gloves and cleansed several items and then exited the room and placed the items back into the cart. The nurse was not observed to wash or sanitize her hands. In an interview with the wound nurse (staff #25) on (MONTH) 2, (YEAR) at 2:33 p.m., she stated her regular procedure is to wash her hands or use an antibacterial gel before, during and after treatment. In an interview with the Director of Nursing (staff #129) on (MONTH) 2, (YEAR) at 2:46 p.m., he stated that the expectation of staff during wound treatments is to wash or sanitize hands before, during, and after wound care. Included in a policy titled, Pressure Ulcer Treatment it stated to wash hands before treatment and to wash and dry hands thoroughly after performing ordered treatment.",2020-09-01
94,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,465,E,0,1,TPN311,"Based on observations, staff interviews and review of the safety data sheet, the facility failed to provide a safe environment, by failing to ensure the facility was free from chemical odors. Findings include: During a random observation conducted on (MONTH) 2, (YEAR) at 9:30 a.m. on the secured Oak nursing unit, a strong chemical odor was detected upon entry into the unit. The odor started at the entry door and proceeded 3/4 of the way down the hall. A small floor fan was on and positioned halfway down the hall. At this time, a resident who was self-propelling himself in a wheelchair to his room, which was located in the area of the chemical odor stated, What is that bad smell. Several other residents were observed in their rooms, which were also located in the area of the chemical smell. No windows or doors were observed to be opened to allow for more ventilation. The nursing staff on the unit were then interviewed and stated that they did not know what was causing the strong chemical odor. An environmental staff member (staff #13) was on the unit at this time and stated that her supervisor had instructed her to spray paint the ceiling air vent covers, in resident rooms. Staff #13 stated that she had just spray painted the ceiling air vent covers in six resident rooms. During this interview, another environmental staff person produced the spray paint can. The product was identified as Appliance Epoxy with warnings on the spray can which included: -Danger-extremely flammable liquid and vapor. -Vapor harmful. -Vapors may cause flash fires. Immediately following, an interview was conducted with the Administrator (staff #48), who was on the Oak unit. He agreed that a strong, chemical odor was present on the unit and directed staff to obtain another fan, to open the resident's room windows and doors, and to move those residents who were in their rooms to the dining room, which was farther away from the chemical odor. Staff #48 stated that the air vent covers should have been removed and spray painted outside. An interview was conducted on (MONTH) 2, (YEAR) at 10:30 a.m., with the Environmental Director (staff #41). He stated that he had purchased the product yesterday and had instructed his staff to spray paint the air vent covers. Staff #41 stated that he had not instructed his staff to remove the air vent covers and spray paint them outside. He acknowledged that he had not read the warnings on the spray paint bottle. He stated that the fumes could be toxic and that he would contact the manufacturer for further information regarding this product. On (MONTH) 2, (YEAR), staff #41 provided the manufacturer's safety data sheet for the Rust-Oleum product/Epoxy. The documentation included the following warnings: -Wear protective gloves/protective clothing/eye protection/face protection. -Use only in a well ventilated area. -Avoid breathing fumes, vapors, or mist. -Avoid contact with eyes, skin and clothing.",2020-09-01
95,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2017-02-03,520,E,0,1,TPN311,"Based on concerns identified during the survey, staff interview and policy and procedures, the facility failed to identify quality concerns through their QA (Quality Assurance) program regarding consistently and thoroughly assessing pressure ulcers. Findings include: During the survey, concerns were identified that pressure ulcers were not being thoroughly and consistently assessed to include measurements and a description of the wound bed. During the survey, interviews were conducted with the interim Director of Nursing (DON/staff #1) and the wound nurse (LPN/staff #25), and both stated that there were no wound assessments performed during the time period when there was no wound nurse. During an interview conducted with the Administrator (staff# 48) on (MONTH) 3, (YEAR) at 12:30 p.m., he stated that they had not identified any issues in QA regarding pressure ulcers. A review of the Quality Assessment and Assurance Committee policy and procedure revealed the committee shall serve as the final authority for implementing the facility's quality assessment and assurance programs. The policy included the committe shall meet as necessary, but at least quarterly to assure that the QA program is meeting the needs of the facility.",2020-09-01
96,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,567,B,0,1,WXKF11,"Based on observation, facility documentation, resident and staff interviews, and policy and procedures, the facility failed to ensure that residents have access to their personal funds on the weekends. Findings include: Review of facility documentation revealed that multiple residents had trust fund accounts through the facility. During the survey, an observation was conducted of a sign which was posted in the business office. The sign read that the resident trust fund bank was open Monday through Friday from 9:00 a.m. until 3:00 p.m., and that the bank was closed on the weekends and holidays. An interview was conducted with a resident at 9:45 a.m. on (MONTH) 26, (YEAR). She stated that she does not have access to her trust fund on the weekends, as the bank is closed. An interview with the business office manager (staff #113) was conducted at 11:20 a.m. on (MONTH) 29, (YEAR). She said that there are a lot of residents who have trust fund accounts in the facility. She stated that she manages these accounts and is the one who provides money for the residents at their request. Staff #113 stated that the banking hours that are posted are correct and are from 9:00 a.m. until 3:00 p.m., Monday through Friday. She said that this is the only time that residents can get their money. She stated that residents are not able to get money on the weekends or holidays. Staff #113 stated the residents and their families are aware of this and they make provisions to get money on Friday, before the bank closes. She said that she has never heard that residents should have access to their accounts on the weekends. Another interview was conducted with the same resident as above on (MONTH) 29, (YEAR) at 1 p.m. She stated that it is a pain that she cannot get money out of her trust fund on the weekends. She said that she has wanted to get money out of her account on the weekends at times, but is unable too. She said that it is hard for some residents because they may have relatives that come to the facility on the weekends and they will have no money to go out to eat with them. The resident stated that it is difficult not being able to get money on the weekends, because she does not have a safe place to keep it if she gets some out of her account on Friday, because she does not like having it on herself as it could get stolen. She also stated that staff do not like residents to have money on them, as it could be misplaced or stolen. During an interview with the Administrator (staff #45) on (MONTH) 30, (YEAR) at 1:00 p.m., he stated that he was not aware that the residents should have access to their trust fund accounts on the weekend, but has seen other facilities offer this to residents. Review of the facility's Resident Trust Account policy and procedure revealed that all nursing facilities are required to provide resident nursing home trust funds to their residents as requested, and that the funds managed by the facility on the resident's behalf must be held in a resident trust fund. The policy noted that the Administrator and the business office manager are accountable for the proper management and safeguarding of resident trust funds. The policy included that resident trust accounts will be managed in accordance with all federal and state regulations. The policy further included that residents will have reasonable and convenient access to the trust account and that petty cash should be available to meet the daily needs of the residents at the facility. The policy noted that trust fund hours of operation were Monday through Friday 9:00 a.m. to 3:00 p.m.",2020-09-01
97,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,600,D,1,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to ensure one resident (#74) was free from physical abuse by another resident (#49). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR), included a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severe cognitive impairment. Review of resident #49's current care plan revealed the resident was exit seeking and displayed wandering, pacing, or roaming behaviors. The care plan included the resident required psycho-active medications to help manage mood and behavior symptoms which included hitting and combativeness. The care plan also included the resident utilized a wheelchair. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. An annual MDS assessment dated (MONTH) 27, (YEAR) identified the resident had been assessed with [REDACTED]. A review of the resident's current care plan revealed documentation that the resident demonstrates limited social interaction related to [DIAGNOSES REDACTED]. The care plan included the resident exhibited behaviors of yelling, verbal aggression towards staff and that the resident spends most of his time alone watching television and isolating self in his room. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the unit dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. An interview was conducted with a CNA (Certified Nursing Assistant/staff #35) on (MONTH) 27, (YEAR) at 11:30 a.m. Staff #35 stated that resident #74 and resident #49 were in the dining room during breakfast. Staff #35 stated she was assisting other residents in the dining room and heard resident #49 and #74 yelling at each other in Spanish. Staff #35 stated that she heard resident #74 tell resident #49 to leave him alone. She said she turned around and resident #49 hit resident #74 in the mouth. Staff #35 stated that she got between the residents and separated them. Staff #35 stated the nurse assessed the residents and the residents went back to their tables and finished their breakfast, with no further incidents. An interview was conducted on (MONTH) 27, (YEAR) at 12:00 p.m., with a LPN (Licensed Practical Nurse/staff #63). Staff #63 stated that staff #35 reported that resident #49 had left his table and wandered over to resident #49 and hit resident #49 in the mouth. Staff #63 stated she checked both residents and neither had sustained any injury. On (MONTH) 27, (YEAR) at 1:50 p.m., an interview was conducted with resident #74. Resident #74 stated that he remembered the incident that occurred on (MONTH) 20, (YEAR), in the dining room. Resident #74 stated that resident #49 came up to him and hit him in the face. Resident #74 stated he did not know why resident #49 had hit him and that he told resident #49 to leave him alone. Review of the Abuse policies revealed that the facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, family members or other residents. The policy defined physical abuse as the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental anguish.",2020-09-01
98,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,604,E,0,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff and resident interviews and policy and procedures, the facility failed to ensure that three residents (#68, #20 and #75) were assessed and/or monitored for the use of physical restraints. Findings include: -Resident #68 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 22, (YEAR) included for a Velcro self releasing belt when in wheelchair, due to poor safety awareness. A physical restraint informed consent was completed on (MONTH) 22, (YEAR). The documentation indicated that the restraint being used was a self releasing belt, when in the wheelchair. The documentation included specific target behaviors and that the resident had poor safety awareness. The form was signed by the resident's Power of Attorney (POA). However, an initial restraint evaluation could not be located in the resident's clinical record. There was no clinical record documentation that the resident was assessed for the use of the device, in order to determine if the device was a restraint. Review of a physical restraint evaluation dated (MONTH) 16, (YEAR) revealed the resident had an unsteady gait, agitated behavior, aggressive behaviors, attempts to self-transfer, and climbs out of bed. It was noted that the resident continues to ambulate and get out of bed, without assistance. The evaluation indicated that the restraint (self releasing belt) was effective and to continue it's use. The documentation did not include if the resident was assessed to be able to release the self releasing belt. Another physical restraint evaluation dated (MONTH) 18, (YEAR), included that the restraint (was considered to be effective and would be continued. The documentation did not include if the resident was assessed to be able to release the self releasing belt. Review of the nursing notes revealed that the resident was discharged on (MONTH) 24, (YEAR). The clinical record documentation showed that the order for the Velcro self releasing belt when in wheelchair had been discontinued on (MONTH) 28, (YEAR). The resident was then readmitted to the facility on (MONTH) 31, (YEAR). Review of a current care plan indicated that the resident was at risk for falls related to disease processes. One of the interventions was to apply the Velcro protective device, when up in wheelchair. A physical restraint evaluation was completed on (MONTH) 1, (YEAR). This assessment indicated the resident had an unsteady gait, aggressive behaviors, and attempts to self-transfer. The waist restraint (self releasing belt) was noted to be effective in the past. The assessment indicated that other alternative attempts had been tried prior to using the restraint including a recliner, a companion, one on one activities, a positioning device, regular toileting, and scheduled rest times. The assessment also included that a physician's order had not been obtained for the self releasing belt, but a message was left with the physician on (MONTH) 31, (YEAR) to obtain an order. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR), revealed the resident scored a two on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS did not code the resident as using a physical restraint. Review of the current physician's orders for (MONTH) (YEAR) revealed there were no orders for the use of the Velcro self releasing belt upon the resident's return to the facility. In addition, there was no clinical record documentation of any direct monitoring and supervision which was done, when the self releasing belt was being utilized, and there was no documentation regarding the time and frequency of when the restraint should be released. An interview was conducted with a Licensed Practical Nurse (LPN/staff #101) at 2:22 p.m. on (MONTH) 27, (YEAR). She said that the resident has a Velcro belt on for safety, as he wheels around in his wheelchair and tends to slide down. She said that she did not think it was a restraint for him, because he is able to get up if he wants too. Staff #101 stated that if he tries to get up, the belt will eventually loosen and slide down as he gets up. She said there should be a physician's order for the belt. An interview was conducted with a Certified Nursing Assistant (CNA/staff #107) at 8:30 a.m., on (MONTH) 28, (YEAR). She said that she thinks the resident has the Velcro belt, because he is a fall risk as he tries to get up by himself. She said that he slides up and down in his chair and the belt helps him to stay in the chair. She said that the resident is able to remove it as needed, so she did not think it was a restraint. During an interview with the resident at 10:00 a.m. on (MONTH) 28, (YEAR), he said that he could remove the belt but when asked to remove it, he was unable. An interview was conducted with the unit manager (staff #36) at 11:40 a.m. on (MONTH) 28, (YEAR). She said the belt is not a restraint for the resident, because they only use them if residents are able to remove them. She said that he might have moments where he is angry or agitated and he will not display that he knows how to remove it, but removes it later. She stated that he has removed the belt from time to time and has fallen. She said that she checks the belt at least weekly to make sure it is applied correctly and is in good shape. She said if he tries to stand up the belt will loosen, but will do so slowly, so that staff are able to get to him before he falls. Staff #36 stated that the belt is helpful, because the resident constantly leans forward. She said the process for obtaining a device like the belt is to obtain a physician's order and then get consent from the family. After reviewing the chart, staff #36 stated that there was no order probably because he had gone out of the facility and come back. She said they do not use restraints in the facility. She said that she did not know much about the physical restraint assessments in the computer charting system. During an interview with the Director of Nursing (DON/staff #18) at 11:15 a.m. on (MONTH) 29, (YEAR), he said that the process regarding safety devices is that when the need for such a device arises, the interdisciplinary team will meet and discuss which device to use for a resident. He said they will talk about what they have done prior to using the device and the reason behind using a device. He said that once they decide to use a device, they will apply the device and then discuss it from time to time to determine if it should be discontinued. Staff #18 said that currently, they are not looking at devices such as this resident's Velcro belt as a restraint and they do not go through all of the documentation that is required for a restraint, including removing it every 2 hours and documenting the removal on the TAR. He said that this has changed in the facility, as they used to consider some of these devices as restraints. He said that he is not aware of an assessment to determine if a device is a restraint or not, but they do discuss this. Another interview was conducted with staff #18 at 10:00 a.m. on (MONTH) 30, (YEAR). He said the facility previously used a pre-restraint assessment to determine if a device was a restraint, but they stopped using this form since they no longer consider these devices as restraints. Staff #18 stated that he understands the facility should assess to determine if a device is a restraint, but currently they are not doing this. He said there should be an order for [REDACTED]. -Resident #20 was admitted (MONTH) 28, 2011, with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 29, (YEAR) included for a lap buddy when the resident is in the wheelchair for positioning, due to left-sided weakness related to a [MEDICAL CONDITION]. Review of the clinical record revealed there was no documentation that the resident was assessed for the use of the lap buddy, in order to determine if the device was a restraint for the resident. There was also no documentation that the resident/responsible party had been notified of the risks and benefits of the lap buddy. A quarterly MDS assessment dated (MONTH) 27, (YEAR), revealed the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS included the resident had been assessed to require extensive assisstance with bed mobility, transfers, locomotion on the unit and was totally dependent on staff for locomotion off the unit. The MDS further documented that the resident had limited range of motion to upper and lower extremities. The MDS did not code the resident as using a restraint device. Review of the current physician's orders for (MONTH) (YEAR) revealed orders for a lap buddy when the resident is in the wheelchair for positioning, due to left-sided weakness related to a [MEDICAL CONDITION]. A physician's order dated (MONTH) 25, (YEAR) included for an occupational therapy evaluation for her wheelchair. Review of the Occupational Therapy evaluation dated (MONTH) 26, (YEAR), revealed the resident was in a high back wheelchair and was not in a good position, which will cause falls. The evaluation included that the resident should be seen by a company that will fit the resident with a wheelchair which will put her in a good position to prevent falls and pressure ulcers. The evaluation did not address the use of a lap buddy. Observations were conducted of resident #20 on (MONTH) 26, (YEAR) at 10:00 a.m., on (MONTH) 28, (YEAR) at 11:32 a.m., and on (MONTH) 20, (YEAR) at 8:44 a.m. During these observations, the resident was observed to be in a high back wheelchair, with a lap buddy applied. Further review of the clinical record revealed there were no ongoing assessments which were completed, in order to determine if the lap buddy was a restraint and for the continued need for the lap buddy. In addition, there was no documentation regarding any direct monitoring and supervision which was provided during its use, nor the frequency of when to remove the device. An interview was conducted with a LPN (staff #27) on (MONTH) 28, (YEAR) at 11:46 a.m. Staff #27 stated that he had seen resident #20 attempt to remove the lap buddy but was unable too. An interview was conducted on (MONTH) 30, (YEAR) at 9:00 a.m. with a CNA (staff #70), who stated that he provided care to resident #20. Staff #70 stated that he applies the lap buddy, but has not seen the resident take it off. Staff #20 stated the resident has asked for staff to reposition her, as the lap buddy was pressing on her babies. Staff #70 stated the only time he has removed the resident's lap buddy was when he assisted the resident to bed. An interview was conducted with staff #18 on (MONTH) 30, (YEAR) at 9:56 a.m. Staff #18 stated that since the resident could not release the lap buddy, then it would be considered a restraint device that would need to be evaluated. -Resident #75 was admitted on (MONTH) 12, 2013, with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 5, (YEAR) included for a geri-chair as needed for safety and comfort. A review of the resident's care plan revealed the resident requires a geri-chair to promote functioning at the highest practicable level. The need for this level of intervention is related to [MEDICAL CONDITIONS] and bilateral lower extremity weakness. Interventions included to assess the resident to determine the most enabling, therapeutic and least restrictive treatment approaches. Consider factors such as behavioral symptoms, fall risk, medical symptoms, and ADL self-performance. Emphasize quality of life: confer with the attending physician and IDT members to evaluate alternative devices and least restrictive interventions; evaluate the resident's response to the restraint and share this evaluation with the IDT; advocate for increased quality of life through minimal use of restrictive devices; monitor and report to the physician the following restraint related issues (increased behavior/mood problems, decreased mobility, development of contractures, skin problems, increased incontinence; increased risk of falls) and offer sensory and social stimulation at intervals throughout the day with particular emphasis on the restraint release periods. This care plan was updated on (MONTH) 8, (YEAR). Review of the clinical record revealed there was no documentation of any evaluations which had been completed from (MONTH) 5, (YEAR) through (MONTH) (YEAR), in order to determine if the use of a geri-chair would be a restraint for the resident, and there was no documentation of any medical symptoms that warranted its use. There was also no documentation of the least restrictive measures which were utilized, prior to implementing a geri-chair and that the resident/responsible party had been notified of the risks and benefits of using a geri-chair. In addition, there was no documentation regarding any direct monitoring and supervision which was provided when utilizing the geri-chair, nor the frequency of when to remove the device. According to a quarterly MDS assessment dated (MONTH) 28, (YEAR), the resident was assessed with [REDACTED]. The MDS did not identify the use of a restraint device. Observations were conducted of the resident on (MONTH) 27, (YEAR) at 8:30 a.m., on (MONTH) 27, (YEAR) at 11:30 a.m., and on (MONTH) 29. (YEAR) at 11:30 a.m. During these times, the resident was observed to be seated in a geri-chair. During an interview with staff #18 on (MONTH) 28 (YEAR) at 12:03 p.m., staff #18 stated that any device could be considered a restrictive device and should be assessed as to whether or not it's a restraint and monitored on a regular basis for effectiveness and should be the least restrictive option. An interview was conducted on (MONTH) 29, (YEAR) at 12:18 p.m., with the unit manager (LPN/staff #22) regarding potential restraint devices. Staff #22 stated that the residents (#20 and #75) can't get up from their wheelchairs, so the devices are not restraints and therefore, they do not need assessments. A follow-up interview was conducted with staff #18 on (MONTH) 30, (YEAR) at 9:56 a.m. Staff #18 stated that upon receipt of a physician's orders for devices such as a geri-chair or lap buddy, the order needs to include a medical symptom, and the resident needs to be evaluated or screened by therapy to assess for the need and safety of a potential restraint device. Staff #18 stated that at least quarterly, the IDT teams should evaluate for the continued use of the device, and if the device was determined to be a restraint, then informed consent should be obtained after explaining the risks and benefits of the restraint to the resident/representative. Staff #18 said that staff would need to monitor the use of the devices at least every 2 hours for appropriate application and release of the restraint if appropriate. Regarding resident #75, staff #18 stated that the use of a geri-chair was the resident's choice, however, there was no documentation of that and there were no assessments or evaluations. Staff #18 further stated that the MDS assessments were not coded for residents having restraint devices, as staff had determined that there were no restraints in the building and that all the devices were to be considered mobility devices, even though a resident can not use a geri-chair or lap-buddy to assist with mobility. A review of the facility policy regarding physical restraints revealed to ensure that residents were using the least restrictive restraint and that residents have been assessed for the need of a restraint for safety. The policy stated the nursing staff will evaluate the need for a restraint by trying the least restrictive device possible. If nursing staff are unsure, they will consult with physical therapy and the medical doctor. The MDS coordinator will review physical restraints quarterly along with the care plan review. The policy further included that restraints include, but are not limited to the use of chair alarms, hand mitts, soft ties or vests, wheelchairs, geri-chairs, self-release seat belts, side rails and lap buddies. Practices that meet the definition of a restraint include but are not limited to using devices (e.g., trays, tray tables, bars or belts) that a resident can not remove easily and that prevent the resident from rising when used in conjunction with a chair or wheelchair. The policy also noted that restraints will only be used after alternative methods have been tried, unsuccessfully and upon the written order of a physician which specifies the circumstances (medical symptoms) for the use of the restraint. The order should also include the type of device and the length of time to be used. The need for restraints will be re-evaluated at least quarterly to determine if continued restraint use is necessary to treat the resident's medical symptoms.",2020-09-01
99,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,607,D,1,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to implement their Abuse policy regarding four residents (#18, #49, #58 and #74). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the unit dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. Further review of the facility's investigative report revealed a statement from a staff member who had witnessed the incident, however, there were no statements from other staff and there was no documentation that resident #49 or #74 were interviewed regarding the incident. An interview was conducted with the DON (Director of Nursing/staff #18) on (MONTH) 27, (YEAR) at 12:42 p.m. Staff #18 stated that he did not interview other staff who may have witnessed the incident between resident #49 and resident #74. In a later interview on (MONTH) 27, (YEAR) at 2:16 p.m., staff #18 stated that he did not interview resident #49 or #74, due to the resident's having cognitive impairment. -Resident #18 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 26, (YEAR), a Certified Nursing Assistant (CNA) was providing care to the resident in his room. The CNA called for help and staff assisted the CN[NAME] The resident was observed to be bleeding from a laceration above his eyebrow. When questioned, the CNA stated that the resident had started to become combative during care and was swinging and hit himself in the head, causing the laceration. Further review of the investigative documentation revealed it did not include interviews with other residents, who may have been cared for by this CN[NAME] An interview was conducted with staff #18 at 7:45 a.m. on (MONTH) 28, (YEAR). He said that he was involved in the investigation of this incident and that normally as part of the investigation, they will interview residents who may have received care by the alleged perpetrator. He stated that he thought this had happened for this incident. He said that sometimes the social worker conducts the interviews with the residents. In an interview with the social service director (staff #16) at 8:50 a.m. on (MONTH) 28, (YEAR), he said that he did not interview residents regarding this incident. He said that a few years ago, he used to be more involved in the investigations, but now he does not get very involved in them. During another interview with staff #18 at 1:00 p.m. on (MONTH) 29, (YEAR), he said that he did not locate any interviews with other residents and that this should have been done, as per facility policy. -Resident #58 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A behavior note dated (MONTH) 21, (YEAR) at 9:35 a.m. revealed this writer heard yelling down the hallway and entered the resident's room. The resident was squirming around in her bed, as a CNA (staff #33) was attempting to dress her following a shower. Per the note, the resident stated, she hit me in the face, she's going to be fired. There was no redness, swelling or any injury to the face. The note further included the CNA had stated that the resident hit her and she denied hitting the resident. Review of the facility's investigation revealed that on (MONTH) 21, (YEAR), a licensed practical nurse (staff #54) heard yelling from resident #58's room. Staff #54 entered the resident's room and staff #33 was inside. The resident told staff #54 that staff #33 had hit her in the face. Upon assessment, staff #54 reported that there were no signs of injury. Staff #33 denied striking the resident. Further review of the facility's investigative report revealed there was no documentation that resident #58 was interviewed or that other resident's were interviewed who may have been provided care by this CN[NAME] An interview was conducted with staff #18 on (MONTH) 28, (YEAR) at 12:45 p.m. He stated that he did not have any documentation that the resident was interviewed during the investigation. Review of the facility's Abuse policy revealed that all allegations and signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management. The policy also included that the individual conducting the investigation at a minimum will interview the resident, the resident's roommate, interview other residents to whom the accused employee provides care or services, and interview all staff members who have had contact with the resident(s) during the period of the alleged incident.",2020-09-01
100,DESERT HAVEN CARE CENTER,35062,2645 EAST THOMAS ROAD,PHOENIX,AZ,85016,2018-03-30,608,D,1,1,WXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation, and policies and procedures, the facility failed to ensure that staff reported a reasonable suspicion of a crime to law enforcement regarding a resident to resident altercation involving two residents (#49 and #74). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR) included a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severe cognitive impairment. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. An annual MDS assessment dated (MONTH) 27, (YEAR) included the resident had been assessed with [REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. Further review of the facility's investigative documentation revealed that there was no documentation that law enforcement had been notified. An interview was conducted with the DON (Director of Nursing/staff #18) on (MONTH) 27, (YEAR) at 12:42 p.m. Staff #18 stated that he did not call law enforcement, due to the residents' cognitive impairments and that resident #49 was not able to make informed intent to hit resident #74. Staff #18 stated he had informed staff to report to him and that he would make the determination as to whether a call needed to be made to law enforcement. During an interview with a LPN (Licensed Practical Nurse/staff #63) on (MONTH) 27, (YEAR) at 1:24 p.m., staff #63 stated that she had not witnessed the incident, but she did assess the residents and no injuries were found. Staff #63 stated she did not notify law enforcement, as there was no physical injuries and the incident was defused, immediately. Staff #63 stated she had received in-services regarding reporting of witnessed or suspected crimes to law enforcement, but was unsure of the time frames for reporting and thought reporting was only required if there was physical injury or a huge fight or altercation. An interview was conducted with a CNA (Certified Nursing Assistant/staff #35) on (MONTH) 27, (YEAR) at 2:00 p.m. Staff #35 stated that on (MONTH) 20, (YEAR) during the breakfast meal, she witnessed resident #49 hit resident #74 in the mouth. Staff #35 stated she reported the incident to the nurse. She said that she thought the incident was physical abuse, but did not call law enforcement. Staff #35 stated that the incident occurred on a behavior unit and hitting was one of resident #49's behaviors. Staff #35 stated she had received yearly in-services regarding the reporting of abuse to law enforcement. Review of the facility's policy regarding Reporting Abuse and Witnessed or Suspected Crimes revealed that it was the responsibility of employees, facility consultants, attending physicians, family members, visitors, etc., to immediately report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property, to facility management and all required outside agencies, such as the State Agency and local law enforcement. The policy further included that if staff had reasonable suspicion that a crime had occurred against a person receiving care at this facility, Federal law requires that you report your suspicion directly to both law enforcement and the State Survey Agency.",2020-09-01