cms_AZ: 20

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
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