Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
38% better than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Deficiencies: 1
Date: Oct 18, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with proper completion of the Resident Assessment Instrument (RAI), specifically focusing on the accuracy of the Discharge Minimum Data Set (MDS) assessment for Resident #31.
Findings
The facility failed to properly complete the Discharge MDS assessment for Resident #31, resulting in discrepancies between progress notes and the MDS regarding the resident's discharge destination. The RN/MDS Coordinator inaccurately recorded the discharge to a short-term hospital instead of home health, contrary to facility expectations and Medicare guidelines.
Deficiencies (1)
Failure to properly complete a Discharge Minimum Data Set (MDS) assessment for Resident #31, causing inaccurate resident discharge information.
Report Facts
Resident ID: 31
Discharge date: Jul 5, 2024
Discharge summary date: Jul 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/MDS Coordinator | Interviewed regarding the inaccurate MDS assessment for Resident #31 | |
| Director of Nursing | Interviewed regarding facility expectations for MDS completion |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 9, 2023
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to properly transfer and discharge residents, provide timely notification to residents and ombudsman, notify residents of bed-hold policies, and implement infection prevention and control practices.
Complaint Details
The investigation was complaint-driven, focusing on issues related to resident transfers, notifications, bed-hold policies, and infection control. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure proper readmission of a Covid-19 positive resident, timely written notification of transfer reasons to residents and ombudsman, notification of bed-hold policies, and appropriate infection control practices during wound care. Interviews and documentation review revealed multiple deficiencies related to communication, policy implementation, and infection prevention.
Deficiencies (4)
Failed to permit one resident (#86) to return to the facility after hospitalization due to positive Covid-19 status without a signed bed-hold policy.
Failed to provide timely written notification to residents (#86, #26) and ombudsman regarding reasons for transfer and discharge.
Failed to notify residents (#86, #26) in writing about the bed-hold policy upon transfer to hospital.
Failed to use appropriate hand hygiene and PPE practices during wound care for resident (#18), increasing risk of infection.
Report Facts
Date of Covid-19 positive test: Nov 14, 2023
Mental status score: 13
Mental status score: 12
Pressure ulcer size: 3
Pressure ulcer size: 0.8
Vital signs: 112
Vital signs: 121
Vital signs: 72
Vital signs: 102.7
Vital signs: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding resident transfers, Covid-19 policies, and bed-hold policy implementation. |
| Administrator | Administrator | Interviewed regarding facility policies on Covid-19 positive residents and notification procedures. |
| Registered Nurse/Clinical Nurse Manager | Registered Nurse/Clinical Nurse Manager | Observed and interviewed regarding wound care practices and infection control. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements, focusing on treatment and monitoring of a skin injury for resident #86.
Findings
The facility failed to ensure a physician's order was obtained for treatment and monitoring of a skin tear sustained by resident #86 after a fall. The wound care was inconsistently managed, with staff unaware or not responsible for dressing changes, and the Director of Nursing acknowledged the wound should have been monitored with a physician's order.
Deficiencies (1)
Failure to obtain a physician's order to treat and monitor a skin injury for resident #86.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)/Staff #29 | Stated awareness of resident #86's fall and skin tear but did not change dressing as it was the wound nurse's responsibility. | |
| Licensed Practical Nurse (LPN)/Staff #25 | Observed providing wound care; stated unawareness of wound and that an order should have been present to change dressing and monitor infection. | |
| Director of Nursing (DON)/Staff #47 | Acknowledged wound should have been monitored with a physician's order and that she would have followed up if aware of the skin tear. |
Inspection Report
Recertification
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with care standards, specifically focusing on treatment and monitoring of a resident's skin injury.
Findings
The facility failed to ensure a physician's order was obtained to treat and monitor a skin injury for resident #86, resulting in inadequate wound care and oversight. Observations and interviews confirmed the wound was not properly monitored or treated according to policy.
Deficiencies (1)
Failure to obtain a physician's order to treat and monitor a skin injury for resident #86.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (Staff #29) | Interviewed regarding wound care and dressing changes for resident #86 | |
| Licensed Practical Nurse (Staff #25) | Observed providing wound care and interviewed about wound dressing for resident #86 | |
| Director of Nursing (Staff #47) | Interviewed about wound monitoring and physician's order requirements |
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