Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Capacity: 38
Deficiencies: 3
Date: Oct 23, 2024
Visit Reason
Recertification survey for Medicare under Life Safety Code 2012; facility met standards based on acceptance of plan of correction; four deficiencies related to emergency preparedness and fire safety.
Findings
Recertification survey for Medicare under Life Safety Code 2012; facility met standards based on acceptance of plan of correction; four deficiencies related to emergency preparedness and fire safety.
Deficiencies (3)
Emergency preparedness communication plan and drills
Fire Alarm System installation and marking
Portable Fire Extinguishers maintenance
Inspection Report
Deficiencies: 1
Date: Oct 18, 2024
Visit Reason
The inspection was conducted to assess 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 reported the resident was discharged to a short-term hospital when the resident was actually discharged home with Home Health services.
Deficiencies (1)
Failure to properly complete a Discharge Minimum Data Set (MDS) assessment for Resident #31, causing inaccurate reporting of discharge destination.
Report Facts
Resident ID: 31
Discharge date: Jul 5, 2024
Interview dates: Oct 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/MDS Coordinator | Staff interviewed regarding the inaccurate MDS assessment for Resident #31 | |
| Director of Nursing | Staff interviewed regarding facility expectations for MDS completion |
Inspection Report
Complaint Investigation
Capacity: 38
Deficiencies: 1
Date: Oct 15, 2024
Visit Reason
State compliance survey conducted with complaint investigation; one deficiency cited related to administrator ensuring policies and procedures.
Findings
State compliance survey conducted with complaint investigation; one deficiency cited related to administrator ensuring policies and procedures.
Deficiencies (1)
R9-10-403.C — Administrator policies and procedures
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to allow a resident (#86) to return after hospitalization related to a positive Covid-19 status.
Complaint Details
The complaint investigation found that the facility did not allow resident #86 to return after hospitalization due to Covid-19 positivity. The facility was a Covid-19 free facility and transferred positive residents to hospitals. The resident's family was upset about the readmission denial. Interviews with staff confirmed the facility's policy and lack of implementation of a Covid-19 care unit.
Findings
The facility failed to ensure that resident #86 was permitted to return after hospitalization due to a positive Covid-19 test. The facility did not have a bed-hold policy signed by the resident or family, did not implement a Covid-19 care unit plan, and transferred Covid-19 positive residents to hospitals without documented efforts to provide alternative care or staffing.
Deficiencies (1)
Failure to transfer or discharge a resident without an adequate reason and failure to provide documentation and convey specific information when a resident is transferred or discharged.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding resident transfer and Covid-19 policies |
| Registered Nurse/Critical Nurse Manager | Registered Nurse/Critical Nurse Manager | Interviewed regarding discharge planning and family concerns |
| Administrator | Administrator | Interviewed regarding bed-hold policy and Covid-19 care plan |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to properly transfer and discharge residents, notify residents and ombudsman in writing about transfers, provide bed-hold policy information, and implement infection prevention and control practices.
Complaint Details
The complaint investigation focused on issues related to resident transfers, discharge notifications, bed-hold policy communication, and infection control practices. The investigation found substantiated deficiencies in these areas.
Findings
The facility failed to ensure proper readmission of a Covid-19 positive resident, timely written notification to residents and ombudsman about transfers, and provision of bed-hold policy information to residents. Additionally, the facility failed to follow appropriate hand hygiene and PPE protocols during wound care, potentially risking infection.
Deficiencies (4)
Failed to ensure one resident (#86) was permitted to return to the facility after hospitalization due to positive Covid-19 status.
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 the hospital.
Failed to use appropriate hand hygiene and PPE practices during wound care for resident #18, risking infection.
Report Facts
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident transfer, bed-hold policy, and infection control practices |
| Administrator | Administrator | Interviewed regarding resident transfer policies and notification procedures |
| Registered Nurse | Registered Nurse/Clinical Nurse Manager | Observed and interviewed regarding wound care and infection control practices |
Inspection Report
Capacity: 38
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
Recertification survey for Medicare under Life Safety Code 2012; no deficiencies found.
Findings
Recertification survey for Medicare under Life Safety Code 2012; no deficiencies found.
Inspection Report
Complaint Investigation
Capacity: 38
Deficiencies: 8
Date: Nov 6, 2023
Visit Reason
State compliance survey with complaint investigation; nine deficiencies cited related to transfer/discharge policies, personnel records, infection control, and administrator responsibilities.
Findings
State compliance survey with complaint investigation; nine deficiencies cited related to transfer/discharge policies, personnel records, infection control, and administrator responsibilities.
Deficiencies (8)
R9-10-403.C — Administrator policies and procedures
§483.15(c) Transfer and discharge policies
§483.15(c)(3) Notice before transfer
§483.15(d) Notice of bed-hold policy and return
R9-10-406.F — Personnel record maintenance
R9-10-408.A — Resident transfer/discharge documentation
§483.80 Infection Control
R9-10-422 — Hand hygiene and PPE
Inspection Report
Complaint Investigation
Capacity: 38
Deficiencies: 0
Date: Aug 9, 2023
Visit Reason
Complaint survey conducted with no deficiencies cited.
Findings
Complaint survey conducted with no deficiencies cited.
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. |
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