Deficiencies (last 5 years)
Deficiencies (over 5 years)
26 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
603% worse than Arizona average
Arizona average: 3.7 deficiencies/year
Deficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
51% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding resident-to-resident abuse involving verbal and physical abuse between two roommates at the facility.
Complaint Details
The complaint investigation substantiated that resident #33 physically struck resident #7 on the left arm while the resident was lying in bed. The incident was verified by staff observations and interviews. Resident #7 was moved to another room for safety and emotional wellbeing. The facility concluded the allegation of resident-to-resident abuse was verified.
Findings
The facility failed to protect one resident (#7) from verbal and physical abuse by another resident (#33), resulting in a verified incident of resident-to-resident abuse. The investigation included clinical record reviews, staff and resident interviews, and documentation assessments, revealing behavioral issues and inadequate roommate compatibility assessments.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Report Facts
Facility census: 122
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #25 | Registered Nurse | Witnessed and intervened during the physical altercation between residents |
| Staff #88 | Certified Nurse Assistant | Separated residents during the incident and provided eyewitness account |
| Staff #28 | Social Services Director | Conducted interviews and provided information on roommate compatibility and care planning |
| Staff #15 | Behavioral Health Therapist | Provided behavioral assessments and insights on resident interactions |
| Staff #21 | Registered Nurse | Assessed residents post-incident and coordinated safety measures |
| Staff #100 | Interim Director of Nursing | Discussed roommate assignment policies and safety priorities |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding resident-to-resident abuse involving two residents in a shared room at Sandstone of Tucson Rehab Centre.
Complaint Details
The complaint investigation substantiated that Resident #33 physically struck Resident #7, with staff intervening to separate the residents. The allegation of resident-to-resident abuse was verified by the facility. Resident #7 was moved to another room for safety, and behavioral health interventions were initiated for Resident #33.
Findings
The facility failed to protect Resident #7 from verbal and physical abuse by Resident #33, resulting in verified resident-to-resident abuse. The investigation included clinical record reviews, interviews, and observations, confirming the incident and subsequent interventions including relocation and behavioral health support.
Deficiencies (1)
Failure to protect residents from verbal and physical abuse by another resident.
Report Facts
Facility census: 122
Sample size: 5
BIMS score: 3
Monitoring frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #25 | Registered Nurse | Witnessed and intervened during the altercation between residents |
| Staff #88 | Certified Nurse Assistant | Separated residents during the incident and provided a statement about the event |
| Staff #28 | Social Services Director | Conducted interviews and provided information on room assignment and care planning |
| Staff #15 | Behavioral Health Therapist | Provided behavioral health assessment and information on resident behaviors |
| Staff #21 | Registered Nurse | Responded to the incident and conducted assessments post-incident |
| Staff #100 | Interim Director of Nursing | Provided information on room assignment policies and safety priorities |
| Staff #125 | Insurance Registered Nurse Manager | Expressed concern regarding resident safety and roommate selection |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to multiple allegations and incidents of abuse involving residents and staff, including staff to resident abuse, resident to resident abuse, and failure to timely report abuse incidents.
Complaint Details
The investigation was complaint-driven based on multiple allegations of abuse including staff hitting residents, inappropriate touching, resident to resident physical altercations, and failure to report abuse timely. The complaint was substantiated with evidence from interviews, clinical records, and incident reports.
Findings
The facility failed to protect residents from abuse by staff and other residents, failed to update care plans or review effectiveness after abuse incidents, and failed to timely report abuse allegations to the state agency. Multiple interviews, clinical record reviews, and incident investigations confirmed abuse occurrences and inadequate responses.
Deficiencies (4)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect by staff and other residents.
Failure to timely report alleged abuse to the state agency within required 2-hour timeframe.
Failure to update care plans or review effectiveness of interventions after incidents of resident to resident abuse.
Failure to conduct appropriate assessments such as skin assessments or fall assessments after abuse-related incidents.
Report Facts
Residents affected: 9
BIMS scores: 0
BIMS scores: 15
BIMS scores: 1
BIMS scores: 11
Incident report dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #198 | Certified Nursing Assistant (CNA) | Alleged to have hit Resident #9 and was suspended and banned from agency. |
| Staff #200 | Certified Nursing Assistant (CNA) | Reported witnessing abuse by Staff #198 and described abuse definitions. |
| Staff #154 | Certified Nursing Assistant (CNA) | Involved in care of Resident #10 with allegations of rough treatment and abuse. |
| Staff #93 | Director of Nursing (DON) | Reviewed abuse investigations and confirmed abuse definitions and reporting expectations. |
| Staff #38 | Administrator | Provided statements on abuse reporting procedures and investigation delays. |
| Staff #196 | Certified Nursing Assistant (CNA) | Provided interview on abuse definitions and reporting requirements. |
| Staff #115 | Human Resource Director | Confirmed Staff #198 was an agency CNA and was banned after incident. |
| Staff #50 | Licensed Practical Nurse (LPN) | Provided interview on abuse types and reporting timelines. |
| Staff #155 | Licensed Practical Nurse (LPN) | Provided interview on abuse reporting and resident care refusals. |
| Staff #99 | Certified Nursing Assistant (CNA) | Provided interview on resident refusals and abuse reporting. |
| Staff #118 | Certified Nursing Assistant (CNA) | Provided interview on abuse definitions and reporting. |
| Staff #199 | Staffing Agency Representative | Confirmed Staff #198 was banned from agency. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to multiple allegations and reports of abuse involving residents and staff at Sandstone of Tucson Rehab Centre, including staff to resident abuse, resident to resident abuse, and failure to timely report suspected abuse.
Complaint Details
The complaint investigation involved multiple allegations of abuse including a CNA hitting Resident #9, inappropriate touching of Resident #10 by CNAs, resident to resident altercations involving Residents #41, #42, #16, and #40, and failure to timely report an abuse allegation involving Resident #26. The investigation included interviews with staff, review of clinical records, care plans, incident reports, and facility policies. The allegations were substantiated with findings of abuse and inadequate facility response.
Findings
The facility failed to protect residents from abuse by staff and other residents, failed to update care plans or review effectiveness after abuse incidents, and failed to timely report allegations of abuse to the state agency. Several residents experienced physical and verbal abuse, and investigations revealed inadequate interventions and documentation.
Deficiencies (4)
Failed to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect by staff and other residents.
Failed to timely report suspected abuse to the state agency within required 2-hour timeframe.
Failed to update care plans or review effectiveness of interventions after incidents of resident to resident abuse.
Failed to protect resident from staff to resident abuse and failed to remove or discipline abusive staff appropriately.
Report Facts
Residents affected: 9
BIMS score: 0
BIMS score: 15
BIMS score: 1
BIMS score: 11
BIMS score: 15
Timeframe for abuse report: 2
Date of survey completion: Nov 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #198 | Certified Nursing Assistant (CNA) | Involved in hitting Resident #9 and suspended; agency CNA banned from agency |
| Staff #200 | Certified Nursing Assistant (CNA) | Reported abuse incident involving Resident #9 and staff #198 |
| Staff #196 | Certified Nursing Assistant (CNA) | Provided definition of abuse and reporting procedures |
| Staff #115 | Human Resource Director | Confirmed staff #198 was agency CNA and 'do not return' |
| Staff #38 | Administrator | Discussed abuse reporting and video footage retention |
| Staff #93 | Director of Nursing (DON) | Reviewed abuse investigations and expectations for reporting and removal of perpetrators |
| Staff #154 | Certified Nursing Assistant (CNA) | Involved in care of Resident #10 with allegations of rough treatment |
| Staff #155 | Licensed Practical Nurse (LPN) | Provided statements on abuse definitions and care refusal procedures |
| Staff #99 | Certified Nursing Assistant (CNA) | Provided statements on abuse and care refusal |
| Staff #118 | Certified Nursing Assistant (CNA) | Provided statements on abuse and care refusal |
| Staff #50 | Licensed Practical Nurse (LPN) | Provided statements on abuse examples and reporting requirements |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 19, 2025
Visit Reason
The inspection was conducted in response to complaints alleging resident-to-resident abuse involving residents #200 and #300, and staff-to-resident abuse involving resident #400.
Complaint Details
The complaint investigation was substantiated. Resident #200 was physically abused by resident #300 using an electric wheelchair, causing a 3x1 abrasion. Resident #400 reported abuse by staff member staff #2, who stepped on his foot causing broken toes. The facility substantiated the abuse and took corrective actions including termination of staff #2 and reporting to the board of nursing.
Findings
The facility failed to protect resident #200 from physical abuse by resident #300, resulting in a 3x1 inch abrasion on resident #200's leg. Additionally, resident #400 was subjected to physical abuse by staff member staff #2, who was found to have stepped on the resident's foot causing broken toes. Staff #2 was terminated and reported to the board of nursing.
Deficiencies (2)
Failure to protect resident #200 from physical abuse by resident #300, resulting in injury.
Failure to protect resident #400 from physical abuse by staff member staff #2, including stepping on resident's foot causing broken toes.
Report Facts
Injury size: 3
BIMS score: 7
BIMS score: 7
BIMS score: 9
Timeframe: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #2 | Certified Nursing Assistant | Staff member found to have physically abused resident #400 by stepping on his foot; terminated and reported to board of nursing |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse incidents and facility response |
| Licensed Practical Nurse | LPN | On shift during resident #200 and #300 incident; provided statements about resident #300's behavior |
| Certified Nursing Assistant | CNA | Witnessed and intervened in resident #200 and #300 altercation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 19, 2025
Visit Reason
The inspection was conducted following complaints of abuse involving residents and staff at the facility, including allegations of resident-to-resident physical abuse and staff-to-resident abuse.
Complaint Details
The complaint investigation was substantiated. Resident #200 was physically abused by resident #300 with an electric wheelchair causing a 3x1 inch abrasion and bruising. Resident #400 reported abuse by staff member #2 who stepped on his foot causing broken toes. Staff #2 was terminated and reported to the board of nursing.
Findings
The facility failed to protect residents from physical abuse by other residents and staff. Resident #300 physically assaulted resident #200 with an electric wheelchair causing injury, and staff member #2 was substantiated for physically abusing resident #400 by stepping on his foot, resulting in broken toes. The facility took corrective actions including removal and termination of the abusive staff member.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Report Facts
Abrasion size: 3
Timeframe: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | On shift during resident #200 and #300 incident, documented the event | |
| Certified Nursing Assistant (CNA) | Witnessed and intervened during resident #200 and #300 altercation | |
| Director of Nursing (DON) | Interviewed regarding incidents, confirmed abuse, and reported staff #2 to board of nursing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 13, 2025
Visit Reason
The inspection was conducted due to complaints regarding resident-to-resident abuse incidents involving multiple residents at the facility.
Complaint Details
The complaint investigation verified abuse between Resident #1 and Resident #2, and between Resident #5 and Resident #6. Resident #1 physically assaulted Resident #2 and a CNA; Resident #5 struck Resident #6 after an altercation involving a wheelchair. Both incidents were reported to police and family, and appropriate actions such as resident separation and police involvement were taken.
Findings
The facility failed to protect the rights of 2 of 8 sampled residents from abuse by other residents, resulting in physical altercations and injuries. The incidents were verified by the facility and involved police notification and resident separation.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Report Facts
Residents sampled: 8
Residents affected: 2
BIMS score: 3
BIMS score: 7
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #62 | Licensed Practical Nurse | Attended training seminar and responded to Resident #1 hitting Resident #2 and a CNA |
| CNA #160 | Certified Nursing Assistant | Witnessed and intervened in altercations involving Resident #1 and Resident #5 |
| LPN #15 | Licensed Practical Nurse | Assessed residents after altercation between Resident #5 and Resident #6 |
| ED #100 | Administrator | Described facility's process for handling resident-to-resident abuse and notifications |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 13, 2025
Visit Reason
The inspection was conducted due to allegations of resident-to-resident abuse involving multiple residents, specifically incidents where Resident #1 and Resident #5 physically assaulted other residents.
Complaint Details
The complaint investigation substantiated abuse between Resident #1 and Resident #2, and between Resident #5 and Resident #6. Resident #1 was escorted from the facility by police and discharged. Resident #5 was transferred to a different wing away from Resident #6. The facility verified the alleged abuse and followed notification procedures including family, police, Department of Health Services, and Adult Protective Services.
Findings
The facility failed to protect the rights of 2 of 8 sampled residents from abuse by other residents. Multiple incidents of physical abuse were verified between residents, resulting in police involvement and resident transfers. The facility followed procedures for notification and investigation.
Deficiencies (1)
Failure to protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Report Facts
Sampled residents: 8
Residents affected: 2
BIMS score: 3
BIMS score: 7
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN/Staff #62) | Attended training seminar and responded to abuse incident involving Resident #1 hitting Resident #2 and a CNA | |
| Certified Nursing Assistant (CNA Staff #160) | Witnessed and intervened in abuse incidents involving Resident #1 and Resident #5 | |
| Licensed Practical Nurse (LPN/Staff #15) | Assessed residents after altercation between Resident #5 and Resident #6 | |
| Administrator (ED/Staff #100) | Described facility process for handling resident-to-resident abuse and notifications |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect residents from abuse, specifically a resident-to-resident altercation involving Residents #2 and #4 on August 21, 2025.
Complaint Details
The complaint investigation involved an incident on August 21, 2025, where Resident #4 threatened Resident #2 and attempted to hit him. The facility delayed reporting the incident to state agencies and failed to implement immediate safety measures such as increased monitoring, 1:1 supervision, or immediate room change. The allegation was substantiated by witness statements and facility review.
Findings
The facility failed to protect residents from abuse by not timely reporting a resident-to-resident altercation, not updating care plans, not increasing monitoring or supervision after the incident, and delaying room changes. The investigation verified the abuse allegation and identified deficiencies in policy implementation and reporting.
Deficiencies (3)
Failure to protect residents from all types of abuse including physical and verbal abuse.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of incident: Aug 21, 2025
Date of report submission: Aug 22, 2025
Mental status score Resident #2: 2
Mental status score Resident #4: 3
Behavior shifts Resident #4: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Staff #6 | Licensed Practical Nurse | Created progress notes and notified family of room change |
| Licensed Practical Nurse Staff #8 | Licensed Practical Nurse | Witnessed incident, documented event, conducted resident checks, and interviewed |
| Certified Nursing Assistant Staff #10 | Certified Nursing Assistant | Witnessed altercation, attempted to intervene, reported incident to LPN |
| Director of Nursing Staff #12 | Director of Nursing | Interviewed regarding incident awareness, reporting, and facility expectations |
| Assistant Director of Nursing Staff #14 | Assistant Director of Nursing | Became aware of incident from 24-hour report |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect residents from abuse, neglect, and failure to timely report incidents of resident-to-resident abuse.
Complaint Details
The complaint investigation focused on an incident on August 21, 2025, where Resident #4 threatened and attempted to hit Resident #2. The facility failed to update care plans, increase monitoring, or immediately separate the residents. Reporting to state agencies and family was delayed until August 22, 2025. Interviews with staff including the Director of Nursing and Certified Nursing Assistant revealed failures in timely reporting and appropriate follow-up actions. The allegation was substantiated.
Findings
The facility failed to protect residents from physical and verbal abuse by another resident, failed to implement policies consistently to prevent abuse and neglect, and failed to timely report allegations of abuse to appropriate state agencies and other mandated entities. The investigation verified the abuse allegation and identified deficiencies in monitoring, reporting, and care plan updates following the incident.
Deficiencies (3)
Failure to protect residents from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of incident: Aug 21, 2025
Date of report submission: Aug 22, 2025
Mental status score Resident #2: 2
Mental status score Resident #4: 3
Behavior shifts Resident #4: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant Staff 10 | Certified Nursing Assistant | Witnessed resident altercation and reported incident |
| Licensed Practical Nurse Staff 8 | Licensed Practical Nurse | Documented incident, conducted visual checks, and interviewed regarding abuse reporting procedures |
| Director of Nursing Staff 12 | Director of Nursing | Interviewed regarding incident awareness, reporting failures, and facility expectations |
| Assistant Director of Nursing Staff 14 | Assistant Director of Nursing | Became aware of incident from 24-hour report and involved in follow-up |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 16, 2025
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident abuse involving multiple residents, including physical and verbal abuse incidents reported within the facility.
Complaint Details
The complaint investigation substantiated abuse allegations between residents #77 and #76, and found failure to report and investigate an incident involving residents #69 and #81. The facility did not report the July 12, 2025 incident involving residents #69 and #81 to the State Agency and failed to conduct an investigation. Staff interviews confirmed inadequate responses to incidents and lack of timely reporting.
Findings
The facility failed to protect residents from abuse by other residents, including physical aggression and verbal threats. Additionally, the facility failed to timely report an allegation of abuse to the State Agency and did not conduct a proper investigation into the reported incidents. Staff responses to incidents were inadequate, and training on de-escalation was ongoing.
Deficiencies (2)
Failed to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of incident: Jul 11, 2025
Date of incident: Jul 12, 2025
BIMS scores: 11
BIMS scores: 14
BIMS scores: 13
BIMS scores: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Staff #6 interviewed about incident response and prevention measures |
| Licensed Practical Nurse | LPN | Staff #7 who documented and reported on the July 12, 2025 incident involving residents #69 and #81 |
| Certified Nursing Assistant | CNA | Staff #31 who witnessed the July 11, 2025 physical altercation between residents #76 and #77 |
| Certified Nursing Assistant | CNA | Staff #8 who reported the verbal abuse incident between residents #69 and #81 |
| Administrator | Administrator | Staff #77 who validated incidents and commented on staff responses and training |
| Director of Nursing | DON | Staff #66 who validated incidents and commented on staff responses and training |
| Assistant Director of Nursing | ADON | Staff #32 who discussed abuse reporting policies and incident investigations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 16, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse involving multiple residents, including physical and verbal abuse incidents.
Complaint Details
The complaint investigation involved allegations of abuse between residents #69, #77, #76, and #81. The investigation verified physical abuse between residents #77 and #76. However, an incident involving verbal abuse between residents #69 and #81 was not reported to the state agency and no investigation was conducted until the survey. The facility failed to follow its abuse policy and timely report the incident.
Findings
The facility failed to protect residents from abuse by other residents, including physical and verbal abuse. Investigations confirmed incidents of abuse between residents, and the facility failed to timely report and investigate some allegations, particularly a verbal abuse incident that was not reported to the state agency.
Deficiencies (2)
Failure to protect residents from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents involved in abuse allegations: 4
Dates of incidents: Jul 11, 2025
Dates of incidents: Jul 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | LPN (staff #6 and #7) interviewed regarding abuse incidents and reporting |
| Certified Nursing Assistant | CNA | CNA (staff #31 and #8) witnessed and reported abuse incidents |
| Administrator | Administrator | Administrator (staff #77) involved in interviews and acknowledged failures in reporting and investigation |
| Director of Nursing | DON | Director of Nursing (staff #66) involved in interviews and acknowledged failures in reporting and investigation |
| Assistant Director of Nursing | ADON | Assistant Director of Nursing (staff #32) interviewed regarding abuse policy and reporting |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 22, 2025
Visit Reason
The inspection was conducted to investigate complaints related to abuse and neglect of residents at Sandstone of Tucson Rehab Centre, focusing on incidents involving residents #1, #2, #3, #4, and #5.
Complaint Details
The complaint investigation found substantiated incidents of abuse and neglect involving residents #1, #2, #3, #4, and #5. Physical aggression between residents was documented, including hitting and slapping. Resident #5 sustained a facility-acquired thermal burn from hot coffee due to lack of proper supervision and safety interventions.
Findings
The facility failed to ensure residents were free from abuse and neglect, resulting in actual harm to a few residents. Multiple incidents of physical aggression between residents were documented, including one resident sustaining a burn injury from hot coffee due to inadequate supervision and safety measures.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical and neglect.
Report Facts
BIMS score: 9
BIMS score: 2
BIMS score: 13
BIMS score: 6
Date: Mar 29, 2025
Date: Apr 11, 2025
Date: Apr 13, 2025
Date: Apr 9, 2025
Date: Apr 10, 2025
Date: Apr 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/Staff #112) | Witnessed altercation between Resident #1 and #2 and described aggressive behaviors | |
| Licensed Practical Nurse (LPN/Staff #78) | Described Resident #2's confusion and behaviors post-incident | |
| Assistant Director of Nursing (ADON/Staff #63) | Provided descriptions of residents' behaviors and risks of abuse | |
| Certified Nursing Assistant (CNA/Staff #175) | Observed incident involving Residents #3 and #4 | |
| Activities Assistant (AA/Staff #111) | Present during Resident #5's burn incident and described beverage service | |
| Activities Assistant (AA/Staff #140) | Present during Resident #5's burn incident and described observations | |
| Activities Director (AD/Staff #46) | Described beverage service policies and expectations for resident safety | |
| Administrator (Adm/Staff #187) | Confirmed burn incident and described expectations for staff and safety measures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 22, 2025
Visit Reason
The inspection was conducted due to complaints regarding abuse and neglect of residents at the facility, including physical aggression between residents and a facility-acquired burn injury.
Complaint Details
The complaint investigation found substantiated incidents of abuse and neglect involving residents #1, #2, #3, #4, and #5. Physical aggression between residents was documented, including hitting and slapping. Resident #5 sustained a facility-acquired thermal burn from hot coffee due to lack of proper staff assistance and monitoring. Interviews with staff and residents confirmed these events.
Findings
The facility failed to protect residents from abuse and neglect, resulting in actual harm to a few residents. Incidents included physical aggression between residents, inadequate supervision leading to injury, and a thermal burn from hot coffee due to insufficient staff monitoring.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical and neglect.
Report Facts
BIMS scores: 9
BIMS scores: 2
BIMS scores: 13
BIMS scores: 6
Date of care plan initiation: Mar 29, 2025
Date of care plan revision: Apr 10, 2025
Date of incident: Apr 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/Staff #112) | Witnessed altercation between Resident #1 and #2 and described aggressive behavior | |
| Licensed Practical Nurse (LPN/Staff #78) | Described Resident #2's confusion and behavior after altercation | |
| Assistant Director of Nursing (ADON/Staff #63) | Provided details on residents' behaviors and risks of abuse | |
| Certified Nursing Assistant (CNA/Staff #175) | Observed incident between Resident #3 and #4 | |
| Activities Assistant (AA/Staff #111) | Present during Resident #5's burn incident and described circumstances | |
| Activities Assistant (AA/Staff #140) | Confirmed presence during Resident #5's burn incident and described observations | |
| Activities Director (AD/Staff #46) | Discussed food and beverage safety protocols and response to incident | |
| Administrator (Adm/Staff #187) | Confirmed injury and discussed staff expectations and safety measures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The inspection was conducted due to an allegation of verbal abuse and neglect involving resident #4, focusing on whether the facility reported the allegation to the State Survey Agency within the required timeframe.
Complaint Details
The complaint involved an allegation of verbal abuse and neglect by a CNA (staff #31) toward resident #4. The allegation was not reported to the State Survey Agency within the required timeframe despite being known by multiple staff. The allegation was substantiated by interviews and record review.
Findings
The facility failed to timely report an allegation of verbal abuse and neglect for resident #4 to the State Survey Agency. Interviews with multiple staff and review of records confirmed the allegation was known but not reported as required, posing a risk of continued abuse.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents Affected: 1
BIMS score: 14
Date of survey completion: Mar 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #31 | Certified Nursing Assistant (CNA) | Named in verbal abuse allegation |
| Staff #24 | Certified Nursing Assistant (CNA) | Interviewed regarding abuse reporting procedures |
| Staff #42 | Licensed Practical Nurse (LPN) | Interviewed regarding knowledge of abuse allegation and reporting |
| Staff #63 | Director of Nursing (DON) | Interviewed regarding reporting expectations and knowledge of allegation |
| Staff #57 | Certified Nursing Assistant (CNA) | Interviewed regarding abuse reporting and training |
| Staff #9 | Registered Nurse (RN) | Interviewed regarding abuse reporting procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The inspection was conducted due to an allegation of verbal abuse and neglect involving resident #4, to determine if the facility reported the allegation to the State Survey Agency within the required timeframe.
Complaint Details
The complaint involved an allegation of verbal abuse and neglect by a CNA (staff #31) toward resident #4. The allegation was not reported to the State Survey Agency within the required timeframe. Interviews with multiple staff including CNAs, LPN, RN, and the Director of Nursing confirmed knowledge of the allegation but no timely reporting. The complaint was substantiated as the facility failed to report the abuse allegation as required.
Findings
The facility failed to timely report an allegation of verbal abuse and neglect for one resident (#4) to the State Survey Agency. Interviews with staff and review of records confirmed the allegation was known but not reported as required, posing a risk of continued abuse.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA), staff #31 | Named in verbal abuse allegation toward resident #4 | |
| Certified Nursing Assistant (CNA), staff #24 | Interviewed regarding abuse reporting procedures and resident #4 behavior | |
| Licensed Practical Nurse (LPN), staff #42 | Interviewed regarding abuse reporting and knowledge of allegation | |
| Director of Nursing (DON), staff #63 | Interviewed regarding abuse reporting expectations and knowledge of allegation | |
| Certified Nursing Assistant (CNA), staff #57 | Interviewed regarding abuse reporting and training | |
| Registered Nurse (RN), staff #9 | Interviewed regarding abuse reporting procedures and knowledge of allegation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 17, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate treatment and care according to professional standards, specifically related to neurochecks after a fall and monitoring behaviors prior to medication administration for residents.
Complaint Details
The investigation was complaint-related, focusing on failure to provide appropriate neurochecks after a fall and failure to monitor behaviors before medication administration. The complaint was substantiated based on clinical record review, staff interviews, and policy review.
Findings
The facility failed to ensure that one resident received treatment and care according to professional standards, including inadequate neurochecks after an unwitnessed fall and failure to monitor and document behaviors prior to medication administration for two residents. Interviews with staff and review of policies confirmed these deficiencies, which could lead to harm such as missed brain injuries or over-medication.
Deficiencies (2)
Failure to conduct and document neurochecks as required after an unwitnessed fall for resident #2.
Failure to monitor and document behaviors prior to medication administration for residents #1 and #2.
Report Facts
Sample size: 3
Fall assessment score: 65
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #181) | Interviewed regarding neurochecks and behavior tracking | |
| Registered Nurse (RN/staff #151) | Interviewed regarding neurochecks and medication behavior tracking | |
| Assistant Director of Nursing (ADON/staff #199) | Interviewed regarding neurochecks and medication behavior tracking | |
| Director of Nursing (DON/staff #16) | Interviewed regarding neurochecks and medication behavior tracking |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 17, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication administration, and neurological evaluation following incidents including a resident fall and medication monitoring.
Findings
The facility failed to ensure appropriate treatment and care for a resident who experienced a fall, including incomplete neurological checks. Additionally, the facility did not monitor or document behaviors prior to medication administration for two residents, risking over-medication.
Deficiencies (2)
Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically incomplete neurochecks after a resident fall.
Failed to ensure each resident’s drug regimen was free from unnecessary drugs by not monitoring and documenting behaviors prior to medication administration for 2 out of 3 residents sampled.
Report Facts
Sample size: 3
Fall assessment score: 65
BIMS score: 6
Neurocheck entries: 1
Expected neurocheck entries: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #181) | Interviewed regarding neurocheck procedures and behavior tracking | |
| Registered Nurse (RN/#151) | Interviewed regarding neurocheck procedures and medication behavior tracking | |
| Assistant Director of Nursing (ADON/#199) | Interviewed regarding neurocheck expectations and medication behavior tracking | |
| Director of Nursing (DON/staff #16) | Interviewed regarding neurocheck and medication behavior monitoring expectations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of abuse involving residents #114 and #129, specifically concerning failure to protect residents from abuse including sexual abuse and neglect.
Complaint Details
The complaint investigation substantiated incidents where resident #129 was found with his hand inside resident #114's brief without consent. Both residents were cognitively impaired and unable to consent. Staff interviews revealed inadequate supervision and staffing issues contributing to the incident.
Findings
The facility failed to ensure residents were free from abuse, including incidents where resident #129 was found touching resident #114 inappropriately. Both residents had severe cognitive impairments and were on frequent safety checks, but staff failed to adequately monitor and redirect them. Interviews with staff and nursing leadership confirmed inadequate supervision and inconsistent care plan updates.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Report Facts
Level of Harm: 1
Residents Affected: 2
BIMS Score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant staff #27 | Certified Nursing Assistant | Reported the incident and described staffing and supervision issues |
| Certified Nursing Assistant staff #81 | Certified Nursing Assistant | Found residents during the incident and reported details |
| Licensed Practical Nurse staff #14 | Licensed Practical Nurse | Provided information about residents' conditions and care unit |
| Registered Nurse staff #30 | Registered Nurse | Described response actions and care plan update process |
| Director of Nursing staff #43 | Director of Nursing | Discussed care plan updates, residents' cognitive status, and consent capability |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect residents from abuse, specifically involving incidents of sexual abuse and neglect between residents.
Complaint Details
The complaint investigation found substantiated incidents of sexual abuse involving resident #129 touching resident #114 without consent. Both residents had severe cognitive impairments and were unable to consent. Staffing shortages and inadequate supervision contributed to the incidents.
Findings
The facility failed to ensure residents were free from abuse, including incidents where resident #129 was found touching resident #114 inappropriately. Both residents had severe cognitive impairments and were unable to consent. Staffing levels and supervision were inadequate to prevent these incidents.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Report Facts
BIMS score: 3
Frequency of safety checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Smith | Director of Nursing | Mentioned as the Director of Nursing who stated care plans are updated as needed and commented on residents' consent capability. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident physical abuse involving two residents at the facility.
Complaint Details
The complaint investigation found that resident #2, who required one-to-one supervision, was not adequately watched by staff #46 CNA, allowing resident #2 to leave the bathroom and physically abuse resident #1. The incident was substantiated with multiple staff interviews and documentation including a disciplinary notice for staff #46.
Findings
The facility failed to ensure that two residents were free from physical abuse when resident #2 hit resident #1 multiple times in the head and face with a television remote control. The incident occurred due to inadequate supervision by staff assigned as one-on-one for resident #2, which allowed the altercation to happen.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident due to inadequate supervision.
Report Facts
Date of incident: Oct 19, 2024
Date of disciplinary notice: Oct 21, 2024
Date of resident #2 transfer: Oct 25, 2024
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #46 CNA (Certified Nursing Assistant) | Assigned one-on-one staff for resident #2 who failed to supervise, allowing the abuse incident | |
| Staff #10 CNA | Interviewed staff aware of the incident and supervision requirements | |
| Staff #30 RN (Registered Nurse) | Interviewed staff who explained supervision expectations and incident details | |
| Staff #118 DON (Director of Nursing) | Interviewed staff who stated expectations for resident safety and supervision |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident physical abuse involving two residents at the facility.
Complaint Details
The complaint investigation substantiated that resident #2 physically abused resident #1. Staff failed to provide required one-on-one supervision, which allowed the incident to occur. Resident #2 was moved to another facility following the incident.
Findings
The facility failed to ensure that two residents were free from physical abuse when resident #2 hit resident #1 multiple times with a television remote control, causing injury. The investigation revealed inadequate supervision by staff assigned as one-on-one for resident #2, which allowed the altercation to occur.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident due to inadequate supervision.
Report Facts
Date of incident: Oct 19, 2024
Date of disciplinary notice: Oct 21, 2024
Date of resident #2 transfer: Oct 25, 2024
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) staff #46 | Assigned one-on-one staff for resident #2 who failed to provide adequate supervision | |
| Certified Nursing Assistant (CNA) staff #10 | Interviewed staff aware of the incident and supervision requirements | |
| Registered Nurse (RN) staff #30 | Interviewed staff who explained supervision expectations and incident details | |
| Director of Nursing (DON) staff #118 | Interviewed staff who stated expectations for abuse-free environment and supervision |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent an avoidable elopement of a resident from a secured Behavioral Health Unit (BHU).
Complaint Details
The complaint investigation found that resident #1, considered low risk for elopement, was able to leave the secured BHU unit on September 20, 2024, after a kitchen staff member let him out. Staff attempted to redirect the resident but were unsuccessful. Police and the resident's cousin were contacted to assist. The facility lacked a policy for security doors, and staff interviews confirmed procedural lapses.
Findings
The facility failed to ensure adequate supervision and security to prevent resident #1 from eloping the secured BHU unit on September 20, 2024. Staff allowed the resident to exit the unit without proper authorization, resulting in the resident leaving the facility and requiring police and family intervention. The facility lacked a policy for security doors.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, specifically an avoidable elopement.
Report Facts
Date of survey completion: Sep 26, 2024
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Certified Nursing Assistant | Observed kitchen staff letting resident #1 out and attempted to redirect resident |
| Staff #9 | Licensed Practical Nurse | Explained BHU entry/exit procedures and alerted staff after resident eloped |
| Staff #5 | Cook | Let resident #1 out of secured BHU unit mistakenly thinking he was a visitor |
| Staff #8 | Director of Nursing | Provided information on resident risk assessment and staff expectations for BHU security |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent an avoidable elopement of a resident from a secured Behavioral Health Unit (BHU).
Complaint Details
The complaint investigation found that resident #1, considered low risk for elopement on admission, was able to exit the secured BHU unit on September 20, 2024, after a kitchen staff member let him out. Staff attempted to redirect the resident but were unsuccessful. Police and the resident's cousin were contacted to assist. The facility lacked a policy for security doors, and staff interviews confirmed procedural lapses.
Findings
The facility failed to ensure adequate supervision and security to prevent resident #1 from eloping the secured BHU unit on September 20, 2024. Staff allowed the resident to exit the unit unsupervised, resulting in the resident leaving the facility and requiring police and family intervention. The facility lacked a policy for security doors and staff did not consistently follow procedures to secure exits.
Deficiencies (1)
Failure to ensure an avoidable elopement was prevented, resulting in resident #1 leaving the secured Behavioral Health Unit unsupervised.
Report Facts
Date of survey completion: Sep 26, 2024
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Certified Nursing Assistant | Observed kitchen staff letting resident #1 out of the secured BHU unit and attempted to redirect resident |
| Staff #9 | Licensed Practical Nurse | Described BHU entry/exit procedures and alerted staff after resident #1 left the unit |
| Staff #5 | Cook | Let resident #1 out of the BHU unit on September 20, 2024, mistaking him for a visitor |
| Staff #8 | Director of Nursing | Provided information on resident #1's risk status and expectations for staff regarding BHU security |
Inspection Report
Annual Inspection
Census: 154
Deficiencies: 12
Date: Nov 3, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, resident rights, care planning, medication administration, and food safety.
Findings
The facility was found deficient in multiple areas including failure to serve meals simultaneously to residents at tables, irregular resident council meetings with lack of grievance follow-up, failure to provide resident rights notices, inadequate prevention of resident-to-resident abuse, untimely PASARR referrals, lack of resident participation in care planning, medication administration errors exceeding acceptable rates, expired medications and supplies accessible, inadequate qualifications of the activities director, unsafe medication storage practices, and food safety concerns including improper food temperatures and unsanitary resident refrigerators.
Deficiencies (12)
Failed to ensure meals were provided to residents seated together at the same time, compromising dignity and mental health.
Failed to hold regular resident council meetings and provide documented responses to grievances.
Failed to ensure one resident was informed of their rights during their stay.
Failed to prevent physical abuse of one resident by another resident.
Failed to obtain timely PASARR level II referrals for two residents.
Failed to ensure one resident or representative participated in care planning process.
Failed to administer medications as ordered for three residents, resulting in medication errors.
Activities program was not directed by a qualified professional as the Activity Director lacked required training.
Failed to ensure environment was free from accident hazards due to medications at bedside without proper authorization.
Failed to ensure expired medications and devices were not accessible in medication storage areas.
Failed to ensure food was palatable, served at safe and appetizing temperatures, and food complaints were addressed.
Failed to ensure resident refrigerator was clean, food items were dated, and expired foods were not available for consumption.
Report Facts
Facility census: 154
Medication administration opportunities observed: 27
Medication errors observed: 3
Medication error rate: 11.11
Expired tube feed devices: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #81 | Food Service Director | Interviewed regarding meal service and food safety deficiencies |
| Staff #150 | Administrator | Interviewed regarding meal service, resident council, care planning, and food safety deficiencies |
| Staff #8 | Director of Social Services | Interviewed regarding resident council, grievance process, and PASARR referrals |
| Staff #24 | Director of Nursing | Interviewed regarding medication errors, abuse prevention, care planning, and expired medications |
| Staff #69 | Assistant Director of Nursing | Interviewed regarding resident council and medication storage |
| Staff #80 | Activities Director | Personnel file reviewed and interviewed regarding qualifications |
| Staff #44 | Licensed Practical Nurse | Observed and interviewed regarding medication administration error |
| Staff #17 | Registered Nurse | Observed and interviewed regarding medication administration error |
| Staff #56 | Licensed Practical Nurse | Observed and interviewed regarding medication administration error and medication storage |
| Staff #147 | Licensed Practical Nurse | Observed expired medication in medication cart |
| Staff #131 | Licensed Practical Nurse | Interviewed regarding medication self-administration policies |
Inspection Report
Routine
Census: 154
Deficiencies: 12
Date: Nov 3, 2023
Visit Reason
Routine inspection conducted to assess compliance with regulatory standards including resident rights, care planning, medication administration, food safety, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to serve meals simultaneously to residents at tables, irregular resident council meetings with lack of grievance follow-up, failure to provide resident rights information, inadequate abuse prevention care planning, untimely PASARR referrals, lack of resident participation in care planning, medication administration errors, expired medications and supplies, inadequate activities program staffing qualifications, unsafe medication storage practices, and food safety concerns including improper food temperatures and unsanitary resident refrigerators.
Deficiencies (12)
Meals were not provided to residents seated together at the same time, compromising dignity and mental health.
Resident council meetings were irregular and grievances were not addressed or documented.
One resident was not informed of their rights during their stay.
Failure to ensure one resident was not physically abused by another resident; inadequate care planning for aggressive behaviors.
Failure to obtain timely PASARR level II referrals for two residents.
Failure to ensure one resident or representative participated in care planning process.
Medication administration errors observed for three residents involving wrong medication or dose.
Activities program directed by staff lacking required qualifications.
Medications found at bedside without proper authorization and risk of self-administration.
Expired medications and supplies found in medication storage and carts.
Food served was not consistently palatable or at safe, appetizing temperatures.
Resident refrigerator was unsanitary, contained expired and undated food items, and food was not properly covered during distribution.
Report Facts
Facility census: 154
Medication administration opportunities observed: 27
Medication errors observed: 3
Medication error rate: 11.11
Tube feed tubing expired devices: 13
Food test tray temperatures: 123
Food test tray temperatures: 106
Food test tray temperatures: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding meal service and food safety concerns | |
| Administrator | Interviewed regarding meal service, resident council, care planning, and food safety | |
| Director of Nursing | Interviewed regarding medication errors, abuse prevention, and medication storage | |
| Licensed Practical Nurse (Staff #44) | Observed and interviewed regarding medication administration error | |
| Registered Nurse (Staff #17) | Observed and interviewed regarding medication administration error | |
| Licensed Practical Nurse (Staff #56) | Observed and interviewed regarding medication administration error and medication at bedside | |
| Director of Social Services (Staff #8) | Interviewed regarding resident council, grievance process, PASARR referrals, and care planning | |
| Activities Director (Staff #80) | Personnel file reviewed and interviewed regarding qualifications | |
| Assistant Director of Nursing (Staff #69) | Interviewed regarding resident council, medication at bedside, and resident refrigerator | |
| Licensed Practical Nurse (Staff #131) | Interviewed regarding medication self-administration and risks | |
| Director of Human Resources (Staff #58) | Interviewed regarding activities director qualifications | |
| Ombudsman (Individual #148) | Interviewed regarding resident council meetings and grievances |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
Annual survey inspection of Sandstone of Tucson Rehab Centre to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Sandstone of Tucson Rehab Centre, summarizing the findings of a regulatory survey completed on 2023-09-01.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident (#10) who eloped from the facility, raising concerns about the facility's ability to prevent accidents and ensure resident safety.
Complaint Details
The investigation was unsubstantiated for elopement after the resident left the facility on his own accord. The facility attempted to contact the resident's power of attorney, but the phone number was no longer in service. Police and Adult Protective Services were notified.
Findings
The facility failed to ensure that resident #10, identified as an elopement risk, did not leave the facility unattended. Despite care plans and risk assessments indicating moderate risk, the resident was found outside unsupervised and eventually left the premises without authorization. The facility's monitoring and supervision practices, including reception desk coverage and resident tracking, were found inadequate.
Deficiencies (1)
Failure to ensure one resident (#10) did not elope from the facility, risking physical and/or emotional harm.
Report Facts
Elopement Risk Assessment score: 4
Brief Interview Mental Status Score: 10
BIMS Score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #80 | Licensed Practical Nurse (LPN) | Interviewed regarding resident's whereabouts and actions during elopement incident. |
| Staff #120 | Licensed Practical Nurse (LPN) Unit Manager | Contacted during elopement incident and provided information on resident supervision. |
| Staff #60 | Certified Nursing Assistant (CNA) | Interviewed about resident's statement and actions prior to elopement. |
| Staff #22 | Certified Nursing Assistant (CNA) | Interviewed about smoking area supervision and resident monitoring. |
| Staff #128 | Receptionist | Interviewed about monitoring residents at the smoking area and reception desk duties. |
| Staff #19 | Director of Nursing (DON) | Interviewed regarding facility policies and expectations for resident supervision and elopement risk. |
| Staff #36 | Receptionist | Interviewed about resident supervision and use of binder with pictures of residents not allowed to leave unsupervised. |
| Staff #26 | Receptionist | Interviewed about logging residents in and out and monitoring residents via camera. |
| Staff #1 | Administrator | Interviewed about the resident's elopement status and facility response. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident (#10) who eloped from the facility without supervision, posing a risk of physical and emotional harm.
Complaint Details
The investigation was unsubstantiated for elopement after police and Adult Protective Services were notified. The resident was alert and oriented and left the facility on his own. The facility attempted to contact the resident's power of attorney but was unsuccessful.
Findings
The facility failed to ensure adequate supervision to prevent elopement of a resident at moderate risk. Interviews and documentation revealed lapses in monitoring, lack of a Leave of Absence authorization, and incomplete adherence to facility policies on elopement prevention. The resident left the facility unsupervised and was not located despite police involvement.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, specifically related to resident elopement.
Report Facts
Elopement Risk Assessment score: 4
Brief Interview for Mental Status Score: 10
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #80 | Licensed Practical Nurse (LPN) | Interviewed regarding resident's whereabouts and actions during elopement incident |
| Staff #120 | Licensed Practical Nurse (LPN) Unit Manager | Contacted during elopement incident and provided information on resident supervision |
| Staff #60 | Certified Nursing Assistant (CNA) | Interviewed about resident's statement and actions prior to elopement |
| Staff #22 | Certified Nursing Assistant (CNA) | Interviewed about smoking area supervision and resident monitoring |
| Staff #128 | Receptionist | Interviewed about monitoring residents at the smoking area and front door procedures |
| Staff #19 | Director of Nursing (DON) | Interviewed regarding facility policies and expectations for resident supervision |
| Staff #36 | Receptionist | Interviewed about resident supervision and use of binder for residents not allowed to leave unsupervised |
| Staff #26 | Receptionist | Interviewed about logging residents in and out and monitoring residents on camera |
| Staff #1 | Administrator | Interviewed about the incident and resident's elopement status |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2023
Visit Reason
The inspection was conducted due to complaints and incidents of resident-to-resident abuse and neglect within the facility, involving multiple residents exhibiting aggressive and harmful behaviors toward others.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident abuse involving residents #3, #15, #24, #31, #18, and #9. Incidents included hitting, striking with objects, and verbal aggression. Some residents required hospital evaluation. Staff interviews confirmed the incidents and described behavioral challenges and interventions.
Findings
The facility failed to ensure that residents were free from abuse by other residents, with documented incidents involving physical aggression, hitting, and assault among residents. Staff interviews and clinical records confirmed multiple episodes of abuse with minimal harm but potential for actual harm.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Report Facts
Deficiencies cited: 1
BIMS scores: 0
BIMS scores: 6
BIMS scores: 15
BIMS scores: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding resident #15's behavior and incidents | |
| Registered Nurse (RN) | Interviewed regarding abuse definitions and resident behaviors | |
| Assistant Director of Nursing (ADON) | Interviewed regarding abuse incidents involving residents #24 and #31 | |
| Director of Nursing (DON) | Interviewed regarding facility abuse prevention and specific resident incidents | |
| Nurse Practitioner (NP) | Provided progress notes on resident #9's aggressive behavior and hospital evaluation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of abuse among residents at the facility, focusing on incidents involving multiple residents exhibiting aggressive and harmful behaviors toward each other.
Complaint Details
The complaint investigation was substantiated with findings of multiple incidents of resident-to-resident abuse, including hitting, striking with objects, and physical altercations. The facility documented incidents involving residents #3, #15, #24, #31, #18, and #9, with some residents requiring hospital evaluation. Staff interviews confirmed the abuse and described the facility's efforts to monitor and manage aggressive behaviors.
Findings
The facility failed to ensure that three residents (#3, #24, and #18) were free from abuse by other residents. Multiple incidents of physical aggression, hitting, and assault among residents were documented, with minimal harm or potential for actual harm noted. Staff interviews and clinical record reviews confirmed these events and the facility's response.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Report Facts
BIMS score: 0
BIMS score: 6
BIMS score: 15
BIMS score: 12
Medication dosage: 0.5
Laceration size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN staff #125 | Registered Nurse | Provided interview details regarding abuse definitions and resident behaviors. |
| LPN staff #92 | Licensed Practical Nurse | Described resident #9's aggressive behaviors and conflict with roommate. |
| DON staff #70 | Director of Nursing | Discussed facility efforts to prevent abuse and described resident incidents. |
| ADON staff #8 | Assistant Director of Nursing | Reported on abuse incidents involving residents #24 and #31 and facility response. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 23, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision to prevent a resident's elopement.
Complaint Details
The complaint investigation focused on resident #5's elopement. The resident had a history of elopement and was assessed as medium to high risk. The facility failed to monitor the resident adequately, resulting in the resident leaving the facility undetected overnight. The investigation included interviews with nursing staff, the Director of Nursing, and the facility Administrator. The Administrator did not substantiate the event as an elopement due to the resident's alert and oriented status but acknowledged failures in notification and monitoring.
Findings
The facility failed to provide adequate supervision to resident #5, who eloped by climbing out of a bedroom window and leaving the premises. Interviews and documentation revealed lapses in communication about the resident's elopement risk and inconsistent monitoring practices.
Deficiencies (1)
Failure to ensure adequate supervision to prevent resident elopement.
Report Facts
Elopement Risk Assessment Score: 8
Date of elopement event: Feb 24, 2023
Date of survey completion: Mar 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | RNUM | Provided statement regarding resident's elopement risk and communication. |
| Licensed Practical Nurse | LPN | Interviewed about resident monitoring and knowledge of elopement risk. |
| Director of Nursing | DON | Discussed care plan expectations and monitoring requirements. |
| Facility Administrator | Administrator | Interviewed regarding the elopement event and facility policies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 23, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision to prevent a resident's elopement.
Complaint Details
The investigation was triggered by a complaint related to resident #5's elopement. The resident had a history of elopement and was placed on a secured behavioral unit. The facility did not substantiate the resident leaving as an elopement because he was alert and oriented, but the event was considered a failure in supervision. The resident was found off-site with family after leaving through a window from which the latch and alarm batteries had been removed.
Findings
The facility failed to provide adequate supervision to resident #5, who eloped by climbing out of a secured window and leaving the premises. Interviews and documentation revealed lapses in communication about the resident's elopement risk and inconsistent monitoring practices. The resident was found off-site with family after the elopement. The facility's policies on safety, supervision, and elopement risk were reviewed and found to require proper implementation.
Deficiencies (1)
Failure to ensure adequate supervision to prevent resident elopement.
Report Facts
Elopement Risk Assessment Score: 8
Date of elopement event: Feb 24, 2023
Monitoring interval: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | RNUM | Provided written statement about resident's elopement risk and communication prior to resident's arrival. |
| Licensed Practical Nurse | LPN | Interviewed regarding resident monitoring and knowledge of elopement risk. |
| Certified Nursing Assistant | CNA | Interviewed about frequency of resident checks and monitoring practices. |
| Facility Administrator | Administrator | Interviewed about resident placement, elopement definition, and notification procedures. |
| Licensed Practical Nurse | LPN | Night shift nurse who last saw resident and identified resident missing the following morning. |
| Director of Nursing | DON | Interviewed about care plan expectations and monitoring requirements for elopement risk. |
Inspection Report
Complaint Investigation
Deficiencies: 15
Date: Sep 15, 2022
Visit Reason
The inspection was conducted due to complaint investigations regarding allegations of staff to resident abuse, failure to refer residents with serious mental illness to appropriate authorities, failure to initiate baseline care plans timely, incomplete care plans, failure to meet professional standards of care, inadequate bathing assistance, delayed diagnostic testing, pressure ulcer care deficiencies, behavioral health safety concerns, medication regimen review follow-up failures, food allergy accommodations, infection preventionist designation, COVID-19 notification failures, contract staff vaccination tracking, and staff training deficiencies.
Complaint Details
The visit was complaint-related involving allegations of abuse, neglect, failure to provide appropriate care and services, and regulatory noncompliance in multiple areas as detailed in the findings.
Findings
The facility was found deficient in multiple areas including failure to timely report suspected abuse, failure to refer residents with serious mental illness for PASRR Level II evaluations, failure to initiate baseline care plans within required timeframes, incomplete care plans missing diabetes management, failure to meet professional standards in enteral feeding and medication administration, inadequate bathing assistance, delayed ultrasound testing, inadequate pressure ulcer care and repositioning, failure to transfer or discharge a resident with unsafe behavioral health needs, failure to act on pharmacy medication regimen review recommendations, failure to accommodate resident food allergies, failure to designate a qualified infection preventionist, failure to timely notify residents and families of COVID-19 cases, failure to track vaccination status of contract staff, and failure to provide required staff training on abuse and dementia care.
Deficiencies (15)
Failure to timely report suspected staff to resident abuse within required 2-hour timeframe.
Failure to refer residents with serious mental illness to appropriate state-designated mental health authorities for PASRR Level II evaluation.
Failure to initiate baseline care plans within required 48 hours and failure to provide summary to residents and representatives.
Incomplete comprehensive care plan for resident #19 missing diabetes management and insulin use.
Failure to meet professional standards of care in enteral feeding administration and PICC line medication administration by untrained staff.
Failure to provide bathing assistance twice weekly for residents #38, #510, and #132.
Failure to provide timely ultrasound testing for resident #38 with STAT order.
Failure to provide appropriate pressure ulcer care including turning/repositioning every 2 hours and lack of physician orders for pressure relief surfaces.
Failure to transfer or discharge resident #205 with extensive behavioral health needs endangering self and others.
Failure to act upon pharmacy medication regimen review recommendations for resident #81 regarding heparin discontinuation and Furosemide hold parameters.
Failure to ensure resident #125 was consistently served food that accommodated food allergies.
Failure to designate a qualified infection preventionist on an ongoing basis.
Failure to timely notify residents, representatives, and families of positive COVID-19 cases in the facility.
Failure to track and ensure COVID-19 vaccination status of contracted staff.
Failure to provide evidence of required training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management for contracted staff member.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staff affected: 2
Staff affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #141 | Interim Director of Nursing | Interviewed regarding multiple deficiencies including abuse reporting, care plans, professional standards, COVID-19 notification, and staff training. |
| Staff #120 | Administrator | Interviewed regarding abuse reporting, PASRR process, and staff training. |
| Staff #61 | Director of Social Services | Interviewed regarding PASRR referrals and mental health services. |
| Staff #128 | Licensed Practical Nurse Manager | Interviewed regarding care plans, bathing assistance, and pressure ulcer care. |
| Staff #3 | Dietary Manager | Interviewed regarding food allergy incident. |
| Staff #70 | Registered Nurse Wound Care Nurse | Observed and interviewed regarding pressure ulcer care and turning/repositioning. |
| Staff #102 | Certified Nursing Assistant | Interviewed regarding bathing assistance and shower documentation. |
| Staff #143 | Registered Nurse (Contracted) | Interviewed regarding lack of abuse and dementia training. |
| Staff #80 | Licensed Practical Nurse | Interviewed regarding behavioral health safety concerns. |
| Staff #130 | Registered Nurse | Interviewed regarding care plan completeness. |
| Staff #103 | Licensed Practical Nurse | Interviewed regarding enteral feeding and PICC line medication administration. |
Inspection Report
Complaint Investigation
Deficiencies: 15
Date: Sep 15, 2022
Visit Reason
The inspection was conducted due to complaint investigations regarding allegations of staff to resident abuse, failure to refer residents with serious mental illness to appropriate authorities, failure to initiate baseline care plans timely, incomplete care plans, failure to meet professional standards of care, inadequate bathing assistance, delayed diagnostic testing, pressure ulcer care deficiencies, failure to transfer a resident due to behavioral health needs, medication regimen review issues, food allergy accommodation failures, infection preventionist designation, COVID-19 notification failures, COVID-19 vaccination tracking for contract staff, and staff training deficiencies.
Complaint Details
The investigation was complaint-driven, focusing on allegations of staff to resident abuse, failure to provide appropriate mental health referrals, inadequate care planning, medication errors, infection control deficiencies, and failure to protect residents' safety and rights.
Findings
The facility was found deficient in multiple areas including failure to timely report suspected abuse, failure to complete PASRR Level II referrals for residents with serious mental illness, failure to initiate baseline care plans within required timeframes, incomplete care plans lacking diabetes management, failure to meet professional standards in medication administration and enteral feeding, inadequate bathing assistance, delayed ultrasound diagnostic testing, insufficient pressure ulcer care and repositioning, failure to transfer a resident with behavioral health needs, failure to act on pharmacy medication regimen review recommendations, failure to accommodate resident food allergies, lack of a designated qualified infection preventionist until late August 2022, failure to timely notify residents and families of COVID-19 cases, failure to track COVID-19 vaccination status of contract staff, and failure to provide required staff training on abuse and dementia care.
Deficiencies (15)
Failure to timely report suspected abuse of resident #19 to the State agency within the required 2-hour timeframe.
Failure to ensure residents with serious mental illness (#10, 42, 44) were referred to appropriate state-designated mental health authorities for review.
Failure to initiate baseline care plans within 48 hours and provide summaries to residents and representatives for residents #405, 506, and 510.
Failure to include diabetes management and insulin use in the comprehensive care plan for resident #19.
Failure to meet professional standards of care for resident #16 related to enteral feeding administration and PICC line medication administration.
Failure to provide adequate bathing assistance for residents #38, 510, and 132, resulting in infrequent showers and incomplete documentation.
Failure to provide timely ultrasound diagnostic testing for resident #38 as ordered STAT.
Failure to provide appropriate pressure ulcer care and repositioning every 2 hours for resident #16, resulting in new deep tissue injury.
Failure to transfer or discharge resident #205 with extensive behavioral health needs whose care needs could not be met and who endangered others.
Failure to act upon pharmacy medication regimen review recommendations for resident #81 regarding discontinuation of Heparin and modification of Furosemide hold parameters.
Failure to ensure resident #125 was consistently served food that accommodated his allergies to fish, peaches, and seafood.
Failure to designate a qualified infection preventionist on an ongoing basis until August 25, 2022.
Failure to timely notify residents, representatives, and families of positive COVID-19 cases among staff within required timeframe.
Failure to track and ensure COVID-19 vaccination status of contracted staff entering the facility.
Failure to provide evidence that agency staff RN #143 received training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management.
Report Facts
Residents in sample: 31
Residents in sample: 9
Residents in sample: 5
Staff with positive COVID-19 tests: 2
Days without repositioning: 12
Days between showers: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #141 | Interim Director of Nursing | Interviewed multiple times regarding abuse reporting, care plan expectations, infection prevention, COVID-19 notifications, and staff training |
| Staff #120 | Administrator | Interviewed regarding abuse reporting and PASRR process |
| Staff #61 | Director of Social Services | Interviewed regarding PASRR referrals and mental health services |
| Staff #128 | Licensed Practical Nurse Manager | Interviewed regarding care plan and bathing deficiencies |
| Staff #3 | Dietary Manager | Interviewed regarding food allergy incident |
| Staff #103 | Licensed Practical Nurse | Observed medication and enteral feeding errors |
| Staff #143 | Registered Nurse (Agency) | Lacked documented training on abuse and dementia care |
| Staff #70 | Registered Nurse Wound Care Nurse | Observed wound care and discussed pressure ulcer care deficiencies |
Inspection Report
Routine
Census: 164
Deficiencies: 16
Date: Mar 11, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, resident care, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, incomplete PASARR screenings, inadequate care planning for depression and dietary preferences, failure to report and investigate an injury of unknown origin, incomplete monitoring of psychotropic medication side effects and behaviors, improper medication storage, incomplete nurse staffing postings, inadequate infection control practices including PPE use and COVID-19 testing, and failure to maintain social distancing during communal dining.
Deficiencies (16)
Failure to obtain informed consent for psychotropic medications for residents #58, #74, and #106 prior to administration and failure to correctly identify medication classification on consent forms.
Failure to timely report and thoroughly investigate an injury of unknown origin for resident #78, including failure to notify State Agency, Adult Protective Services, and Ombudsman.
Failure to complete PASARR level 1 screenings for residents #6 and #38 and failure to update PASARR for resident #104 after 30 days.
Failure to develop care plans addressing depression and antidepressant medication for resident #74 and failure to develop care plan addressing Jewish dietary preferences for resident #16.
Failure to have a physician order for hospice care and initial evaluation for resident #16.
Failure to thoroughly address and implement interventions for a fall for resident #131, including absence of floor mats and inadequate supervision.
Failure to have a physician order for oxygen use for resident #358 despite resident receiving oxygen therapy.
Failure to consistently post complete nurse staffing information including clinical staff numbers, scheduled hours, and resident census.
Failure to act timely on pharmacist medication regimen review recommendations for resident #74 regarding medication consents.
Failure to monitor and document side effects and targeted behaviors for psychotropic medications for residents #58, #74, and #78.
Failure to ensure expired medications and glucose test strips were removed and medications stored at proper temperature.
Failure to accommodate resident #16's Jewish dietary preferences including no pork and no dairy with meat.
Failure to maintain quaternary ammonium sanitizing solution at required concentration levels in kitchen sanitation buckets.
Failure to implement infection prevention and control measures including social distancing during communal dining, incomplete staff COVID-19 screening documentation, improper PPE donning and doffing, and incomplete cleaning of eye protection.
Failure to test two staff members (#107 and #212) for COVID-19 at the required twice weekly frequency during outbreak status.
Failure to tie gowns at the waist during COVID-19 testing, increasing infection control risk.
Report Facts
Resident census: 164
Morse Fall Scale score: 80
Morse Fall Scale score: 15
BIMS score: 10
BIMS score: 7
BIMS score: 13
BIMS score: 0
BIMS score: 5
Quaternary ammonium concentration: 100
Quaternary ammonium concentration: 200
COVID-19 staff testing missing: 2
Nurse staffing postings missing: 5
Nurse staffing postings missing clinical staff info: 7
Nurse staffing postings missing census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #51 | Director of Nursing | Interviewed regarding medication consents, monitoring, infection control, and COVID-19 testing |
| Staff #216 | Administrator | Interviewed regarding communal dining, nurse staffing postings, sanitizing solution, and COVID-19 testing |
| Staff #217 | Assistant Administrator | Interviewed regarding nurse staffing postings, sanitizing solution, and COVID-19 testing |
| Staff #143 | Infection Preventionist | Interviewed regarding infection control, PPE, and COVID-19 testing |
| Staff #124 | Dietician | Interviewed regarding dietary assessments and resident #16 preferences |
| Staff #173 | Kitchen Manager | Interviewed regarding dietary preferences and sanitizing solution |
| Staff #180 | Licensed Practical Nurse | Interviewed regarding psychotropic medication monitoring |
| Staff #171 | Licensed Practical Nurse | Interviewed regarding medication regimen reviews and monitoring |
| Staff #96 | Licensed Practical Nurse | Interviewed regarding fall incident and reporting |
| Staff #189 | Licensed Practical Nurse | Interviewed regarding fall incident investigation |
| Staff #90 | Certified Nursing Assistant | Interviewed regarding fall incident |
| Staff #212 | Certified Nursing Assistant | Interviewed regarding fall incident and COVID-19 testing |
| Staff #81 | Licensed Practical Nurse | Interviewed regarding dietary preferences and fall prevention |
| Staff #125 | Certified Nursing Assistant | Interviewed regarding fall prevention |
| Staff #139 | Licensed Practical Nurse | Interviewed regarding medication storage |
| Staff #15 | Licensed Practical Nurse | Interviewed regarding oxygen order |
| Staff #95 | Certified Nursing Assistant | Interviewed regarding PPE donning and COVID-19 testing |
| Staff #47 | Licensed Practical Nurse | Interviewed regarding COVID-19 testing |
| Staff #1 | Certified Nursing Assistant | Interviewed regarding COVID-19 testing |
Inspection Report
Routine
Census: 164
Deficiencies: 15
Date: Mar 11, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including medication consent, abuse reporting, fall investigations, PASARR screening, care planning, medication management, infection control, and COVID-19 protocols.
Findings
The facility failed to ensure informed consent for psychotropic medications was obtained timely for multiple residents, failed to report and investigate an injury of unknown origin thoroughly, failed to complete PASARR screenings timely, failed to develop care plans addressing depression and dietary preferences, failed to have a physician order for hospice care, failed to implement fall prevention interventions fully, failed to have an oxygen order for a resident receiving oxygen, failed to post complete nurse staffing information, failed to act timely on pharmacist medication regimen review recommendations, failed to monitor psychotropic medication side effects and target behaviors consistently, failed to maintain medication storage standards, failed to accommodate dietary preferences, failed to maintain proper sanitizing solution levels, failed to ensure staff COVID-19 testing compliance, and failed to implement infection control measures including proper PPE use and social distancing during communal dining.
Deficiencies (15)
Failure to obtain timely informed consent for psychotropic medications for residents #58, #74, and #106.
Failure to timely report and thoroughly investigate an injury of unknown origin for resident #78.
Failure to complete PASARR level 1 screening for residents #6 and #38 and failure to update PASARR for resident #104.
Failure to develop care plans addressing depression and antidepressant medication for resident #74 and dietary preferences for resident #16.
Failure to have a physician order for hospice care and initial evaluation for resident #16.
Failure to implement fall prevention interventions and ensure fall mats were in place for resident #131.
Failure to have a physician order for oxygen use for resident #358.
Failure to post complete nurse staffing information including clinical staff numbers, scheduled hours, and resident census on multiple days.
Failure to act timely on pharmacist medication regimen review recommendations for resident #74.
Failure to monitor psychotropic medication side effects and target behaviors consistently for residents #58, #74, and #78.
Failure to ensure expired medications and glucose test strips were removed and medications stored at proper temperature.
Failure to accommodate resident #16's Jewish dietary preferences including no pork and no dairy with meat.
Failure to maintain quaternary sanitizing solution at required concentration levels.
Failure to implement infection prevention and control measures including social distancing during communal dining, complete staff COVID-19 screening documentation, proper PPE donning and doffing, hand hygiene, and cleaning of eye protection.
Failure to ensure staff COVID-19 testing was conducted at required frequency for two staff members (#107 and #212).
Report Facts
Resident census: 164
Morse Fall Scale score: 80
Morse Fall Scale score: 15
Quaternary ammonium concentration: 100
Quaternary ammonium concentration: 200
COVID-19 staff testing missing entries: 140
COVID-19 staff testing missing entries: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) staff #180 | Licensed Practical Nurse | Interviewed regarding psychotropic medication consent and monitoring |
| Director of Nursing (DON) staff #51 | Director of Nursing | Interviewed regarding multiple deficiencies including medication consent, monitoring, hospice orders, infection control, and COVID-19 testing |
| Licensed Practical Nurse (LPN) staff #171 | Licensed Practical Nurse Unit Manager | Interviewed regarding medication regimen review and monitoring |
| Social Services Coordinator staff #207 | Social Services Coordinator | Interviewed regarding PASARR screening |
| Dietician staff #124 | Dietician | Interviewed regarding dietary assessment and preferences |
| Kitchen Manager staff #173 | Kitchen Manager | Interviewed regarding dietary preferences and sanitizing solution |
| Housekeeper staff #196 | Housekeeper | Observed and interviewed regarding PPE use and cleaning |
| Certified Nursing Assistant (CNA) staff #95 | Certified Nursing Assistant | Interviewed regarding COVID-19 testing and screening |
| Licensed Practical Nurse (LPN) staff #81 | Licensed Practical Nurse | Interviewed regarding fall prevention and oxygen orders |
| Licensed Practical Nurse (LPN) staff #126 | Licensed Practical Nurse Unit Manager | Interviewed regarding medication monitoring and oxygen orders |
| Certified Nursing Assistant (CNA) staff #125 | Certified Nursing Assistant | Interviewed regarding fall risk and care |
| Licensed Practical Nurse (LPN) staff #47 | Licensed Practical Nurse | Interviewed regarding COVID-19 testing |
| Certified Nursing Assistant (CNA) staff #1 | Certified Nursing Assistant | Interviewed regarding COVID-19 testing |
| Licensed Practical Nurse (LPN) staff #107 | Licensed Practical Nurse | Identified in COVID-19 testing non-compliance |
| Certified Nursing Assistant (CNA) staff #212 | Certified Nursing Assistant | Identified in COVID-19 testing non-compliance |
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