Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 9
Oct 16, 2024
Visit Reason
State-compiled facility profile showing 12 inspections from 2023-09 to 2024-10 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility had several complaint investigations with some deficiencies cited related to discharge notification, nursing coverage, medication administration, dialysis transportation and assessments, abuse reporting, and COVID-19 reporting. Several inspections found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted including complaint numbers AZ00216706, AZ00216777, AZ00215637, AZ00215738, AZ00215422, AZ00193369, AZ00191191, AZ00189364, AZ00188462, AZ00209061, AZ00205760, AZ00205859, and others. Some complaints resulted in deficiencies while others had no deficiencies cited.
Deficiencies (9)
| Description |
|---|
| R9-10-408.D. Except in an emergency, a director of nursing shall ensure that before a resident is discharged: R9-10-408.D.1.b. The state long-term care ombudsman's name, address, and telephone number; - Failed to notify the ombudsman of transfer or discharge for Resident #70. |
| R9-10-412.B. A director of nursing shall ensure that: R9-10-412.B.3. At least one nurse is present and responsible for providing direct care to not more than 64 residents; - Failed to ensure RN coverage for 8 consecutive hours on multiple dates. |
| R9-10-412.B. A director of nursing shall ensure that: R9-10-412.B.7. An unnecessary drug is not administered to a resident. - Failed to administer pain medication according to physician's orders for Resident #15. |
| §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. - Failed to ensure dialysis assessments were completed and transportation arranged for Resident #4. |
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. - Failed to maintain highest practicable well-being by failing to ensure dialysis assessments and transportation for Resident #4. |
| R9-10-403.E. If abuse, neglect, or exploitation of a resident is alleged or suspected to have occurred before the resident was admitted or while the resident is not on the premises and not receiving services from a nursing care institution's employee or personnel member, an administrator shall report the alleged or suspected abuse, neglect, or exploitation of the resident as follows: - Failed to report an allegation of abuse for Resident #45 to the State within required time frame. |
| §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment... are reported immediately but not later than 2 hours after the allegation is made... - Failed to report an allegation of abuse for Resident #45 within required time frame. |
| §483.80(g) COVID-19 reporting. The facility must-- §483.80(g)(1) Electronically report information about COVID-19 in a standardized format specified by the Secretary... §483.80(g)(2) Provide the information specified... at a frequency specified by the Secretary, but no less than weekly to the CDC's NHSN. - Failed to report complete COVID-19 information to CDC's NHSN during required seven-day periods in 2023. |
| §483.80(g) COVID-19 reporting. The facility must-- §483.80(g)(1) Electronically report information about COVID-19 in a standardized format specified by the Secretary... §483.80(g)(2) Provide the information specified... at a frequency specified by the Secretary, but no less than weekly to the CDC's NHSN. - Failed to report complete COVID-19 information to CDC's NHSN during required seven-day periods in 2023. |
Report Facts
Inspections on page: 12
Total deficiencies: 9
Complaint inspections: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #66 | Care Manager LPN | Named in discharge notification deficiency for Resident #70 |
| Staff #167 | Care Manager Licensed Practical Nurse (LPN) | Named in discharge notification deficiency for Resident #70 |
| Staff #52 | Certified Nurse Assistant (CNA) | Interviewed regarding nursing coverage deficiency |
| Staff #34 | Director of Nursing | Interviewed regarding nursing coverage and medication administration deficiencies |
| Staff #110 | Registered Nurse | Interviewed regarding medication administration deficiency for Resident #15 |
| Staff #90 | Licensed Practical Nurse (LPN) | Interviewed regarding dialysis transportation and assessments deficiency for Resident #4 |
| Staff #88 | Director of Nursing (DON) | Interviewed regarding dialysis transportation and assessments deficiency for Resident #4 |
| Staff #76 | Unit Clerk | Interviewed regarding dialysis transportation and assessments deficiency for Resident #4 |
| Staff #65 | Nurse Care Manager | Interviewed regarding dialysis transportation and assessments deficiency for Resident #4 |
| Executive Director | Executive Director | Interviewed regarding abuse reporting deficiency for Resident #45 |
| Social Services Director | Social Services Director | Interviewed regarding abuse reporting deficiency for Resident #45 |
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