22 Reports
Inspection Report — Nov 25, 2025
Complaint Investigation State
Date: Nov 25, 2025
Visit Reason
On-site complaint investigation of complaints AZ00161381/2278158, AZ00168869/2278107, AZ00177824/2278172, AZ00177825/2278173, AZ00180497/2278181, AZ00182234/2278185, and AZ00183178/2278186 at a Nursing Care Institution, conducted 25 November 2025.
Complaint Details
The state risk based survey was conducted October 23, 2025 in conjunction with the investigation of complaints: AZ00161381/2278158, AZ00168869/2278107, AZ00177824/2278172, AZ00177825/2278173, AZ00180497/2278181, AZ00182234/2278185, and AZ00183178/2278186. There were no deficiencies noted.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 7
Inspection Report — Sep 11, 2025
State
Date: Sep 11, 2025
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 11 September 2025.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid Life Safety Code requirements at 42 CFR Subpart 483.90(a). One deficiency was cited related to cooking facilities, but no evidence text was provided.
Deficiencies (1)
Cooking facilities — No evidence text provided for the cited deficiency regarding protection of cooking equipment according to NFPA 96 standards.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 2, 2025
CMS
Date: Jul 2, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with resident rights and safety protocols, specifically regarding the implementation of a password protocol for visitation to protect residents from harm.
Findings
The facility failed to implement and properly document a password protocol for visitation to protect one resident (#634) with cognitive impairment and safety concerns. Interviews and record reviews revealed that the password protocol was not reflected in the resident's care plan or clinical record, and involved staff could not locate documentation of the protocol. This deficiency posed a risk of residents being further victimized.
Deficiencies (1)
Failure to implement and document a password protocol for visitation to protect resident #634 from harm.
Report Facts
Residents affected: 4
Residents affected: 1
Frequency of abuse training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) Staff #77 | Interviewed regarding visitation and abuse definitions | |
| Assistant Director of Nursing (ADON) Staff #39 | Interviewed regarding visitation procedures | |
| Licensed Practical Nurse (LPN) Staff #43 | Interviewed regarding abuse definitions | |
| Director of Social Services (DoSS) Staff #10 | Interviewed regarding abuse training and password protocol documentation | |
| Executive Director (ED) Staff #61 | Interviewed regarding password protocol documentation |
Inspection Report — Oct 16, 2024
Complaint Investigation State
Date: Oct 16, 2024
Visit Reason
On-site complaint investigation of complaints AZ00216706 and AZ00216777 at a Nursing Care Institution, conducted 16 October 2024.
Complaint Details
The complaint survey was conducted on October 16, 2024 of the following complaint #'s AZ00216706 and AZ00216777. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 11, 2024
Complaint Investigation State
Date: Sep 11, 2024
Visit Reason
On-site complaint investigation of complaints AZ00215637 and AZ00215738 at a Nursing Care Institution, conducted 11 September 2024.
Complaint Details
The onsite investigation of complaint AZ00215637 and AZ00215738 was conducted on September 11, 2024. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 11, 2024
State
Date: Sep 11, 2024
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted on 11 September 2024.
Findings
No deficiencies were found during this inspection. The facility met all applicable standards and requirements.
Inspection Report — Sep 6, 2024
Routine CMS
Date: Sep 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including timely notification of resident transfers or discharges, staffing requirements for registered nurses, and proper administration of medications.
Findings
The facility failed to notify the ombudsman of a resident transfer, did not ensure an RN was on duty for 8 consecutive hours on multiple days, and did not administer pain medication according to physician orders for one resident, potentially resulting in inadequate care and risk to residents.
Deficiencies (3)
Failed to notify the ombudsman of resident transfer or discharge.
Failed to ensure a Registered Nurse was on duty for 8 consecutive hours on multiple days.
Failed to administer pain medication according to physician's orders for one resident.
Report Facts
Oxycodone administrations below pain rating parameters in July 2024: 33
Oxycodone administrations below pain rating parameters in August 2024: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #66 | Care Manager Licensed Practical Nurse (LPN) | Provided information about resident #70's care plan and discharge process |
| Staff #167 | Care Manager Licensed Practical Nurse (LPN) | Interviewed regarding emergency transfer of resident #70 |
| Staff #172 | Social Services Staff | Stated unawareness of need to notify ombudsman |
| Staff #52 | Certified Nurse Assistant (CNA) | Interviewed about typical resident care and communication |
| Staff #34 | Director of Nursing (DON) | Interviewed about RN coverage and medication administration expectations |
| Staff #110 | Registered Nurse (RN) | Interviewed about pain medication administration and assessment |
Inspection Report — Sep 6, 2024
Annual Inspection State
Date: Sep 6, 2024
Visit Reason
On-site complaint investigation and annual compliance survey conducted September 3 through September 6, 2024, including investigation of complaints AZ00215422, AZ00193369, AZ00191191, AZ00189364, AZ00188462, AZ00191124, AZ00189363, AZ00188461, AZ00191190, AZ00193367, and AZ00198368 at a Nursing Care Institution.
Complaint Details
The state compliance and recertification surveys were conducted in conjunction with investigations of complaints AZ00215422, AZ00193369, AZ00191191, AZ00189364, AZ00188462, AZ00191124, AZ00189363, AZ00188461, AZ00191190, AZ00193367, and AZ00198368.
Findings
The inspection identified three deficiencies related to failure to notify the ombudsman of a resident discharge, lack of registered nurse coverage for eight consecutive hours on multiple days, and improper administration of pain medication outside physician orders. Plans of correction were provided for all deficiencies.
Deficiencies (3)
R9-10-408 — The facility failed to notify the ombudsman of the transfer or discharge of Resident #70, and documentation of discharge and ombudsman notification was missing.
R9-10-412 — The facility failed to ensure a registered nurse was present and providing direct care for eight consecutive hours on multiple days despite census ranging from 58 to 69 residents.
R9-10-412 — The facility failed to administer pain medication to Resident #15 according to physician's orders, with oxycodone given below the required pain rating multiple times without documentation or physician notification.
Report Facts
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #66 | Care Manager LPN | Interviewed regarding discharge and ombudsman notification for Resident #70. |
| Staff #167 | Care Manager Licensed Practical Nurse (LPN) | Interviewed about transfer of Resident #70 and discharge documentation. |
| Staff #172 | Social Services Staff | Interviewed about awareness of ombudsman notification requirements. |
| Staff #52 | Certified Nurse Assistant (CNA) | Interviewed about staffing and resident care. |
| Staff #34 | Director of Nursing | Interviewed about nurse coverage and medication administration. |
| Staff #110 | Registered Nurse | Interviewed about pain medication administration for Resident #15. |
Inspection Report — Sep 6, 2024
Complaint Investigation CMS
Date: Sep 6, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify the ombudsman of resident transfers or discharges, lack of required registered nurse coverage for 8 consecutive hours during the day, and improper administration of pain medication for a resident.
Complaint Details
The complaint investigation revealed that the facility failed to notify the ombudsman of a resident transfer or discharge, failed to maintain RN coverage for 8 consecutive hours on multiple days, and improperly administered pain medication outside of physician orders for one resident. The deficiencies were substantiated with interviews, record reviews, and policy analysis.
Findings
The facility failed to notify the ombudsman of a resident transfer or discharge, did not ensure an RN was on duty for 8 consecutive hours on multiple days, and administered pain medication outside of physician-ordered parameters for one resident, potentially resulting in inadequate pain management and increased fall risk.
Deficiencies (3)
Failure to provide timely notification to the resident, resident representative, and ombudsman before transfer or discharge.
Failure to have a registered nurse on duty for 8 consecutive hours during the day on multiple dates.
Failure to ensure pain medications were administered according to physician's orders, resulting in administration outside prescribed pain parameters.
Report Facts
Medication administration count: 33
Medication administration count: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #66 | Care Manager Licensed Practical Nurse (LPN) | Interviewed regarding resident #70 transfer and discharge notification |
| Staff #167 | Care Manager Licensed Practical Nurse (LPN) | Interviewed regarding emergency transfer of resident #70 |
| Staff #172 | Social Services Staff | Interviewed regarding awareness of ombudsman notification requirements |
| Staff #52 | Certified Nurse Assistant (CNA) | Interviewed regarding staffing and resident care |
| Staff #34 | Director of Nursing | Interviewed regarding RN coverage and medication administration |
| Staff #110 | Registered Nurse | Interviewed regarding pain medication administration practices |
Inspection Report — Jul 8, 2024
Complaint Investigation State
Date: Jul 8, 2024
Visit Reason
On-site complaint investigation of intakes AZ00212312, AZ00203581, AZ00200491, AZ00198118, and AZ00197277 at a Nursing Care Institution, conducted 8 July 2024.
Complaint Details
An onsite complaint survey was conducted on July 8, 2024 for the investigation of intake #s AZ00212312, AZ00203581, AZ00200491, AZ00198118, AZ00197277. There were no deficiencies cited. Federal comments confirm the same intakes were investigated with no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 5
Inspection Report — Apr 17, 2024
CMS
Date: Apr 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing safe and appropriate dialysis care and services, specifically focusing on dialysis assessments and transportation arrangements for residents requiring dialysis.
Findings
The facility failed to ensure dialysis assessments were completed and transportation to dialysis appointments was arranged for one of three sampled residents (#4). The resident missed a scheduled dialysis session on April 10, 2024, resulting in an emergency room visit. Interviews and record reviews confirmed lack of dialysis assessments and transportation scheduling errors.
Deficiencies (2)
Failure to ensure dialysis assessments were completed for resident #4.
Failure to arrange transportation to dialysis appointments for resident #4, resulting in missed dialysis treatment.
Report Facts
Dialysis frequency: 3
Dialysis appointment time: 1130
Dialysis chair time: 230
Missed dialysis dates: 1
Post dialysis assessments documented: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) staff #90 | Licensed Practical Nurse | Stated no dialysis assessments were completed for resident #4 and responsible for setting up transportation |
| Director of Nursing (DON) staff #88 | Director of Nursing | Confirmed dialysis assessments were not completed and stated expectations for transportation and assessments |
| Unit Clerk staff #76 | Unit Clerk | Responsible for scheduling transportation and explained failure to arrange transport for resident #4 |
| Nurse Care Manager staff #65 | Nurse Care Manager | Conducted admission intake and communicated transportation needs for resident #4 |
| Assistant Director of Nursing (ADON) staff #43 | Assistant Director of Nursing | Provided information on transportation scheduling and resident's hospital stay |
Inspection Report — Apr 17, 2024
Complaint Investigation CMS
Date: Apr 17, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure dialysis assessments were completed and transportation to dialysis appointments was arranged for a resident requiring such services.
Complaint Details
The complaint investigation found that the facility did not complete dialysis assessments or arrange transportation for resident #4, resulting in missed dialysis and an emergency room visit. The deficiency was substantiated with evidence from clinical records, staff interviews, and dialysis center documentation.
Findings
The facility failed to complete required pre- and post-dialysis assessments and did not arrange transportation for a resident (#4) to dialysis appointments, resulting in missed dialysis treatment and an emergency room visit. Interviews with staff confirmed lapses in communication and documentation related to dialysis care and transportation.
Deficiencies (2)
Failure to ensure dialysis assessments were completed for resident #4.
Failure to arrange transportation to dialysis appointments for resident #4.
Report Facts
Dialysis frequency: 3
Dialysis appointment time: 1130
Dialysis chair time: 230
Post dialysis assessments documented: 2
Emergency room visit time: 145
Rescheduled dialysis appointment: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed and stated no dialysis assessments were completed for resident #4. | |
| Director of Nursing (DON) | Interviewed and confirmed no dialysis assessments were completed and discussed expectations for dialysis care. | |
| Unit Clerk | Responsible for scheduling transportation; provided details on transportation lapses for resident #4. | |
| Nurse Care Manager | Conducted admission intake and communicated transportation needs for resident #4. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding transportation and dialysis scheduling issues for resident #4. |
Inspection Report — Jan 31, 2024
Complaint Investigation State
Date: Jan 31, 2024
Visit Reason
On-site complaint investigation of intakes AZ00205760, AZ00205859, and AZ00205835 at a Nursing Care Institution, conducted 31 January 2024.
Complaint Details
The complaint survey was conducted on January 31, 2024 for the investigation of intake numbers AZ00205760, AZ00205859, and AZ00205835. The facility failed to timely report allegations of abuse as required.
Findings
The inspection found two deficiencies related to the facility's failure to timely report an allegation of abuse involving Resident #45 to the State as required by Arizona and federal regulations.
Deficiencies (2)
R9-10-403.E — The facility failed to ensure that an allegation of abuse for Resident #45 was reported to the State within the required time frame despite documented concerns and grievance logs indicating the resident felt abused.
§483.12(c) — The facility failed to report an allegation of abuse for Resident #45 to the administrator and other officials within the required time frames, risking further unreported incidents of abuse.
Report Facts
Deficiencies cited: 2
Inspection Report — Jan 25, 2024
Complaint Investigation State
Date: Jan 25, 2024
Visit Reason
On-site complaint investigation of complaints AZ00205512 and AZ00205307 at a Nursing Care Institution, conducted 25 January 2024.
Complaint Details
The Complaint Survey was conducted January 25, 2024 through January 25, 2024 investigating complaints AZ00205512 and AZ00205307. Federal comments also reference complaints AZ00205510 and AZ00205305. There were no deficiencies cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Nov 29, 2023
Complaint Investigation State
Date: Nov 29, 2023
Visit Reason
On-site complaint investigation of intake AZ00203652 and AZ00203651 at a Nursing Care Institution, conducted 29 November 2023.
Complaint Details
The complaint survey was conducted on November 29, 2023 for the investigation of intake #AZ00203652 and intake #AZ00203651. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Sep 18, 2023
State
Date: Sep 18, 2023
Visit Reason
Inspection of type Other using the Nursing Care Institution worksheet was conducted on 18 September 2023 at SANTE OF MESA.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Sep 11, 2023
State
Date: Sep 11, 2023
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 11 September 2023.
Findings
The inspection found one deficiency related to incomplete COVID-19 reporting to the CDC's National Healthcare Safety Network during a required seven-day period.
Deficiencies (1)
§483.80(g) — The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation, potentially causing more than minimal harm to residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Sep 5, 2023
State
Date: Sep 5, 2023
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 5 September 2023.
Findings
The inspection found one deficiency related to incomplete COVID-19 reporting to the CDC's National Healthcare Safety Network during a required seven-day period.
Deficiencies (1)
§483.80(g) — The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation, potentially causing more than minimal harm to residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 10, 2022
CMS
Date: Nov 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident notification, self-administration of drugs, discharge notification, and food safety in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure residents and/or their representatives were informed about psychotropic medication risks and benefits, medications left unattended with residents not assessed for self-administration, failure to notify the ombudsman of a resident discharge, administration of medication outside physician-ordered parameters, and improper food storage practices in the kitchen.
Deficiencies (5)
Failure to ensure one resident and/or their representatives were informed in advance of the risks and benefits of proposed treatment with psychotropic medications.
Failure to ensure medications were not left unattended for 4 residents who were not assessed for self-administration of medications.
Failure to notify the ombudsman in writing regarding one resident's discharge.
Failure to ensure medications were administered according to physician ordered parameters for one resident.
Failure to ensure food items in the kitchen dry storage were sealed, dated or not expired.
Report Facts
Sample size: 7
Sample size: 16
Sample size: 2
Sample size: 5
Medication administration occurrences: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN/staff #100 | Interviewed regarding psychotropic medication consent |
| Director of Nursing | DON/staff #171 | Interviewed regarding psychotropic medication consent, medication self-administration, and medication administration parameters |
| Licensed Practical Nurse | LPN/staff #107 | Interviewed regarding medication administration observation |
| Registered Nurse | RN/staff #181 | Interviewed regarding medication administration observation |
| Licensed Practical Nurse | LPN/staff #98 | Observed and interviewed regarding medication administration and self-administration |
| Licensed Practical Nurse | LPN/staff #119 | Interviewed regarding medication administration and self-administration |
| Social Services Coordinator | staff #155 | Interviewed regarding ombudsman notification |
| Administrator | staff #182 | Interviewed regarding ombudsman notification |
| Licensed Practical Nurse | LPN/staff #128 | Interviewed regarding medication administration parameters |
| Dietary Manager | staff #139 | Interviewed regarding food storage and labeling |
Inspection Report — Nov 10, 2022
Routine CMS
Date: Nov 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, discharge notification, and food safety at the nursing facility.
Findings
The facility was found deficient in several areas including failure to ensure residents and/or their representatives were informed about psychotropic medication risks, medications left unattended without proper assessment for self-administration, failure to notify the ombudsman of a resident discharge, administration of medication outside physician ordered parameters, and improper food storage practices in the kitchen.
Deficiencies (5)
Failure to ensure residents were fully informed and understood their health status, care, and treatments related to psychotropic medication consent.
Failure to ensure medications were not left unattended for residents who were not assessed for self-administration of medications.
Failure to provide timely notification to the ombudsman regarding a resident's discharge.
Failure to administer medications according to physician ordered parameters for one resident.
Failure to ensure food items in the kitchen dry storage were sealed, dated, or not expired.
Report Facts
Sample size: 7
Sample size: 16
Sample size: 2
Sample size: 5
Number of occasions: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Interviewed regarding psychotropic medication consent and medication administration | |
| Director of Nursing | Interviewed regarding psychotropic medication consent, medication administration, and self-administration policies | |
| Social Services Coordinator | Interviewed regarding ombudsman notification for resident discharge | |
| Administrator | Interviewed regarding ombudsman notification policy | |
| Licensed Practical Nurse | Interviewed regarding medication administration parameters | |
| Dietary Manager | Interviewed regarding food storage and labeling practices | |
| Culinary Services Director | Interviewed regarding food storage and labeling practices |
Inspection Report — Oct 8, 2021
Routine CMS
Date: Oct 8, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, abuse and neglect prevention, infection control, and other facility policies.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with uncovered catheter bags, inconsistent advance directive documentation, improper medication administration resulting in resident death, failure to timely report neglect, improper pain medication administration, inconsistent bathing, unnecessary medication use, and lapses in infection control practices.
Deficiencies (8)
Failure to ensure one resident's urinary catheter bag was covered, compromising dignity and privacy.
Failure to ensure one resident's code status was consistent in the clinical record.
Failure to prevent neglect resulting in administration of oral medications through an intravenous line causing resident death.
Failure to timely report suspected neglect to the State Agency and Adult Protective Services within required timeframe.
Failure to administer pain medications according to physician orders.
Failure to provide consistent showers/bathing to one resident.
Failure to ensure two residents were free from unnecessary medication.
Failure to ensure proper hand hygiene between glove use and urinary catheter bag placement off the floor.
Report Facts
Deficiencies cited: 8
Medication doses: 10
Medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #179 | Certified Nursing Assistant | Mentioned in catheter bag coverage deficiency and infection control observation |
| Staff #159 | Registered Nurse | Mentioned in catheter bag coverage deficiency and infection control observation |
| Staff #182 | Registered Nurse | Involved in medication error leading to resident death |
| Staff #7 | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration and reporting |
| Staff #126 | Registered Nurse | Interviewed regarding advance directive process |
| Staff #176 | Charge Nurse | Involved in code blue response and investigation |
| Staff #180 | Administrator | Interviewed regarding incident reporting and investigation |
| Staff #62 | Assistant Director of Nursing | Interviewed regarding medication administration and bathing policies |
| Staff #37 | Registered Nurse | Interviewed regarding pain medication administration |
| Staff #174 | Certified Nursing Assistant | Observed and interviewed regarding catheter care and infection control |
| Staff #124 | Certified Nursing Assistant | Interviewed regarding bathing documentation |
| Staff #102 | Licensed Nursing Assistant | Interviewed regarding risks of inconsistent showers |
| Staff #212 | Registered Pharmacist | Interviewed regarding medication administration through PICC line |
| Staff #232 | Medical Director | Interviewed regarding medication administration through PICC line |
Inspection Report — Oct 8, 2021
Complaint Investigation CMS
Date: Oct 8, 2021
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident care, medication administration errors, neglect, and infection control issues at the facility.
Complaint Details
The investigation was triggered by complaints regarding neglect and improper medication administration, including a fatal medication error where oral medications were administered through a PICC line, resulting in resident #318's death. The facility failed to report the neglect timely to the State Agency and Adult Protective Services.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter care, inconsistent advance directive documentation, medication administration errors resulting in resident death, failure to timely report neglect, improper pain medication administration, inconsistent bathing care, unnecessary medication use, and lapses in infection prevention and control practices.
Deficiencies (8)
Failure to ensure resident's urinary catheter bag was covered, compromising dignity and privacy.
Failure to ensure consistent and accurate advance directive documentation for resident code status.
Failure to prevent neglect resulting in administration of oral medications through a PICC line causing resident death.
Failure to timely report suspected neglect to State Agency and Adult Protective Services within required timeframe.
Failure to administer pain medications according to physician orders and pain scale parameters.
Failure to provide consistent showers/bathing to resident, resulting in poor hygiene and dry skin.
Failure to ensure residents were free from unnecessary medications.
Failure to practice proper hand hygiene between glove use and failure to keep urinary catheter bag off the floor.
Report Facts
Deficiencies cited: 8
Medication administration times: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #179 | Certified Nursing Assistant | Observed catheter bag uncovered and stated intention to cover it; provided catheter care |
| Staff #159 | Registered Nurse | Interviewed regarding catheter bag policy and hand hygiene; observed catheter care |
| Staff #182 | Registered Nurse | Administered oral medications through PICC line resulting in resident death; suspended and terminated |
| Staff #7 | Director of Nursing | Interviewed about advance directives, medication error, and reporting procedures |
| Staff #180 | Administrator | Interviewed regarding incident reporting and family notification |
| Staff #126 | Registered Nurse | Interviewed about advance directive procedures |
| Staff #37 | Registered Nurse | Interviewed about pain medication administration |
| Staff #62 | Assistant Director of Nursing | Interviewed about medication administration and bathing policies |
| Staff #174 | Certified Nursing Assistant | Observed providing catheter care and interviewed about hand hygiene |
| Staff #124 | Certified Nursing Assistant | Interviewed about bathing documentation practices |
| Staff #102 | Licensed Nursing Assistant | Interviewed about risks of inconsistent showers |
| Staff #212 | Registered Pharmacist | Interviewed about dangers of administering oral meds through PICC line |
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