BROOKDALE SANTA CATALINA
For profit - Corporation
42 Beds
BROOKDALE SENIOR LIVING
Data: November 2025
Trust Grade
60/100
#65 of 139 in AZ
Photo by Brookdale Santa Catalina
Photo by Brookdale Santa Catalina
Photo by Brookdale Santa Catalina
Photo by Brookdale Santa Catalina
1 / 5 photos
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Brookdale Santa Catalina has a Trust Grade of C+, which means it is slightly above average but not exceptional. It ranks #65 out of 139 nursing homes in Arizona, placing it in the top half of facilities in the state, and #8 out of 24 in Pima County, indicating that only a few local options are better. The facility is improving, having reduced its issues from 7 in 2024 to 3 in 2025, and it has a strong staffing rating of 5 out of 5 stars with a turnover rate of 36%, which is lower than the state average of 48%. Notably, there have been no fines, which is a positive sign, and RN coverage is average, meaning residents receive adequate oversight. However, there are some concerns; for instance, residents were not properly notified about hospital transfers, which could disrupt their care, and there were lapses in infection control during medication administration. Additionally, kitchen equipment was found to be defective, raising hygiene concerns. Overall, while there are strengths in staffing and trend improvement, families should be aware of these specific issues.
- Trust Score
- C+
- In Arizona
- #65/139
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 36% turnover. Near Arizona's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Arizona facilities.
- Skilled Nurses ✓ Good
- Each resident gets 49 minutes of Registered Nurse (RN) attention daily — more than average for Arizona. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 46%
No red flags
7 → 3 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 3 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (36%)
12 points below Arizona average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Arizona average (3.3)
Meets federal standards, typical of most facilities
Staff Turnover: 36%
Near Arizona avg (46%)
Typical for the industry
Chain: BROOKDALE SENIOR LIVING
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 30 deficiencies on record
Jun 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that m...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that medications were administered, stored and residents were assessed for self-administration of medication for one residents (#1). The deficient practice could result in medications not being administered according to physician's orders and medications not being stored safely.Findings include:Resident #1 was admitted to the facility on [DATE] with a diagnosis that included pneumonia, acute on chronic systolic (congestive) heart failure, hypertension, major depressive disorder, and urinary tract infection (UTI).Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.0, cognitively intact.During the survey's initial pool on June 24, 2025 at 10:55 AM, in Resident #1's room at the bedside table was a green covered top container which has Flonase label on it stored in a Ziplock bag and Resident stated that it is there to help him breath, he brought it with him, and it has always been on the table just in case he needed it.On June 24, 2025 at 11:03 AM, a Licensed Practical Nurse (LPN)/Staff #100 came in the room. Staff #100 stated that she did not know anything about the medications at bedside. She informed the resident that he is not supposed to have those in his room. Staff #100 identified the following item inside the ziplock bag as Flonase, lubricant eye drops, and Halls cough drops.Review of physician orders revealed an order for the following medications:- On June 24, 2025 at 11:15 AM, cough drops mouth/Throat lozenge 7.6 mg (milligram) give one drop by mouth every 3 hours as needed for cough and/or dry throat;- On June 24, 2025 at 11:15 AM, Artificial Tears Ophthalmic Solution 0.5-0.6 % (Polyvinyl Alcohol-Povidone (Ophthalmic), Instill 2 drop in both eyes every 4 hours as needed for dry eyes allergies; and - On June 24, 2025 at 11:15 AM, Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (microgram/actuation) (Fluticasone Propionate (Nasal), 1 spray in both nostrils every 12 hours as needed for allergies.Review of care plan and progress notes revealed no self-administration of medication assessment documentation.An interview was conducted on June 25, 2025 at 9:21 AM with a LPN/Staff #60. Staff #60 stated that her role includes medication administration, wound care and catheter care. For medication administration, she compares the medication administration record (MAR) to the medication/bubble pack with the name and dosage of the medication. She verifies the resident's name. She stated that she would not leave medications at bedside because it is not safe, it can mess with the ordered medication time, and the resident can hide or store it and not take the medication. She stated that in some facilities, she is not familiar with this facility's policy, that some residents are allowed medications at bedside if it is specified in the physician's order. An interview was conducted on June 25, 2025 at 2:10 PM with the Director of Nursing (DON)/Staff #92. The DON stated that her staff administers medications and should never leave the medications at the bedside unless authorized. She stated that there is self-administration of medication that their residents can do. She stated that the process for self-administration of medication is they complete an assessment. If the resident is cognitively able to do so, the medications are safe at the bedside. She stated that residents should not have medications at bedside if the residents did not have self-administration assessment. Furthermore, the DON stated that if the resident or his or her family brought in the medication, and the resident or his or her family did not disclose of the medication to staff, the resident and his or her representatives will receive an education related to bringing medications from home, the staff will store the medication, and the staff will notify the provider to get an order for the medication. The DON stated that she was made aware of the medications left at bedside for Resident #1. The DON stated that the provider was notified of the medications, and that there was no self-administration of medication assessment completed because the resident did not disclose the medications to the staff. The DON stated that the risk of medications being left at bedside could interfere with other medications if taken inappropriately.Review of facility's policy titled, Resident Self-Administration of Medications, last revised on March 2019 revealed that residents who desire to self-administer medications may do so if the review determines the resident is capable. Policy detail: (3) The result of the Interdisciplinary Team (IDT) assessment is documented on the 'Self-Administration of Medications Data Collection form, which is placed in the medical record;(5) obtain health care provider's order that the resident may self-administer; and (6) the IDT shall develop and implement a care plan to monitor the resident's ongoing ability to self -administer medications.Review of facility's policy titled, Storage and Expiration Dating of Medications and Biologicals, last revised on August 1, 2024 revealed Procedure: (14) Facility should ensure resident medication and biological storage areas are locked and do not contain non-medication/biological items.Review of facility's policy titled, Medication Orders, 2001 Med-Pass, Inc. revealed Supervision by a Physician: (2) a current list of orders must be maintained in the clinical record of each resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident (#332) was free from preventable accidents including oral administration of Dakins solution. The sample size was 13. This deficient practice could result in an adverse event for the resident.Findings include:Resident #332 was admitted on [DATE] with diagnosis including acute and chronic respiratory failure with hypoxia, atrial fibrillation, hypertension, acute pulmonary edema, asthma, and dysphagia. A review of the 5-day MDS (minimum data set) dated April 14, 2025 revealed a BIMS (brief interview of mental status) score of 13, indicating that the resident was cognitively intact. A review of the progress notes revealed that on April 12, 2025 at 7:08 P.M. there was a noted in change in condition. It was documented that vitals taken April 11, 2025 between 9 and 10 P.M. showed an elevated systolic pressure reading of 147 while lying down, pulse, respirations and body temperature were noted to be in the normal range, blood sugars were elevated at 386. Additional documentation revealed that the resident stated that from now on she will drink from her pitcher instead of a cup. Primary care provider feedback noted to encourage the resident to drink plenty of water. It was further documented that the resident had no signs or symptoms of a swallowing disorder and no observed changes in mental of functional status.A progress note dated April 13 2025 revealed that the resident was alert and oriented. No noted pain or discomfort with chewing and swallowing and documentation indicating that the resident denied any gastro-intestinal symptoms.An order summary dated April 14/2025 revealed that the resident is to be monitored and that the physician is to be notified should the resident present with chest pain or tightness, lack of responsiveness, delirium (agitation and confusion), pain in the mouth or through burning, tearing and red eyes, burns to the esophagus-blistering, drooling or gagging sensation and low blood pressure.A review of the facility investigative report revealed that on April 12, 2025 at 2:30 P.M. licensed practical nurse (LPN/ Staff #61) had gathered all her supplies for treatment which included 1/2 strength Dakin's solution, utilized for wound treatment for another resident. It was documented that prior to doing treatment for the other resident, the LPN went into the room of resident #332 to administer her medications. It was noted that the supplies were placed on the medication cart and that the Dakin's solution was placed in a disposable drinking cup which the resident was handed instead of water. It was noted that the resident drank approximately 30 ml of the Dakin's solutions and reported to the LPN that it tasted weird. Staff #61 smelled it and realized that instead of water it was the Dakin's solution. It was noted that the LPN immediately gave the resident more water to drink. It was noted that the resident did not have any complaints of discomfort when swallowing. The provider was notified and staff were ordered to encourage more fluids. Both DON (director of nursing) and ED (executive director) were notified.Dakin's solution, per the NIH (National Institute of Health), National Library of Medicine, is a dilute solution of sodium hypochlorite, which is commonly known as household bleach. It further notes that when properly applied, it can kill pathogenic microorganisms with minimum cytotoxity.No observed evidence in the electronic health record that poison control had been contacted.An interview was conducted on June 25, 2025 at 10:56 A.M. with assistant director of nursing (ADON/ Staff #91) and the nurse practitioner, Staff #210. The ADON stated that nurses who pass meds also conduct the wound care.An interview was conducted June 25, 2025 at 12:14 P.M. with LPN, staff #87. Staff #87 stated that if a resident was administered an incorrect medication or substance, the first step would to identify the error and immediately report it to the DON (director of nursing) or the ADON and then the provider. Staff #87 stated that based on what was administered or ingested, the provider would render guidance on nest steps. The LPN stated that Dakin's solution is a topical used to treat wounds. Staff #87 stated that steps to avoid errors in adminstering medications and or other substances include double checking and taking care with what is provided to the resident.A telephone call was placed on June 25, 2025 at 12:30 P.M. to LPN/ Staff #61. A message was left on the voicemail requesting a call back. A secondary call was placed on June 25, 2025 at 12:50 P.M., the call again went to voicemail and another message was left. No return call received from staff #.A telephone call was placed to resident #332, the call was observed to go to voicemail. A message was left and no return call was received.An interview was conducted on June 25, 2025 at 2:03 P.M. with the DON/ Staff #92. Staff #92 stated that her expectation is for staff to only take those items into the resident rooms that are immediately needed and then to take out any items that were brought into the room after care had been completed. The DON stated that Dakin's solution should not be ingested. Staff #92 stated that she was familiar with the incident and stated that post incident, she would have called poison control; however, review of the electronic health record revealed no evidence that poison control had been contacted. Staff #92 stated that the risk to the resident could include toxicity, diarrhea and nausea. She stated that staff were re-educated on the existing policy regarding hazardous substances and the ADON conducted a full facility sweep to ensure that all hazard substances were locked up.A review of the policy entitled Poison Control with an effective date of October 2015 revealed that if a resident was suspected of taking poison, the charge nurse should notify the healthcare provider and director of clinical services immediately. The policy further stated treatment should be administered as ordered by the healthcare provider, based on poison control recommendations.
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, review of the National Council of State Boards of Nursing (NCSBN) Licensing verification system...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, review of the National Council of State Boards of Nursing (NCSBN) Licensing verification system and interviews, the facility failed to ensure one Licensed Practical Nurse (LPN/Staff #29) had a valid license to practice in the State of Arizona. The deficient practice could lead to care provided to residents not meeting their needs safely and in a manner that promotes residents' rights, physical, mental, and social well-being.
Findings include:
Based on personnel record review, Staff #29 was hired by the facility on [DATE].
Review of the facility's records indicate Staff #29's Practical Nurse (PN) license was valid on [DATE] and the license originated in Texas.
Review of the NCSBN licensing portal revealed that staff #29's PN license was revoked on [DATE].
Review of the facility's investigative report indicated that staff #29 informed the facility, on [DATE], that her license was revoked. The report further indicated that staff #29 was immediately removed from the schedule and placed on suspension.
Review of staff #29's time punch details reveal that she worked 24 shifts between [DATE] and [DATE].
An interview was conducted with the Director of Nursing (DON/staff #22) on February 13, 2025 at 3:45 PM. Staff #22 explained that prior to hire, all clinical staff have their professional licensed verified by her. However, staff #22 was not sure how the facility ensures those professional licenses continue to be valid ongoing. Staff #22 indicated that she thinks the Human Resources department does monthly license checks but she was not sure. When asked what the risks to the residents would be when a staff is not licensed to provide care, staff #22 indicated that the staff would not be able to do procedures and there would be poor client outcomes as a result, they also wouldn't be able to administer medications or might provide inappropriate treatments.
An interview was conducted with the Director of Human Resources (staff #49) on February 13, 2025 at 4:10 PM. Staff #49 explained that prior to bringing in nurses for interviews, they verify the nurses have a valid professional license. She indicated that she had a spreadsheet that tracks everyone's licenses, CPR, Tuberculosis, and fingerprint dates. Staff #49 explained that because staff #29's original PN license was in Texas, the facility was not notified of the license revocation right away. Staff #49 further explained that the HR department does random audits of staff license expiration dates and remind staff of upcoming renewal dates. The audits also included random checks to ensure nursing licenses are valid. Staff #49 was not aware of possible risks to the residents should they receive care from a nurse that has an invalid nursing license. However, she did indicate that she wants residents to receive good care.
On February 13, 2025 at 9:45 AM a policy on employee licenses and qualifications was requested. The facility provided a policy titled, Associate File which was last revised in [DATE]. The policy indicated that the agency-maintained personnel file for employees will contain the certifications/licenses. It also stated It is the responsibility of the Human Resources Department and agency manager to ensure all files are compliant and complete.
Jun 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to develop a complete...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to develop a complete baseline care plan that included the instructions needed to provide effective and person-centered care for one resident (#3). The deficient practice could result in resident care needs not being met.
Findings include:
Resident #3 was admitted on [DATE] with diagnosis including a displaced fracture of the left femur, pain in the left hip, hypertension, Alzheimer's disease, major depressive disorder, fibromyalgia, dementia, and heart disease.
A review of the MDS (minimum data set) revealed a BIMS (brief interview of mental status) score of 11, indicating the resident had moderate cognitive impairment.
A review of the baseline care plan initiated on June 17, 2024 revealed that resident #3 was noted to be a high fall risk and that the call light should be in reach, and that resident needs prompt responses to all requests for assistance, resident encouraged to wear appropriate footwear, occupational and physical therapy evaluations and treatment, cuing and supervision, bed lowered, mats on the floor by the bedside and initiation into the facilities falling star program for fall prevention and management. The care plan further noted that resident #3 had bladder incontinence; however, the care plan revealed no evidence of any interventions.
An interview was conducted on June 24, 2024 at 1:46 P.M. with Social Services Director (SSD/staff #40). Staff #40 stated that the baseline care plan is generated from the nurse admission data collection. She stated that expectation, even for a baseline care plan, would be that interventions for each area of concern are noted. Staff #40 pulled up the care plan and stated that there were no interventions noted for bladder incontinence. She stated that the risk would include, not having the full picture of what the resident's needs are and if the needs and interventions are not properly identified, then staff would not know how to address them.
An interview was conducted on June 24, 2024 at 2:18 P.M. with staff #35 LPN (licensed practical nurse). Staff #35 stated that the baseline care plan is conducted by nursing and does need to include the identified needs of the resident as well as the response or intervention to that need.
An interview was conducted on June 24, 2024 at 2:19 P.M. with staff #2 (ADON/Assistant director of nursing). Staff #2 reviewed the care plan and observed that area for bladder incontinence, he stated that this did not meet his expectations and that an intervention should have been noted for bladder incontinence. Staff #2 stated that the risk could include lack of oversight when it comes to falls, as well as a potential for skin related issues. He further stated that that it could be catastrophic for the resident if they are not being appropriately monitored due to lack of information in the care plan.
A review of the facility policy entitled Interim Care Plan Policy with a revision date of February 2023 revealed that within 48 hours of admission a baseline care plan should be developed to include minimum healthcare information necessary to care for the resident's immediate health and safety needs.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a resident ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a resident was appropriately monitored post fall. The deficient practice could result in residents being injured.
Findings include:
Resident #3 was admitted on [DATE] with diagnosis including a displaced fracture of the left femur, pain in the left hip, hypertension, Alzheimer's disease, major depressive disorder, fibromyalgia, dementia, and heart disease.
A review of the MDS (minimum data set) revealed a BIMS (brief interview of mental status) score of 11, suggesting moderate cognitive impairment.
A review of the baseline care plan initiated on June 17, 2024 revealed that resident #3 was noted to be a high fall risk and that the call light should be in reach, and that resident needs prompt responses to all requests for assistance, resident encouraged to wear appropriate footwear, occupational and physical therapy evaluations and treatment, cuing and supervision, bed lowered, mats on the floor by the bedside and initiation into the facilities falling star program for fall prevention and management. The care plan further noted that resident #3 has bladder incontinence; however, the care plan revealed no evidence of any interventions for bladder incontinence.
A review of the IDT (interdisciplinary team) note, entered by staff #12 RN (registered nurse) revealed an entry for June 19, 2024 noting that staff had responded to noise from the room of resident #3 and found the resident lying on the floor. The entry further noted that staff from the previous shift had reported that the resident had been attempting to transfer and ambulate on her own. It was further noted that as a result, staff were conducting frequent observations, redirecting the resident and were toileting the resident every 2-hours. It was documented that the resident was impulsive and had poor safety awareness.
An interview was conducted on June 24, 2024 at 12:01 P.M. with the daughter (individual #41) of resident #3. Individual #41 stated that on June 19, 2024 at about 6:15 P.M. she had gone to visit her mother. She stated that she had gone to her mother's room and the door to her room was open about 1.5 feet. She stated that a woman came from behind, entered the room and shut the door in the daughter's face. Individual #41 stated that she heard her mother crying and then opened the door and saw that her mother was on the floor. She stated that she asked staff if her mother had fallen and that she was told that she had. She stated that she had observed her mother lying on her side where she just had surgery and that she already had a pillow under her neck. The daughter stated that her mother shared she had to pee and that no one would come to help her. The daughter stated that a CNA (certified nursing assistant) had told her that she had taken resident #3 to the bathroom [ROOM NUMBER] to 13 minutes ago and that she observed her to be fine at that time. The daughter stated that all staff then left the room. She stated that no one was in the resident's room except for her, her husband and mother for about 5 minutes. Daughter stated that she was given no directions by staff, when they left the room. Daughter stated that she had a broken foot and was not able to provide much assistance, but did ask her mother if she would like another pillow. The daughter stated that resident #3 wanted the pillow. Once the pillow was provided, resident #3 pushed herself on her back. The daughter stated that once her mother was taken by the paramedics, none of the staff came back to the room to speak with her. She stated that she had to collect all of her mother's belongings on her own and then exited the building. The daughter came to the facility on June 24, 2024 and showed this surveyor a video recording during the date and time of the incident. The observation of the video recording, revealed that the daughter and son-in-law were left alone with resident #3. Per the video recording, no observation was made that the resident or family members were instructed not to move the resident post fall.
An interview was conducted on June 24, 2024 at 2:18 P.M. with staff #35 LPN (licensed practical nurse). Staff #35 stated that she was alerted by staff that resident #3 had fallen at about 6:15 P.M. She stated that she called the doctor while one staff member ensured that the resident was okay. Once the resident was assessed, she stated that one staff member called 911 and another was filling out the bed hold paperwork. She stated that the daughter was in the room with the resident, while staff were making the necessary calls and completing paperwork. She stated that when emergency medical services arrived the resident was still on the floor and that the resident had been left on the floor for a short amount of time without supervision.
An interview was conducted on June24, 2024 at 1:30 with staff #15 (LPN). Staff #15 stated that the protocol for an unwitnessed fall includes assessing the resident for injuries, initiating neurological checks, calling the provider and conducting the applicable notifications. She stated that first staff have to ensure that the resident is safe, stay in the room with the resident until the resident can be safely moved or until emergency medical personnel arrive. She stated that she was not present when resident #3 fell.
An interview was conducted on June 24, 2024 at 2:19 P.M. with staff #2 (ADON/Assistant director of nursing). Staff #2 stated that post fall, his expectation is that a staff member needs to be with the resident in the room as long as the resident is still on the floor. Staff #2 stated that the risk for not staying in the room with resident could include a worsening of condition, if the resident were to be moved.
A telephonic interview was conducted on June 24, 2024 at 4:29 P.M. with staff #28 (LPN). Staff #28 stated that the resident was left alone in the room but only briefly as staff were going back and forth into the room. She stated that someone should have stayed in the room with her at all times. She stated that the fall had occurred in the middle of report/ shift change and that it was a very hectic time. She stated that the resident's initial neurological checks were fine. She further stated that there was a risk for leaving the resident on the floor without staff present, but did not indicate what the risk was. She further stated that she could not recall if anyone had informed the resident or family that the resident should not be moved.
A review of the facility policy entitled Incident/ Accident Reporting with a revision date of October 2016 revealed that when a resident sustains a fall, that the extent and injury should be evaluated, health care provider notified and if an unwitnessed head trauma., the resident should be observed for neurological abnormalities. Neither Incident reporting or Falls Management Policy with a revision date of January 2024, provided instructions regarding direct observation and resident movement after a fall had occurred.
May 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one resident (#79) was given a bed-hold policy before a tra...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one resident (#79) was given a bed-hold policy before a transfer to the hospital. The deficient practice may result in the resident and resident representative not being aware of the bed-hold policy and their right to return to the facility immediately after hospital discharge.
Findings included:
Resident #79 was admitted to the facility on [DATE] with diagnoses that included dementia, fracture of the right femur, and heart disease.
Review of a bed hold agreement signed by the resident on admission dated April 4, 2024 revealed the resident agreed with bed hold in the event the resident was admitted to the hospital.
A review of the 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment.
A progress note dated April 14, 2024 revealed resident #79 was sent to the hospital due to a surgical site assessed as red and hot. The note also indicated that the resident's son was made aware of the transfer. There was no evidence that the bed-hold policy was provided to the resident and/or their representative upon transfer.
An interview was conducted on May 1, 2024 at 9:36 A.M. with Licensed Practical Nurse (LPN/Staff #28). Staff #28 indicated that the bed-hold policy was provided to the resident or their family at the time of discharge if possible. Staff #28 reviewed resident #79's records and could not confirm if resident received the bed-hold policy as the staff was not able to locate it in the record.
An interview was conducted with the Director of Social Services (SSD/Staff #45) on May 1, 2024 at 10:55 A.M. When asked when are bed-hold notices provided to residents and/or their representative when they transfer to a hospital, staff #45 indicated that the nursing and admission team will talk with the resident and ask them if they want their bed held. Staff #45 also indicated that the business office will coordinate bed-holds with residents that are private-pay.
An interview was conducted with the Administrator (staff #33) on May 1, 2024 at 1:30 P.M. The Administrator indicated that the bed-hold policy is in the admission packet which they review and sign upon admission. Staff #33 also indicated the bed-hold policy was reviewed with residents or their representatives when they are transferred to the hospital.
A training document titled Bed Hold Policy was provided by the facility. The document was dated May 1, 2024 at 2:30 P.M. The document revealed that training was conducted by staff #45 and five administrative staff members were in attendance. The training revealed that the bed-hold policy was reviewed at admission and at the time of transfer to the hospital.
A review of the facility policy titled Bed-Hold Policy revised on December 2016, indicated a resident and their representative should be informed of the bed hold policy at admission and at time of transfer to the hospitalization or therapeutic leave.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one resident (#20) and their representative were provided w...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one resident (#20) and their representative were provided with a summary of the baseline care plan. The deficient practice could result in residents and their representative not receiving a summary of their baseline care plan.
Findings included:
Resident #20 was admitted to the facility on [DATE] with diagnoses that included noninfective gastroenteritis and colitis, neurocognitive disorder with lewy bodies, and type 2 diabetes mellitus.
A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. The MDS also noted that the resident participated in goal setting.
Review of records revealed a comprehensive care plan was developed on April 4, 2024 and a collaborative care review was conducted with the Interdisciplinary Team (IDT) on April 8, 2024.
During an interview on 4/30/24 at 3:40p, with the social services director, she stated the interim care plan is created using nursing admission data collection. When asked if residents sign the care plan or an attestation, she stated all residents ae given a copy of their care plan and the RAI (Resident Assessment Instrument) Coordinator goes over it with the resident.
Further review of records revealed no evidence that the baseline care plan was provided to the resident and/or to their representative.
An interview was conducted with the RAI Coordinator (staff #8) on April 30, 2024 at 3:45 P.M. She stated that she was responsible for completing resident's baseline care plan and that it was generated from initial interviews on admission. In addition, staff #8 stated baseline care plans were signed by the residents, scanned into their electronic health record, and a copy was provided to the residents and/or their representative. Staff #8 said that she was new in the position and was informed today, April 30, 2024, that she would be responsible for reviewing interim care plans and having the residents sign them. She said that currently residents were not provided a copy of their baseline care plan. Staff #8 stated that she will review the last four and a half months of admissions and have residents or their representatives sign their basic care plan and provide them with a copy. Regarding resident #20, staff #8 was unsure whether he was provided with a copy of his care plan and that she would provide him with one.
An interview was conducted on May 1, 2024 at 3:02 P.M. with the Director of Nursing (DON) and she stated that her expectation was for resident to get a copy of their baseline care plan prior to their comprehensive care plan. The DON stated that interim care plans were signed and a copy were given to residents along with a copy of their prescribed medication list. She also stated that it was then scanned into the resident's electronic chart.
Review of the facility policy titled, Interim Care Plan Policy, reviewed on February 2024 revealed, The resident and/or legal representative should be informed of the interim care plan; the resident and/or legal representative should be provided a summary of the Interim Care Plan; notification of the resident and/or legal representative of the Interim Care Plan should be noted in the resident record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews, the facility failed to ensure two residents (#26 and #79) and their representati...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews, the facility failed to ensure two residents (#26 and #79) and their representatives were notified, in writing, of the reason for a transfer to the hospital. The deficient practice could result in residents being inappropriately transferred or discharged and not having a continuity of care once leaving the facility.
Findings included:
Regarding Resident #26
Resident #26 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, acute respiratory failure, and unsteadiness on their feet.
A review of the admission Minimum Data Set (MDS), assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment.
A progress note by social services dated February 14, 2024 at 11:01 A.M. revealed the resident's wife was contacted regarding the resident's behavior from the previous night.
Review of physician order with a revision date of February 16, 2024 revealed an order to send resident #26 to the emergency room for an evaluation of hypotension and hypoxia.
A progress notes dated February 16, 2024 indicated the resident was taken to the hospital due to a change of condition, hypoxia and hypotension.
Further review of record revealed no evidence that the resident and/or the resident's representative was notified of the transfer to the hospital.
An interview was conducted on May 1, 2024 at 11:52 A.M. with the Director of Social Services (SSD/staff #45). Staff #45 indicated the facility called the hospital to inform the resident about the bed hold but found the resident had passed away on February 18th in the hospital.
Regarding Resident #79
Resident #79 was admitted to the facility on [DATE] with diagnoses that included dementia and fracture of the right femur.
A review of the 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS score of 08 indicating moderate cognitive impaired.
A progress note dated April 14, 2024 indicated resident #79 was sent to the hospital. The same note indicated the resident's son was made aware of the transfer. It did not indicate how the son was made aware.
An interview was conducted with the Licensed Practical Nurse (LPN/Staff #28) on May 1, 2024 at 9:36 A.M. Staff #28 indicated that she will provide the resident with a copy of their care plan and print out any orders once they are discharged . Staff #28 also indicated that when there is a transfer, a floor nurse will notify the family of the transfer, verbally. It is then documented in a progress note in the resident's chart.
An interview was conducted with the SSD (staff#45) on May 1, 2024 at 10:55 A.M. When asked how the facility notifies the resident and their representative of a transfer or a discharge to a hospital, staff #45 indicated the floor nurse will inform both of them verbally.
An interview was conducted on the administrator (ADM/Staff #33) on May 1, 2024 at 1:30 P.M. Staff #33 indicated that facility staff will call the resident and their representative and inform them verbally of their transfers. Staff indicated that in most cases, they are notifying their power of attorney.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations, staff interviews, and record review, the facility failed to ensure infection control protocols were followed during medication administration for two residents (#179 and #6). Th...
Read full inspector narrative →
Based on observations, staff interviews, and record review, the facility failed to ensure infection control protocols were followed during medication administration for two residents (#179 and #6). The deficient practice could result in the development and transmission of infections.
Findings included:
An observation of a medication administration was conducted on April 30, 2024 at 7:30 A.M. with licensed practical nurse (LPN)/staff #35). Staff #35 dispensed resident #179's medications that included an aspirin 81 milligrams (mg) tablet, calcium with vitamin D tablet, colace 100 mg capsule, folic acid tablet, multivitamin with minerals tablet, omega-3 capsule (fish oil) 500 mg capsules, vitamin C 500 mg give tablets, bupropion tablet, duloxetine hydrochloride 60 mg capsule, hydrochloroquine sulfate tablet, isosorbide extended release half a tablet (15 mg), meclizine hydrochloride 25 mg tablet, and pregabalin 100 mg capsule into a medication cup. After dispensing the medications, staff #35 locked the medications cart and signed out of the computer. At approximately 7:50 A.M. staff #35 entered resident #179's room without performing hand hygiene. Staff #179 administered the resident's medications without performing hand hygiene. After administering the resident's medications staff #179 exited the resident's room without performing hand hygiene and proceeded to move the medication cart outside of resident #6's room.
On April 30, 2024 at approximately 7:53 A.M. staff #35 began dispensing resident #6's medications without performing hand hygiene. Staff #35 opened a pro-stat medication container and poured 30 milliliter (ml) in a graduated medicine cup for resident #6. Additional medications were dispensed in a medication cup to include amiodarone 200 mg tablet, eliquis 5 mg tablet, lisinopril 40 mg tablet, metformin 500 mg tablet, pantoprazole sodium 20 mg tablet, tamsulosin 0.4 mg tablet, vitamin C 500 mg tablet, among others. Staff #35 locked her screen and cart and proceeded to administer medications to resident #6 without performing hand hygiene. Staff #35 did not perform hand hygiene before and after administering medications to resident #6.
An interview was conducted on April 30, 2024 at 8:16 A.M. with LPN (staff #35) regarding hand hygiene. Staff #35 stated that hand hygiene are performed in between residents and in the resident room. Staff #35 added that she has a sanitizer on top of her medication cart that can be used to perform hand hygiene.
An interview was conducted with the Director of Nursing (DON/staff #12) on May 1, 2024 at 2:23 P.M. The DON stated that staff should be sanitizing their hands, and unless visibly soiled then soap and water were used. The DON stated her expectation was that staff sanitized their hands before and after patient care, during medication administration, and in between rooms and medication administrations. The DON added that there were sanitizers on the medication carts that staff can use. The DON stated that the risk for not performing hand hygiene was the potential for infection, and that hand hygiene minimized the spread of infection and cross contamination.
A review of the facility's policy, Bloodborne Pathogens Exposure Control Plan effective May 2001, and last revised on September 2019 revealed, All associates should practice handwashing using the following guidelines. Associates should wash their hands between care of residents.
Review of the policy titled, Handwashing/Hand Hygiene effective October 2015, last revised January 2021, revealed that all associates shall follow handwashing/hand hygiene procedures to help prevent the spread of infections to other associates, residents, and visitors. Centers for Disease Control and Prevention (CDC) recommends using alcohol based hand sanitizer with 60-95% alcohol in healthcare settings before and after direct contact with residents, and before preparing or handling medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review, the facility failed to ensure kitchen equipment was in proper working order.
Findings include:
A review of the facility's Food Safety Inspection ...
Read full inspector narrative →
Based on observations, interviews, and record review, the facility failed to ensure kitchen equipment was in proper working order.
Findings include:
A review of the facility's Food Safety Inspection Report, dated January 13, 2024, indicated that the electric meat slicer plastic food contact plate was cracked.
An observation was conducted on April 29, 2024 at 10:45 A.M. of the facility's kitchen and observed that the same plastic food contact plate was still cracked, the meat slicer was not covered, and did not have an out of order sign posted.
A second observation was conducted on April 30, 2024 and the meat slicer was in the same condition as observed yesterday on April 29, 2024.
On May 1, 2024 at 9:00 A.M. a copy of the work order was requested from the facility to determine what was being done to fix the machine.
On May 1, 2024, the facility Administrator (staff #33) provided a copy of the work order dated May 1, 2024 at 9:15 A.M.
An interview was conducted with the Administrator (staff #33) on May 1, 2024 at 10:10 A.M. The Administrator provided a purchase order, dated May 1, 2024 at 9:58 AM, for a new food contact plate. He also provided a picture of the meat slicer with a sign stating Out of Order on a plastic bag covering the meat slicer. The Administrator did not know whether the meat slicer was being used to prepare food for residents after the Food Safety Inspection identified the cracked contact plate or before the Out of Order sign was displayed. When asked why the replacement part was not ordered prior to May 1, 2024 and not when the county food inspection report came in, he indicated that he was not aware it was broken until today.
An interview was conducted with the Head Chef (staff #46) on May 1, 2024 at 10:24 AM. He indicated the meat slicer part was still on order. He also indicated that he had adjusted his food ordering process to have sliced meats and cheese delivered due to not having a functioning meat slicer. When asked why the meat slicer was not repaired during the time in between the county food inspection in January until now, staff #46 indicated that he did not know why it was not fixed and he was not surprised it was taking this long. He indicated that sometimes he has a tough time getting facility maintenance to fix things.
An interview was conducted with the Maintenance Director (staff #13) on May 1, 2024 at 12:59 P.M. Staff #13 indicated that when an equipment broke down, staff are to inform the department manager and to put the order in. The Maintenance Department will either do the repair in-house or contract out the work. When asked if he received a work order for the meat slicer in the kitchen, he indicated it was probably overlooked as they had several issues around that time. Staff #13 indicated that he was verbally informed of the issue this morning so he went online to look for a replacement part.
A second interview was conducted with Administrator on May 1, 2024 at 1:30 P.M. The Administrator's expectation was that staff inform him and the Maintenance Director of any equipment failure in the kitchen immediately so they can get fixed. Staff #33 indicated that he had changed the process moving forward and that all issues will going to him directly.
A review of the facility policy titled, Maintenance Service which was last revised in December of 2009, indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Jan 2023
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility's policy, the facility failed to ensure one resident's (#140...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility's policy, the facility failed to ensure one resident's (#140) advance directives were completed upon admission. The deficient practice could result in resident's advanced directives not being known or honored.
Findings include:
Resident #140 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of pelvis, atherosclerotic heart disease of native coronary artery without angina pectoris, and essential hypertension.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 99 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills and cognitive impairment.
Review of the resident's physician orders conducted on January 3, 2023 revealed no order for a code status.
Review of the advance directive paperwork revealed that it had been completed upon admission.
Additional review of the clinical record revealed the advance directive was not completed until January 4, 2023, the day the document was requested by the surveyor.
During an interview conducted with a licensed practical nurse (LPN/ staff # 82) on January 5, 2023 at 3:05 p.m., she stated upon admission, an advance directive form is offered to the resident and/or responsible party as soon as possible. She stated that if a resident did not have the capacity to make decisions, then she would phone the responsible party to obtain a verbal advance directive. Staff #82 stated the order is inputted in the point-click-care (PCC), then given to the physician for signature.
An interview was conducted with staff the regional nurse (staff #81) on January 5, 2023 at 3:27 p.m. She stated the nurse fills out the advance directive during admission. If a resident is a do not resuscitate (DNR), an orange form will be signed by a resident and/or responsible party, and the physician. The code order is inputted in the PCC after the provider signs the form. Staff #81 stated, it is her expectation that advance directives are completed at the time of admission. She stated there is a risk of not following the resident and/or responsible party's wishes if the advance directive is not obtained at the time of admission.
Review of the facility policy, Advance Directives, with revision date of December 2016, included that on admission, the admission department or designee will notify and provide information to each resident or resident representative, regarding his/her right to make an advance directive. The policy further included that prior to or upon admission; the social service director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. The policy also included information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The policy included that if the resident indicates that he or she has not established advance directives, the facility staff will help in establishing advance directives and that the resident will be given the option to accept or decline the assistance. The policy also included that nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and review of policy, the facility failed to ensure one resident's (#18) care ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and review of policy, the facility failed to ensure one resident's (#18) care plan was updated/revised to meet her changing needs. The sample size was 15. The deficient practice could result in inadequate care and/or not meeting the needs of the resident.
Findings include:
Resident #18 admitted to the facility 01/21/22 with diagnoses that included a pressure ulcer of the sacral region, stage 4, polyneuropathy and age-related osteoporosis without current pathological fracture.
The risk for falls care plan initiated 01/21/22 related to impaired mobility and cognition had a goal to not sustain serious injury. Interventions included lab monitoring.
Review of the clinical record revealed the resident fell without sustaining injury on dates including: 02/23/22 and 03/04/22. However, the risk for falls care plan was not updated to indicate additional fall interventions had been put in place.
According to the resident's record, she sustained additional falls on dates that included: 03/21/22 and 03/30/22. Per review, no additional fall interventions were implemented.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] the resident scored 3 on the brief interview for mental status, indicating severe cognitive impairment. She required limited one-person physical assistance for most activities of daily living.
On 08/22/22 the clinical record reflected the resident sustained a fall without injury. However, the care plan was not updated to reflect additional intervention.
On 08/29/22 at 4:24 a.m. an alert note included that the resident was heard yelling in her room and was found laying on her right side next to her bed. Per the note, her right hip appeared to protrude and she was unable to move it. She was assisted into bed with her leg supported. The on-call provider, Director of Nursing (DON) and Executive Director (ED) were notified of circumstances. The resident's family was called and asked if it was ok to take the resident to the hospital.
An evaluation summary note dated 09/06/22 at 5:09 p.m. included that the resident had been re-admitted to the facility status post fall with injury, femur fracture and surgery.
On 01/05/23 at 11:44 a.m. an interview was conducted with a Registered Nurse (RN/staff #83). She stated that nurses update the care plan. She stated that the resident's care plan should be revised after every fall.
An interview was conducted on 01/05/23 at 3:23 p.m. with the Regional Director of Clinical Operations (RDCO/staff #81). She stated that the resident's care plan should be updated when the resident falls. She stated that the Interdisciplinary team will review and complete an interim care plan.
The Comprehensive Care Plan policy effective 11/2017 included a comprehensive, person-centered care plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment. Care plans will be revised as information about the resident's condition changes. The interdisciplinary team is responsible for the review and updating of the care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to convey the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to convey the discharge summary information to the resident and/or authorized person, and failed to include reconciliation of all pre and post discharge medications for one resident (#33). The deficient practice could result in resident's not receiving the correct discharge information and medications.
Findings include:
Resident #33 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, generalized muscle weakness, type 2 diabetes, stage 4 chronic kidney disease, and malignant neoplasm of the bladder.
A physician progress note dated November 6, 2022 at 3:01 p.m., stated the visit type was skilled nursing facility discharge visit. The note included an assessment plan that stated discharge today, and resident does not need new prescriptions. Further, the note stated home health nursing coming in the morning that was arranged by the family.
Review of nursing progress note dated November 6, 2022 at 5:57 p.m., stated while the daughter was visiting the resident, she requested to take the resident home. The note stated the medical provider was aware, discharge orders completed.
Record review of the facility document, Transition of Care and Discharge Summary-V5, dated November 6, 2022, revealed the resident/representative signature was left blank, and only signed by a licensed practical nurse (LPN/ staff #82). The section 7 of the document, Nursing Discharge Instructions, enumerated task to be completed related to discharging a resident and the instruction stated check all that apply.
However, the reconciliation of all pre and post discharged medication, and review of printed orders summary with resident and/ or representative were left unchecked.
Further record review revealed no evidence that the discharge plan and reconciliation of all pre and post discharge medications was provided to resident #33 and/or their representative.
On January 4, 2023 at 2:38 p.m., the facility provided a copy of the discharge summary/discharge instruction.
However, the record did not include reconciliation of all pre and post discharge medications, and no resident/representative signature was included on the attestation page.
A joint interview was conducted on January 5, 2023 at 3:39 p.m., with regional nurse consultant (staff #81) and social services director (staff #62). The staff stated the discharge process begins with getting a discharge order form the practitioner, then the order is entered in the PCC (point click care). Staff # 62 stated the discharge summary included history recapitulation of stay, diagnoses, treatment, pre and post medication reconciliation, and scripts if available. Staff #62 stated the resident and/or representative signs two copies of the discharge summary; the facility keeps one copy and the resident gets the other copy. The staff stated the purpose of the discharge summary is to educate the resident and the family of the resident's health care status for continuation of care. The staff stated if the discharge summary is not provided, there is a risk for re-hospitalization and missed medications.
Review of a facility policy, Transition of Care and Discharge, revised on November 2017 stated, when a resident discharge is anticipated; a recapitulation of the stay, final summary, and post discharge plan will be completed.
The policy detail included reconciliation of pre and post medication on discharge completed by a nurse or a pharmacist. The process included review with the resident discharge medications, directions for use, and reason for use. The policy detail stated to instruct the resident/representative to give the list to their primary care provider, update the list when medications are added, discontinued, or doses are changed, and to carry the medication list at all times in case of an emergency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based upon personnel file review, interviews, and policy review, the facility failed to complete yearly performance reviews and provide regular in-service education based upon the outcome of the revie...
Read full inspector narrative →
Based upon personnel file review, interviews, and policy review, the facility failed to complete yearly performance reviews and provide regular in-service education based upon the outcome of the reviews for 1 of 2 sampled Certified Nursing Assistants (CNA/staff #35). The inadequate practice could result in insufficient and inadequate care for residents. The facility census was 31.
Findings include:
Review of a personnel file for a CNA (staff #35) revealed a hire date of 04/17/19, for hourly employment. Review of the file did not reveal a yearly performance review had been completed or any evidence of training reflective of the review.
On 01/05/23 at 10:33 a.m. an interview was conducted with the Director of Human Resources (staff #84). She stated that training is monitored in the system and that managers are responsible to enforce that with their employees. She stated that it is her responsibility to get employee reports and to give them to the department heads. She stated that the department heads are responsible for ensuring the training is completed. She stated that she did not know what happened in regard to the CNA #35.
An interview was conducted on 01/05/23 at 3:23 p.m. with the Regional Director of Clinical Operations (staff #81). She stated that the assistant director of clinical services is responsible to ensure training is complete. She stated that recertification for training and skills was expected to be done annually and that it would contain all the required elements.
The Clinical Services Orientation and Skill Checklist policy, updated 03/2020, included clinical service associates who require a license or certification to perform resident care or treatment shall complete the Orientation Checklist upon hire. The Clinical Services Checklist shall be performed upon hire, as needed and at a minimum annually thereafter. The designated associate who is observing and/or explaining the skill shall document on the associate's checklist. If a concern is noted on the associates skills checklist, the corrective action is also documented. Additional associate training shall be provided as indicated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure a pharmacist recommendatio...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure a pharmacist recommendation was reviewed and acted upon for one resident (#5). The sample size was 5 residents. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon.
Findings include:
Resident #5 admitted to the facility on [DATE] with diagnoses that included anemia, major depressive disorder, recurrent and benign prostatic hyperplasia without lower urinary tract symptoms.
A Bupropion (antidepressant) care plan dated 09/28/22 related to a diagnosis of depression as evidenced by verbalizing anger over new placement in the skilled nursing facility had a goal to show adjustment to the placement. Interventions included to give medications as ordered by the physician and to monitor/document side effects and effectiveness.
A Lorazepam (anxiolytic) care plan initiated 09/28/22 related to a diagnosis of anxiety as evidenced by worrying over his current health status/decline had a goal for decreased episodes of worrying. Interventions included to give anti-anxiety medication as ordered by the physician and to monitor/document side effects and effectiveness.
A physician's order dated 10/09/22 included Bupropion HCl extended release 12 hour 100 milligrams (mg). Give one tablet every 12 hours for depression. On 10/18/22, the order was revised to include depression as evidenced by restlessness.
A physician's order dated 10/18/22 included Lorazepam 0.5 mg. Give every 12 hours as needed for anxiety as evidenced by restlessness.
A pharmacy consultation report dated 10/20/22 included the medication review process revealed the following discrepancies on the admission orders, including:
-as-needed Lorazepam with a documented duration for therapy
-psychotropic medications without documented behavior/side effect monitoring
However, review of the clinical record did not indicate the recommendations had been acknowledged or implemented.
The October 2022 Medication Administration Record (MAR) revealed Bupropion HCl and Lorazepam were provided to the resident in accordance with physician's orders.
A pharmacy consultation report dated 11/01/22 included that the resident received Bupropion and Lorazepam but did not have behavior monitoring documented in the medical record. The recommendation included to update the person-centered care plan and medical record to include:
-specific target behaviors
-documentation of the frequency of behaviors
-non-pharmacological interventions and the outcomes of those interventions
-documentation of the impact of the target behaviors including distress or potential harms to the resident or others
-overall goals of therapy
-potential adverse events and associated monitoring
-history and outcomes of prior medications including previous reduction attempts.
However, no indication of acknowledgement or implementation of the recommendations were identified in the resident's record.
Review of the November 2022 MAR revealed Bupropion HCl was administered in accordance with the provider's order. As needed Lorazepam was not administered. Per review, behaviors and adverse side effects were not monitored.
The December 2022 MAR included administration of Bupropion HCl and Lorazepam. However, behaviors and adverse effects were not monitored.
On 01/05/23 at 3:23 pm an interview was conducted with the Regional Director of Clinical Operations (staff #81). She stated that the expectation is for the provider to respond within 2 weeks of the pharmacist's recommendation. She stated that not to respond for 2 months did not meet her expectations.
The Medication Regimen Review (MRR) policy, effective 12/01/07, included the consultant pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement. The facility should ensure that facility physicians/prescribers are provided with copies to MRRs. The facility should encourage the physician/prescriber or other responsible parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require physician/prescriber intervention, the facility should encourage the physician/prescriber to either (a) accept and act upon the recommendations contained in the MRR, or (b) reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. The facility should provide the Medical Director with a copy of the MRRs and should alert the Medical Director when MRRs require follow-up.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#5) receivi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#5) receiving psychotropic medications received consistent monitoring for behaviors and side effects and failed to ensure a PRN (as needed) anti-anxiety medication had a duration of treatment. Five residents were reviewed for medication use. The deficient practice could result in unnecessary medication use and adverse side effects.
Findings include:
Resident #5 admitted to the facility on [DATE] with diagnoses that included anemia, major depressive disorder, recurrent and benign prostatic hyperplasia without lower urinary tract symptoms.
A Bupropion (antidepressant) care plan dated 09/28/22 related to a diagnosis of depression as evidenced by verbalizing anger over new placement in the skilled nursing facility had a goal to show adjustment to the placement. Interventions included to give medications as ordered by the physician and to monitor/document side effects and effectiveness.
A Lorazepam (anxiolytic) care plan initiated 09/28/22 related to a diagnosis of anxiety as evidenced by worrying over his current health status/decline had a goal for decreased episodes of worrying. Interventions included to give anti-anxiety medication as ordered by the physician and to monitor/document side effects and effectiveness.
A physician's order dated 10/09/22 included Bupropion HCl extended release 12 hour 100 milligrams (mg). Give one tablet every 12 hours for depression. On 10/18/22, the order was revised to include depression as evidenced by restlessness.
A physician's order dated 10/18/22 included Lorazepam 0.5 mg. Give every 12 hours as needed for anxiety as evidenced by restlessness. No duration of treatment was included in the order.
Additional review provided no evidence of education regarding the risks and benefits of the medications, or alternatives to drug therapy, prior to their implementation.
The significant change MDS (Minimum Data Set) assessment dated [DATE] included that the resident scored 13 on the brief interview for mental status, indicating intact cognition. The documentation indicated that the resident had received antidepressant medication for 7 out of 7 days in the look-back period, and had received anti-anxiety medication for 1 out of the 7 days.
The October 2022 through December 2022 Medication Administration Records (MARs) revealed Bupropion HCl and Lorazepam were provided to the resident in accordance with the physician's orders.
However, review of the clinical record did not indicate specific target behaviors, frequency of behaviors, non-pharmacological interventions and the outcomes of those interventions and/or potential adverse events and associated monitoring was completed.
On 01/05/23 at 11:44 a.m. an interview was conducted with a Registered Nurse (RN/staff #83). She stated that she would anticipate that psychotropic medications would have ongoing monitoring for adverse side effects and behaviors, or they would not know whether or not the medication was working.
An interview was conducted on 01/05/23 at 3:23 pm with the Regional Director of Clinical Operations (staff #81). She stated that PRN psychotropic medications will be ordered for 14 days with a face-to-face assessment for extension of use, and documentation of the rationale. She stated that adverse side effects and behaviors will be monitored for risks and effectiveness.
The Psychotropic Drug Management Policy, revised 10/2022, included that in order to provide a therapeutic environment, only those medications with a therapeutic benefit to the individual resident will be used. Unnecessary drugs should be avoided. An unnecessary drug is any drug that is used for an excessive duration, without adequate monitoring and without adequate indications for use. This community shall monitor residents using psychotropic medications for efficacy and adverse reactions. Psychotropic is defined as any drug that affects brain activities associated with mental processes or behaviors, including, but not limited to antidepressants and anti-anxiety medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected 1 resident
Based on facility documentation, interviews, policy, and Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to ensure the Infection Preventionist (IP) had completed infecti...
Read full inspector narrative →
Based on facility documentation, interviews, policy, and Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to ensure the Infection Preventionist (IP) had completed infection control training. The deficient practice could lead to unqualified staff acting as the IP and improper infection prevention practices within the facility.
Findings include:
During the entrance conference on January 3, 2023 at 8:09 a.m., the Administrator (staff #61) stated the facility currently had no COVID-19, and that the last COVID-19 outbreak was on November 7, 2022. Staff #61 stated that the facility does have a staff member assigned to be the infection preventionist (IP)and that this person is Licensed Practical Nurse (LPN/staff #6). Staff # 61 stated the IP is responsible for the facility's vaccination efforts, surveillance, and antibiotic stewardship.
An interview was conducted on January 4, 2023 at 1:57 a.m. with IP (staff #6). Staff #6 stated the facility was utilizing her as the IP and had done so since November 15. 2022. She stated the she does not have formal infection control training but she was totally responsible for infection control and prevention in the facility.
Continued interview with the IP (LPN/staff #6) on January 4, 2023 revealed that she was responsible for COVID-19 testing, infection control surveillance, antibiotic stewardship, and maintaining the COVID-19 vaccination logs.
However, the facility failed to provide evidence of completed specialized training in infection control prior to assuming the role of the IP for staff #6.
A joint interview was conducted on January 5, 2023 at 3:39 p.m., with regional nurse consultant (staff #81) and social services director (staff #62). Staff #81 stated as far as she knew the facility had an infection control nurse and that she was not made aware of the infection control issues.
Review of the facility policy, Infection Prevention and Surveillance, that was revised on January 2020, stated the nurse leader designee shall track, trend and monitor infections on an ongoing basis to assist with the prevention, development and transmission of disease and infection.
However, the policy did not include the current CMS (Centers for Medicare and Medicaid Services) requirement for infection preventionist.
Per CMS regulation, the facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must have completed specialized training in infection prevention and control.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interview and policy and procedures, the facility failed to ensure one of five sampled r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interview and policy and procedures, the facility failed to ensure one of five sampled residents (#140) received information regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations, and failed to offer the vaccinations according to their policy. The deficient practice could increase the risk of residents acquiring, transmitting or experiencing complications from influenza and/or pneumococcal disease.
Findings include:
Resident #140 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of pelvis, atherosclerotic heart disease of native coronary artery without angina pectoris, and essential hypertension.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 99 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills.
Review of the clinical record revealed no documentation that the resident and/or the responsible party was provided information regarding the benefits and potential side effects of influenza and pneumococcal vaccines or that the resident and/or responsible party was offered or refused the vaccines.
On January 5, 2023 at 4:18 p.m., an interview was conducted with the regional nurse (staff #81). She stated that it is her expectation that pneumococcal and influenza vaccines are offered to all residents and new admissions.
Review of a policy titled, Influenza Vaccine, last revised on September 2017, revealed the facility offers the influenza vaccine annually to promote the benefits associated with immunization against influenza. The policy detail stated the residents should be immunized as soon as the vaccine becomes available and continue until influenza is no longer circulating in the facility's geographic area. Further, the policy details stated the facility is to obtain written, informed consent upon admission and annually from the resident or resident representative. Per the policy, the informed consent for the influenza vaccine form includes education associated with the benefits and potential side effects or adverse effects if receiving the vaccine.
Review of a policy titled, Pneumococcal Vaccine, last revised on August 2018, revealed the facility offers the pneumococcal vaccine to each resident or his/her representative. The policy detail stated the facility follows the Advisory Committee on Immunization Practices (AICP) which recommends pneumococcal vaccination of certain high-risk adults aged 19-65 years.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to maintain documentation related to COVID-19 vaccine exemption requirement for one s...
Read full inspector narrative →
Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to maintain documentation related to COVID-19 vaccine exemption requirement for one staff (#33).
Findings include:
On January 3, 2023 at 8:00 a.m. the survey team entered the facility. At 8:09 a.m., an entrance conference was conducted with the facility administrator (staff #61). During the conference, a COVID-19 staff vaccination matrix for staff was requested from the administrator (staff #61).
Review of the facility employee list provided on January 3, 2023 indicated staff #33 was an active employee.
On January 4, 2023 the facility provided the facility staff COVID-19 vaccine log. Review of the facility document provided by staff #61, revealed one certified nursing assistant (CNA/ staff #33) was coded GN, indicating the CNA was granted non-medical exemption.
On January 4, 2022 at 8:53 a.m., a document request was given to staff #61 related to staff #33's COVID-19 exemption documents including screening for eligibility, education, and declination form.
On January 4, 2023 at 3:37 p.m., the administrator stated he will provide the documents for staff #33's COVID-19 vaccine exemption tomorrow, January 5, 2023.
On January 5, 2023 at 1:43 p.m., staff #61 provided a form titled, COVID-19 Mandatory Vaccination Declination for SNFs Healthcare Provider Supporting Statement. The form was for a medical exemption signed by a nurse practitioner on November 3, 2021.
However, the facility failed to provide evidence that staff #33 was screened for eligibility, provided education, and signed declination form per the CMS (Center of Medicare and Medicaid Services) infection control guidelines.
An infection control interview was conducted with the facility infection preventionist (staff #6) on January 4, 2023 at 2:00 p.m. Staff #6 stated she and the administrator maintain the staff COVID-19 vaccination log, but not the vaccination cards/documents. Staff #6 stated she has never seen the cards/records, and that the administrator gives her the name of the vaccinated or exempted staff. Staff #6 stated she was under the impression the human resources had the COVID-19 cards/exemption documents. Further, staff #6 stated she notified the administrator that there are missing documents, surveillance, and COVID -19 documentation from former infection preventionist, but the administrator did not respond. Staff #6 stated she maintained a few copies of screening, education, and offering of staff COVID-19 documentation.
Staff #6 stated she was unable to find documentation related to staff #33's COVID-19 exemption.
A joint interview was conducted on January 5, 2023 at 3:39 p.m., with regional nurse consultant (staff #81) and social services director (staff #62). Staff #81 stated as far as she knew the facility had an infection control nurse and that she was not made aware of the infection control issues.
On January 5, 2022 at approximately 5:30 p.m., during the survey exit conference, staff #81 stated the facility will not be able to provide documentation for COVID-19 vaccination exemption for staff #33.
Review of the facility policy, COVID-19 Vaccination Requirement, revised on October 28, 2022, stated pursuant to the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP), the facility require all eligible staff who work in a skilled nursing facility to comply with the vaccination requirement.
The policy details included contraindication information that stated, in the course of hosting an onsite vaccine clinic, the facility may have to collect information about associate's vaccine contraindications or any other health related information. It also stated, the facility will maintain this information as a confidential medical record separate from the personnel file, and state survey agencies may gain access to vaccine and exemption date to verify compliance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
Based on personnel file reviews, staff interviews, and review of policy, the facility failed to provide evidence that 1 out 10 sampled staff (#36) was provided training for abuse, neglect, exploitatio...
Read full inspector narrative →
Based on personnel file reviews, staff interviews, and review of policy, the facility failed to provide evidence that 1 out 10 sampled staff (#36) was provided training for abuse, neglect, exploitation and misappropriation of resident property. The facility census was 31. The deficient practice could result in inadequate recognition, prevention and reporting of abuse.
Findings include:
Review of a personnel file for a Dietary Assistant (staff #36) revealed a hire date of 08/06/13, for hourly employment. The personnel record contained no evidence of training for abuse, neglect, exploitation and misappropriation of resident property.
On 01/05/23 at 10:33 a.m. an interview was conducted with the Director of Human Resources (staff #84). She stated that training is monitored in the system and that managers are responsible to enforce that with their employees. She stated that it is her responsibility to get employee reports and to give them to the department heads. She stated that the department heads are responsible for ensuring the training is completed. She stated she was not sure what happened with staff #36.
An interview was conducted on 01/05/23 at 3:23 p.m. with the Regional Director of Clinical Operations (staff #81). She stated that the assistant director of clinical services is responsible to ensure training is complete. She stated that recertification for training and skills was expected to be done annually and that it would contain all the required elements.
The Abuse, Neglect & Exploitation Policy, revised 10/2018, included the facility ' s commitment to maintaining a safe environment for each resident, visitor and associate. Instances or allegations of abuse, neglect, mistreatment or exploitation should be treated seriously and must be reported to the Administrator or the supervisor on duty for investigation and appropriate follow-up. The facility orientation program will include training on what constitutes and how to recognize abuse, neglect and exploitation. Annual and as necessary in-service will be provided to review how to recognize, prevent and report any actual or suspected resident abuse, neglect, mistreatment or exploitation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on personnel file review, interviews, and Federal guidelines, the facility failed to ensure one of two sampled Certified Nursing Assistants (CNA/staff #35) had no less than 12 hours per year of ...
Read full inspector narrative →
Based on personnel file review, interviews, and Federal guidelines, the facility failed to ensure one of two sampled Certified Nursing Assistants (CNA/staff #35) had no less than 12 hours per year of required in-service training to ensure continuing competencies. The facility census was 31. The deficient practice could result in inadequate care for residents.
Findings include:
Review of a personnel file for a CNA (staff #35) revealed a hire date of 04/17/19, for hourly employment. Per the 2022 User Learning records, staff #35 had completed 3 out of 25 required in-service courses.
On 01/05/23 at 10:33 a.m. an interview was conducted with the Director of Human Resources (staff #84). She stated that training is monitored in the system and that managers are responsible to enforce that with their employees. She stated that it is her responsibility to get employee reports and to give them to the department heads. She stated that the department heads are responsible for ensuring the training is completed. She stated that she did not know what happened in regard to the CNA #35.
An interview was conducted on 01/05/23 at 3:23 p.m. with the Regional Director of Clinical Operations (staff #81). She stated that the assistant director of clinical services is responsible to ensure training is complete. She stated that recertification for training and skills was expected to be done annually and that it would contain all the required elements.
Per Revised Statute 483.95, effective 10/21/22, required in-service training for nurse aides must be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on personnel file review, staff interviews, and facility policy, the facility failed to ensure that two of two sampled Certified Nursing Assistants (CNA/staffs #35 and #8) were able to demonstra...
Read full inspector narrative →
Based on personnel file review, staff interviews, and facility policy, the facility failed to ensure that two of two sampled Certified Nursing Assistants (CNA/staffs #35 and #8) were able to demonstrate competencies and skills necessary to provide care for residents. The census was 31. The deficient practice could result in inadequate care for residents.
Findings include:
Review of a personnel file for a Certified Nursing Assistant (CNA/staff #35) revealed a hire date of 04/17/19, for hourly employment. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies for 2020, 2021 or 2022.
The personnel file for a CNA (staff #8) revealed a hire date of 06/17/20, for hourly employment. Review of the personnel file revealed no evidence of a comprehensive evaluation for nursing skills and competencies for 2022.
An interview with the Human Resources Director (staff #84) was conducted on 01/05/23 at 10:33 a.m. She stated that the CNA skills sheets she had were dated 2021 and that she would ask the administrator if they had anything more current. She stated that the department heads were responsible to ensure their employees complete the training.
An interview was conducted on 01/05/23 at 3:23 p.m. with the Regional Director of Clinical Operations (staff #81). She stated that the assistant director of clinical services is responsible to ensure training is complete. She stated that recertification for training and skills was expected to be done annually and that it should contain all the required elements.
The Clinical Services Orientation and Skill Checklist policy, updated 03/2020, included clinical service associates who require a license or certification to perform resident care or treatment shall complete the Orientation Checklist upon hire. Clinical Services associates who require a license or certification to perform resident care or treatment shall complete the Orientation and Skills Checklist within the first 90 days of employment. The Clinical Skills Checklist shall be completed annually thereafter. The designated associate who is observing and/or explaining the skill shall document on the associate's checklist. If a concern is noted on the associates skills checklist, the corrective action is also documented. Additional associate training shall be provided as indicated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to implement a surveillance plan for identifying, tracking, monitoring of infection a...
Read full inspector narrative →
Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to implement a surveillance plan for identifying, tracking, monitoring of infection and failed to ensure an ongoing analysis of surveillance data and documentation of follow-up activity response. The deficient practice could result in the spread of infections in the facility.
Findings include:
During the entrance conference on January 3, 2023 at 8:09 a.m., the Administrator (staff #61) stated the facility currently had no COVID-19, and that the last COVID-19 outbreak was on November 7, 2022. Staff #61 stated that the facility does have a staff member assigned to be the infection preventionist (IP)and that this person is Licensed Practical Nurse (LPN/staff #6). Staff # 61 stated the IP is responsible for the facility's vaccination efforts, infection surveillance, and antibiotic stewardship.
Record review of the facility's infection surveillance was conducted on January 4, 2022 at 1:57 p.m. with an infection preventionist/licensed practical nurse (LPN/ staff #6). During the record review, staff #6 provided a facility map and a form titled, Infection Control Log, indicating a reporting period of November 1 to November 30, 2022.
However, the onset date column included two entries with no dates, 5 entries for October, and 16 entries for November 2022, in no chronological order.
The form contained columns for residents' names, name of antibiotics, isolation status, and HAI (healthcare acquired infection). Additional columns on the form was marked for culture date, x-ray date, organism, recultured date, and date resolved.
However, the columns were not completely filled out with the required information.
During the record review, additional documents related to infection control surveillance for September and October, 2022 were requested from staff #6. She accessed a filing cabinet and binders and searched for the records.
However, staff #6 was not able to provide additional evidence of infection control surveillance documentation.
Continued review of the infection control surveillance log provided by staff #6 included a facility map titled, Monthly Tracking December 2022. A facility report titled, Order Listing, dated December 13, 2022 that contained the name of the residents with antibiotic orders attached to the facility map.
However, the facility failed to provide evidence of completed infection control surveillance log for December 2022.
An interview was conducted with staff #6 on January 4, 2023 at 2:13 p.m. Staff #6 stated regarding the infection control surveillance, as off mid December 2022 to today, she has not maintained an infection control surveillance due to lack of training and lack of staff. Staff #6 stated she has been working the floor as a nurse. The staff stated she has not been consistent with maintaining the infection control surveillance and antibiotic stewardship because of lack of training and she was always pulled to work on the floor since December 14, 2022. Staff #6 stated, there was no ICP since December 14, 2022 and that she had resigned, but she was asked to hold the title until they find a replacement. She stated she was not able to do her job as infection control nurse because she was working on the floor and that she notified the administrator of the areas that were not being done related to infection control, including surveillance and antibiotic stewardship.
A joint interview was conducted on January 5, 2023 at 3:39 p.m., with regional nurse consultant (staff #81) and social services director (staff #62). Staff #81 stated as far as she knew the facility had an infection control nurse and that she was not made aware of the infection control issues. Staff #62 stated the facility are monitoring and tracking during change of condition.
The facility policy, Infection Prevention and Surveillance, revised on January 2020, stated the nurse leader designee shall track, trend and monitor infections on an ongoing basis to assist with the prevention, development and transmission of disease and infection. The policy detail included the nurse leader designee shall apply scientific principles and methods to determine if the infection meets the criteria, and shall enter data into the infection trend tracker. Further, the policy detail stated the nurse leader designee shall provide updates in the infection trend tracker including changes and resolution.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to conduct an ongoing review for antibiotic stewardship as required by Center for Med...
Read full inspector narrative →
Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to conduct an ongoing review for antibiotic stewardship as required by Center for Medicare and Medicaid Services (CMS) guidelines, and failed to review clinical signs and symptoms and laboratory reports to determine if antibiotics are indicated. The deficient practice could have the potential for residents to have adverse effects due to the lack of protocols and monitoring.
Findings include:
On January 3, 2023 at 8:00 a.m. the survey team entered the facility. At 8:09 a.m., an entrance conference was conducted with the facility administrator (staff #61). During the conference, staff #61 stated he has a full-time infection preventionist (IP), a licensed practical nurse (LPN/staff #6). Staff #61 stated the IP is responsible for the facility's vaccination efforts, infection control surveillance, and antibiotic stewardship.
Record review of the facility's antibiotic stewardship program was conducted on January 4, 2022 at 1:57 p.m. with the IP (LPN/ staff #6). During the record review, staff #6 provided documents pertaining to antibiotic stewardship. She provided a facility map and a form titled, Infection Control Log, indicating a reporting period of November 1 to 30, 2022.
However, the column titled onset date, included two entries with no dates, 5 entries for October, and 16 entries for November 2022, in no chronological order.
The form has multiple columns marked residents' names, name of antibiotics, isolation status, and HAI (healthcare acquired infection). The form also included columns for culture date, x-ray date, organism, recultured date, and date resolved.
However, the columns were inconsistently filled out, and missing the required information for antibiotic stewardship.
During the record review, additional documents related to antibiotic stewardship for September and October, 2022 were requested with staff #6. Staff #6 accessed a filing cabinet and binders and searched for the records. After searching for the records, the IP nurse stated she was not able to find additional records related to antibiotic stewardship.
Continued review of the antibiotic stewardship process conducted on January 4, 2023 with staff #6 revealed a facility map titled, Monthly Tracking December 2022. A facility report titled, Order Listing, dated December 13, 2022 was attached to the facility map. A form titled, Infection Control Log, which indicated for the period of December 1 to December 31, 2022, contained only 3 entries that included the residents' names, diagnoses, and antibiotic prescribed. Additional evidence of antibiotic stewardship document for December 2022 and January 2023 was requested from staff #6.
However, the facility failed to provide evidence of antibiotic stewardship for the month of December 2022, and January 2023.
An infection preventionist (staff#6) interview was conducted on January 4, 2023 at 2:13 p.m. Staff #6 stated she was still trying to catch up with infection control surveillance and antibiotic stewardship. The staff stated she has not been consistent with maintaining the infection control surveillance and antibiotic stewardship because of lack of training and that she was always pulled to work on the floor since December 14, 2022. Staff #6 stated there was no IP since December 14, 2022 and that she had resigned, but she was asked to hold the title until the facility finds a replacement. She stated she was not able to do her job as infection preventionist because she was working on the floor and that she has notified the administrator of the areas that were not being done related to infection control, including infection control surveillance and antibiotic stewardship.
A joint interview was conducted on January 5, 2023 at 3:39 p.m., with regional nurse consultant (staff #81) and social services director (staff #62). Staff #81 stated as far as she knew the facility had an infection control nurse and that she was not made aware of the infection control issues. Staff #62 stated the facility are monitoring and tracking during change of condition.
Review of the facility policy, Antibiotic Stewardship, revised on May 2022, stated the antibiotic stewardship program is a collaborated effort of community leadership, nursing, physicians, and pharmacists focused in continuous improvement in the use of antibiotic agents in an effort to combat the emergence of resistant organisms.
The policy detail included identifying a specific nurse to be responsible for managing infection control and prevention, including antibiotic stewardship activities. Further, the policy detail included documentation of monthly infections and antibiotic usage utilizing the infection trend tracker.
Jan 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#133) was t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#133) was treated with dignity. The facility census was 33 residents. The deficient practice could result in residents not being treated in a dignified manner.
Findings include:
Resident #133 was admitted to the facility on [DATE] with diagnoses that included Spastic quadriplegic cerebral palsy, Epilepsy, and Anxiety disorder.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident Brief Interview for Mental status (BIMS) score was 14 which indicated the resident was cognitively intact. Additionally, section E revealed that the resident did not have delusions, psychosis, or any behaviors exhibited. Section G revealed that the resident required extensive 2-person assistance for bed mobility, dressing, and bathing.
Review of the facility documentation of a self-reported incident revealed that this resident reported to a staff member on May 5, 2020 at approximately 11:15 AM
that resident #133 was not happy with an incident that had occurred the night before (May 4, 2020). The resident reported that a Certified Nursing Assistant (CNA/staff #87) had drawn on her arm and upper lip with a permanent marker. Resident #133 reported that staff #87 had written on her arm and upper lip but she could not see what the drawings were. She further stated that she and staff #87 tend to joke around with each other but felt like staff #87 took it a little too far. The resident reported that she asked the CNA to stop however he did not and told the resident it was okay because they were was going to give the resident a scheduled shower. After an interview with resident #133, the facility staff members decided to file an official report to the Department of Health Services and all other required parties.
On May 5, 2020 after 12:00 PM the former Administrator and former Director of Nursing (DON) conducted an interview with staff #87. The CNA stated that he did not draw on the resident's arm however, he admitted to drawing a small mark on the resident's upper lip.
The facility provided evidence that a statement was taken from another CNA (staff #93) regarding the incident. The facility records showed that staff #93 was working at the time of the incident. Staff #93 stated that while transferring resident #133, the resident was telling her what happened. The CNA reported that the markings looked like the beauty mark that a famous female actress had.
The facility reported that the incident was substantiated and staff #87 was terminated following the results of the facility's investigation.
The facility provided evidence that an in-service training was conducted for employees following the incident in May of 2020. The education provided included topics such as, work place violence prevention, reporting, abuse and neglect, as well as resident rights.
An attempt to call staff #87 was made on January 13, 2022 at 12:09 PM. The voice mail box was full and no voicemail was able to be left.
An interview was conducted on January 13, 2022 at 1:38 PM with a Licensed Practical Nurse (LPN/staff#92). The nurse stated that respecting a resident's dignity is important because they are all adults and have rights and the staff need to accommodate. Additionally, she stated that if a resident reported being unhappy with any care or had a grievance she would try to find out what the problem was and then attempt to fix it. Further, she stated that if the resident reported being drawn on with a permanent maker, that is not respecting the resident's dignity unless the resident did it themselves. Additionally, she stated if a staff member did it, then that would be a big issue and she would have to notify the DON and the Administrator immediately. The LPN further stated that she has been educated on resident rights and dignity as well as reporting abuse, neglect, and grievances.
An interview was conducted on January 13, 2022 at 2:38 PM with a CNA (staff# 22). The CNA stated that resident dignity needs to be respected and that means the resident leads their own healthcare and are encouraged to make their own choices. Further, she stated that residents have the right to tell you how they like things and the staff need to respect that and try to accommodate. The CNA further stated that she has received training on dignity and resident rights. She stated that if a resident made an allegation of not being treated in a dignified manner then she would notify the DON immediately or the Administrator.
An interview was conducted on January 13, 2022 at 2:42 PM with the current Director of Nursing (DON/staff #45). The DON stated that respecting a resident dignity means to approach the resident calling them by the name they like to be called. Additionally, she stated that staff should not tell residents what to do, but ask and respect their preferences. The DON stated that if staff comes to her regarding concerns about resident dignity, then she would gather information and address the issue, educate the staff and investigate. Further, she stated that currently she feels that the facility staff follows respecting the resident's dignity. The DON stated however, the allegation that occurred in May of 2020 was able to be substantiated and was not an example of respecting the resident's dignity.
An interview was conducted on January 13, 2022 at 2:54 PM with the current Administrator (staff #78). The administrator stated that he expected staff to respect residents' dignity by respecting their privacy and choices. Further, he stated residents should be able to lead their own care and not make recommendations, but allow for preferences. The Administrator stated that staff has been educated to report issues to him, then complete a grievance form. Further, the Administrator stated that at the time of this incident he was not the Administrator of the facility. Further he explained that if this incident occurred and a resident was written on by a staff member, then that would not be appropriate of the staff member.
The facility policy titled Quality of Life, Dignity revised October 2019 stated residents should be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents should be treated with dignity and respect. The community culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's community stay. Individual needs and preferences of the resident are identified through the assessment process. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this community. Residents' private space and property are respected. Associates do not handle or move a resident's personal belongings without the resident's permission. Associates are expected to knock and request permission before entering residents' rooms. Associates speak respectfully to residents, including addressing the resident by their name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. Associates inform and orient residents to their environment. Procedures are explained before they are performed and residents should be told in advance if they are going to be taken out of their usual or familiar surroundings. Demeaning practices and standards of care that compromise dignity is prohibited. Associates are expected to promote dignity and assist residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one of two ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one of two sampled residents (#2) received pressure ulcer care and assessment in accordance with professional standards of practice. The deficient practice could result in further pressure ulcer development and/or complications with the healing of pressure ulcers.
Findings include:
Resident #2 was admitted to the facility on [DATE] with diagnoses that included personal history of traumatic brain injury, spastic hemiplegia affecting right dominant side, and other dysphagia.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored 6 on the Brief Interview for Mental Status, indicating severe cognitive impairment. The resident required total-extensive 2-person physical assistance for most activities of daily living, and the resident had no pressure ulcers or injuries.
A Situation-Background-Assessment-Recommendation (SBAR) Summary for Providers dated 12/04/21 at 7:02 a.m. revealed for a Change In Condition (CIC) related to a skin wound or ulcer. The note indicated that an open area to the sacral coccyx was found during the resident's shower. The note described the wound as having a superficial, pink wound base. The Primary Care Provider (PCP) was notified and the feedback/recommendation was to initiate wound care orders and change of condition (COC) monitoring.
However, review of the physician's orders did not reveal wound care to the sacral coccyx. In addition, review of the clinical record did not reveal a thorough assessment of the wound had been completed, including measurements, staging, assessment of the surrounding skin, and whether or not there was odor or drainage.
A potential for impairment to skin integrity care plan revised on 12/04/21 related to shearing to sacrum, revealed that it was resolved, and had a goal to be free from further skin breakdown. Interventions included to keep skin clean and dry and to use lotion on dry skin.
The comprehensive nursing note dated 12/05/21 at 12:45 a.m. stated that the wound was treated per orders.
A nursing progress note dated 12/06/21 at 12:54 p.m. included the writer observed the resident's skin related to the open area to the sacrum. The note stated that the area was not pressure, it was shearing. The note stated that a new order was obtained and carried out.
However, review of the physician's orders did not include the order for wound care. Additional review of the clinical record did not provide evidence that a complete and thorough assessment of the wound had been completed.
A Weekly Skin Integrity Review dated 12/08/21 at 9:39 a.m. stated the resident's skin was intact, dry, and discolored. However, the area to the resident's sacral coccyx was not mentioned.
The Weekly Skin Integrity Review dated 12/15/21 at 9:39 a.m. included that the resident's skin was not intact. The documented observations indicated that the resident's skin was dry with maceration to the sacrum, and that generalized poor skin turgor was noted. However, no evidence was identified in the clinical record indicated that the wound to the sacrum had been assessed.
A physician progress note dated 12/20/21 at 12:44 p.m. included that per resident or nursing there were no wounds to the resident's skin.
Review of the December 2021 Treatment Administration Record (TAR) did not include for documentation regarding wound care to the sacral coccyx area.
A Nutrition Risk Review dated 01/05/22 at 8:30 a.m. included that there was a wound to the resident's skin that presented on 01/08/22 (a date which would occur 3 days after the note was documented).
A Weekly Skin Integrity Review dated 01/05/22 at 9:39 a.m. indicated the resident's skin was intact.
An SBAR Summary for Providers dated 01/08/22 at 12:13 p.m. included for a COC related to a skin wound or ulcer. The note stated that nursing had been informed by a Certified Nursing Assistant (CNA) that the resident had an open area on his coccyx. After viewing the area, the note stated the wound was cleansed and a dressing had been placed. The note stated that the area had no drainage, no smell, and no blood. Follow-up recommendations provided by Primary Care Provider included to call the on-call Nurse Practitioner and follow up with the wound care team.
A Weekly Skin Integrity Review dated 01/08/22 at 12:22 p.m. revealed for a new pressure injury to the resident's coccyx. The wound was described as open. However, there was no evidence identified in the clinical record that the wound had been thoroughly assessed in accordance with professional standards of practice.
Review of a physician's order dated 01/09/22 at 6:00 a.m. included to cleanse coccyx and place foam dressing, change every 3 days, every day shift for coccyx open area.
A Comprehensive Nursing Note dated 01/09/22 at 8:13 p.m. stated that the resident was on CIC due to the reopening of the area on the coccyx. The note stated the area was managed with peri care and treatment per orders.
Review of the 01/09/22 Treatment Administration Record (TAR) revealed wound care was provided in accordance with the physician order.
A revised potential for impairment to skin integrity care plan dated 01/10/22 had a goal for the pressure injury to the coccyx to resolve. Interventions included to monitor effectiveness of treatment as needed per weekly skin assessment.
An interview was conducted on 01/13/22 at 10:08 a.m. with a Licensed Practical Nurse (LPN/staff #86). She stated that skin treatments will be documented on the TAR. She stated that if the treatment was not documented on the TAR, it was probably not provided. She stated that nursing would be responsible to provide the identified treatments to the residents. She stated that a wound assessment should be completed any time an open area has been identified on the resident's skin. She stated that wound assessments, or Weekly Wound Data Collection Flow Sheets, are found in the Forms section of the electronic record. She stated that the wound nurse is responsible to complete the wound assessments.
On 01/13/22 at 10:54 a.m., an interview was conducted with the Assistant Director of Nursing (ADON)/wound care nurse (staff #50). She stated that she has been working in the facility for 3 weeks and has not been certified as a wound nurse. She stated that relative to wound care, her intention is to come in for the day, print out a 24-hour report, and to review the notes. Staff #50 stated this is just in case someone forgets to tell her. She stated when a new lesion is identified, a COC will be triggered. She stated she will assess the wound which would include measurements of the lesion, a description of the wound bed, staging, and to go by whatever the national pressure ulcer program states because she is just learning how to do this. She stated that she will report to the provider and obtain orders. The ADON stated that she will chart this information in a progress note.
An interview was conducted on 01/14/22 at 11:35 a.m. with an LPN (staff #17). She stated when she becomes aware of a skin injury or pressure ulcer she will call the wound nurse and let them know. She stated she will document the notification in the record. She stated that right now they do not have a wound care nurse. She stated that the charge nurse is responsible for wound care, and that the ADON does wound assessments.
On 01/14/22 at 12:16 p.m., an interview was conducted with the Director of Nursing (DON/staff #45). She stated that the nurses are responsible for completing the weekly skin reviews. She said that if a wound is identified it should be documented in the progress notes and in the weekly skin note. The DON stated an initial assessment, including identifying information, description, measurements, etc. should be completed. She stated that the wound should be assessed twice per week- once by the floor nurse and once by the wound nurse. She said that documentation should include progress notes, skin care notes, and wound reports on Fridays. The DON stated that there should have been an initial description of the wound. The DON stated that this did not meet her expectations.
The facility policy titled Wound Observation and Pressure Injury/Ulcer Staging included that all licensed nurses should follow established guidelines and protocols to observe, describe tissue, evaluate, measure wounds and stage of pressure injuries/ulcers. A pressure injury/ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Clinical standards do not support reverse staging or back staging pressure injuries/ulcers as a way to document healing as it does not accurately characterize what is physiologically occurring as the ulcer heals. Staging protocol for pressure injuries/ulcers will be conducted according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines. All pressure injuries/ulcers will be measured weekly by the Director of Clinical Services or Licensed designee. Document all wounds and wound evaluations on the Wound Evaluation Flow Sheet. Pressure injury data will also be entered on the Weekly Pressure Injury/Ulcer Summary and the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and policy review, the facility failed to ensure one of two sampled residents...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and policy review, the facility failed to ensure one of two sampled residents (#16) weight loss greater than 5% in one month was addressed. The deficient practice could result in residents' weight loss not being addressed.
Findings include:
Resident #16 was admitted to the facility on [DATE] with diagnosis of urinary tract infection, cognitive communication deficit and major depressive disorder.
An undated Care Plan included this resident was at nutritional risk. Interventions included monitoring weights monthly/weekly and supplements as ordered.
Review of the clinical record revealed the resident weighed 157 lbs. (pounds) on December 13, 2021.
A Nutritional Risk Review dated December 13, 2021 included the recommendation that this resident would receive 1 carton of Glucerna three times a day and be weighed weekly.
However, a Dietary Recommendation dated December 15, 2021 requesting a recommendation for 1 carton of Glucerna three times a day for needs not being met was not signed or notated on by the physician.
An admission/5-day Minimum Data Set (MDS) assessment dated [DATE] included that this resident had a Brief Interview for Mental Status of 8, which indicated moderate cognitive impairment. This assessment also included this resident was on a therapeutic diet.
A second weight obtained on January 2, 2022 revealed the resident weighed 133.6 lbs. which indicated a weight loss of 17.51%.
Continued review of the clinical record revealed weekly weights were not obtained.
An interview was conducted on January 14, 2022 at 9:25 AM with a Diet Technician (staff #51), who said that if the resident's oral intakes are low and they are not meeting their oral intakes, she will recommend a supplement for them. She said that she takes the recommendation and put it in the physician's box, then they sign it, and she gives it to the Director of Nursing and the staff to put it in the computer. She reviewed this resident's documentation and said that one just slipped by her. She said that usually if the physician does not sign it and they do not want it, she documents a note. This staff said that if a resident refused to be weighed that the staff have to document the resident refused weights. Staff #51 said that a resident is weighed on admission and then weekly for 4 weeks. Staff #51 said that if the staff had done a weekly weight, it would have been picked up right away.
An interview was conducted on January 14, 2022 at 10:11 AM with a Licensed Practical Nurse (LPN/staff #16), who said that during admission, they receive orders from the admission coordinator and input the orders. The LPN said that they receive an admission package and they review the orders, the diagnoses, and input the medications individually. She said the height and weight is the first thing obtained and that all residents have orders for weights every week for 3 weeks and then monthly.
An interview was conducted on January 14, 2022 at 1:57 PM with the Director of Clinical Services (staff #45). Staff #45 stated that when a resident is admitted she expects as part of the admission process the nurses would obtain the resident's weight. She said there are basic orders, and orders specific to the resident. She said a basic order is that everyone gets weighed weekly for 3 weeks and then monthly. Staff #45 said that she is concerned of the accuracy of the weight differences for this resident. She said that it did not meet her expectations that the staff did not obtain weekly weights for the first 3 weeks for this resident. Regarding the Dietary Recommendations, she said that staff #51 gives them to the providers before she gives them to her. Staff #45 stated that normally she receives the original and it is initialed when she receives it. She said that she does not know what happened in this case because she never saw it. Staff #45 stated that it does not meet her expectation that it did not get reviewed. Staff #45 also stated that the main physician was out on leave which may have contributed this.
A facility policy titled Weight and Height revealed that that residents should be weighed upon admission/re-admission, weekly for three weeks, and as needed. This policy revealed that the staff should notify the charge nurse of the weight variances as indicated. This policy included that the Interdisciplinary Team (IDT) should review significant weight variances during the collaborative care review team meeting and that significant weight variances may include: 3% weight gain/loss within one week or 5% weight gain/loss within 30 days. This document also included that the staff should notify the health care provider and the resident and/or legal representative of any significant weight changes as indicated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one sampled...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one sampled resident (#5) received urinary catheter care in accordance with physician's orders. The deficient practice increases the risk for infection, use of antibiotics, and rehospitalization.
Findings include:
Resident #5 was readmitted to the facility on [DATE] with diagnoses that included necrotizing fasciitis, sepsis, and type 2 diabetes mellitus.
Review of a physician's order dated 11/01/21 revealed for catheter care for indwelling catheter; cleanse area every shift, monitor for redness, irritation, swelling, or signs and symptoms of a urinary tract infection (UTI). Another order from the same date included to monitor indwelling catheter, document size and urinary output every shift for catheter care.
The 5-day Minimum Data Set assessment dated [DATE] revealed the resident scored 11 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The assessment included the resident required extensive 2-person physical assistance for most activities of daily living, and had an indwelling catheter and an ostomy.
An indwelling Foley catheter care plan dated 11/10/21 related to the necrotizing fasciitis wound to the sacral area had a goal to show no signs or symptoms of a UTI. Interventions included to provide catheter care per policy.
However, review of the 11/01/21 - 12/11/21 Treatment Administration Records (TARs) did not reveal for nursing documentation indicating that indwelling catheter care had been provided in accordance with the physician's order.
A physician's order dated 12/12/21 revealed for ceftriaxone sodium solution (broad-spectrum antibiotic) reconstituted 2 grams (gm); Inject 2 gm intramuscularly one time only for a UTI, possible bacteremia for 1 day.
Review of the 12/12/21 Medication Administration Record (MAR) revealed the medication was administered per physician's orders.
However, further review of the 12/12/21 - 01/12/22 TARs did not include for documentation of catheter care being provided.
An observation of catheter care was conducted on 01/13/22 at 11:13 a.m. with a Licensed Practical Nurse (LPN/staff #86). She stated that the resident had received pain medication prior to the procedure. The LPN observed the urine in the collection bag and stated that it was yellow and had no odor. She prepared a clean area on the resident's over-the-bed table and placed a basin of warm water onto it. She stated she had added a small amount of skin cleanser to the water. She placed clean washcloths and clean towels on the table beside the basin. She removed the resident's pants and covered the resident with a sheet. Staff #86 washed her hands with soap and water and donned clean gloves. She pulled back the sheet to exposed the resident's peri area. A sticky brownish substance was noted to be scattered across the resident's penis and groin. The nurse stated this was residue, but could not state what it was from. As the LPN attempted to lift the resident's penis to begin cleaning, it was noted that the resident's penis appeared to be stuck to his abdomen. Staff #86 began to clean the head of the resident's penis, and continued the process until the peri area and catheter tubing were clean. The resident complained of moderate pain throughout the process and stated he felt a strong urge to urinate after the procedure was finished. Staff #86 stated that nursing tries to provide catheter care on a daily basis.
An interview was conducted on 01/13/22 at 2:44 p.m. with the LPN (staff #86). She stated that she documents catheter care on the TAR. She reviewed the resident's TAR and stated that catheter care is documented in the area designated for monitoring the indwelling catheter and documenting urinary output. She reviewed the resident's orders and stated that the order for catheter care, which included cleansing and monitoring for signs and symptoms of infection, was a different order. She reviewed the TAR and stated that for some reason the order was not there. She stated she had not noticed that before now. The LPN stated that she could not say how someone would be able to know whether or not catheter care had been performed if it was not documented.
On 01/14/22 at 11:35 a.m., an interview was conducted with an LPN (staff #17). She reviewed the resident's orders and stated that sometimes, when the nurse transcribes an order into the clinical record for catheter care, they do not put the specific order type such as TAR. She said that if the order is marked as other it will not populate onto the TAR. The LPN stated that she could not be sure that catheter care was being provided if it was not on the TAR, but she could assume it was.
An interview was conducted on 01/14/22 at 12:16 p.m. with the Director of Nursing (DON/staff #45). She stated that either the provider or nursing will transcribe the resident's orders. She said that every morning, new resident's charts are reviewed to ensure that everything that should be there is there. She stated that catheter care and maintenance (cleaning) would be part of the 3-part order set, in addition to the order for the catheter itself and the order to change the catheter. She stated that she was aware that the resident's catheter care was not showing up on the TAR. She stated that she knows the staff and knows the care was being done. The DON stated that because it was not documented on the TAR she could not say with 100% surety that it was being done.
The facility policy titled Urinary Catheter Care included that the purpose of this procedure is to prevent infection of the resident's urinary tract. Should the resident indicate that his or her bladder is full or that he needs to void (urinate), report it immediately to your supervision. Report complaints the resident may have of burning, tenderness, or pain in the urethral area. The following information should be recorded in the resident's medical record: the date the catheter care was given, drainage, redness, bleeding, irritation, crusting, or pain at meatus, and how the resident tolerated the procedure.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that one resident (#5) was not administered ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that one resident (#5) was not administered an unnecessary medication, by failing to administer an opioid pain medication in accordance with the physician's ordered parameters. The sample size was 5. The deficient practice increases the risk for residents receiving unnecessary medications.
Findings include:
Resident #5 was readmitted to the facility on [DATE] with diagnoses that included necrotizing fasciitis, sepsis, and type 2 diabetes mellitus.
Review of the physician orders dated 11/02/21 included for:
-oxycodone HCl (opioid analgesic) 5 milligrams (mg) by mouth every 4 hours as needed for pain 7-10 and 30 minutes before wound care; and 5 mg by mouth every 6 hours for chronic pain.
-ibuprofen (non-steroidal anti-inflammatory) 400 mg 1 tablet by mouth every 6 hours as needed for pain 1-5.
-acetaminophen (analgesic) 650 mg by mouth every 4 hours as needed for pain 1-6, not to exceed 3 grams in 24 hours.
The 5-day Minimum Data Set assessment dated [DATE] revealed the resident scored 11 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The resident reported occasional pain of 9 out of 10 on a pain scale. Additionally, the assessment included the resident received opioid medications for 6 out of 7 days during the lookback period.
A pain care plan dated 11/10/21 had a goal for no interruption in normal activities due to pain. Interventions included administering pain medication per orders.
However, review of the December 2021 Medication Administration Record (MAR) revealed the resident received as-needed oxycodone on more than 4 occasions when the resident reported pain levels of less than 7 and was not associated with wound care, including:
-12/13 for a pain level of 4 - for back pain
-12/24 for a pain level of 5 - for back pain
-12/25 for a pain level of 3 - for back pain
-and 12/27 for a pain level of 4 - for back pain
On 01/14/22 at 11:35 a.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #17). She stated that her process is to ask the resident what the pain level is, and then to administer the appropriate medication. She said that if the pain is less than 7, she will offer the resident ibuprofen or acetaminophen. She reviewed the MAR and stated it was not acceptable to have administered oxycodone for pain levels of less than 7. The LPN stated that the resident frequently demands oxycodone and she did not know what else to do.
An interview was conducted with the Director of Nursing (DON/staff #45) on 01/14/22 12:16 PM. She stated that her expectation for administration of an as-needed opioid analgesic is to first ask the resident to evaluate their pain on a pain scale. She stated that the nurse should give the appropriate medication as the physician ordered it. The DON stated that she would expect the nurse to call the physician if the resident still requested the oxycodone.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, staff interviews, and policy reviews, the facility failed to ensure hairnets were appropriately worn in the kitchen and that equipment, dishware and cookware were clean. The def...
Read full inspector narrative →
Based on observations, staff interviews, and policy reviews, the facility failed to ensure hairnets were appropriately worn in the kitchen and that equipment, dishware and cookware were clean. The deficient practice could result in a potential for foodborne illness.
Findings include:
Regarding hair nets
An observation was conducted on 01/13/22 at 11:48 AM of the long-term care kitchen on the first floor. During tray line the dining supervisor (staff #90) was observed with her fringe outside of her hairnet preparing meal trays with plates of food, cups of drink and soup. A server (staff #91) was observed organizing trays with food and drink with her hair net not covering the very front of her hair. The administrator (staff #78) came by halfway through the service and told staff #90 and staff #91 to cover the front of their hair. A dietician consultant (staff #93) was observed in the kitchen area observing tray line with a hair net on that did not cover the whole back of his head.
An observation was conducted on 01/13/22 at 01:05 PM of the main kitchen on the second floor. (2). Staff #90 was observed with her fringe outside of her hair net. A cook (staff #92) was observed to have her fringe outside of her hair net while preparing some food. An unidentified male kitchen staff was observed to enter the walk-in refrigerator, pull out a box of food, and leave the kitchen with the box with no hair net on covering his short, buzz cut hair. An unidentified female kitchen staff was observed in the kitchen with a hair net that only covered the top of her hair bun and 1/4 of her head; all 360 degrees of the rest of the 3/4 top of her hair was uncovered. This same female staff then exited the kitchen and reentered on 01/13/22 at 01:51 PM wearing no hair net. This female kitchen staff transported some drying kitchenware from the dry rack to the storage rack, said her salutations to other staff, and left the kitchen as to end her shift.
An interview was conducted on 01/13/22 at 02:36 PM with the Director of Dietary Services (staff #44). Staff #44 stated that the expectation of the kitchen staff is to wear a hair net correctly and properly. Staff #44 stated he expects their hair to be inside the hair net. Staff #44 stated he counted a baseball cap as a hair net. Staff #44 stated the risk of not wearing hair nets properly is the spread of foodborne illness.
A facility policy titled Hair Restraints revealed all associates working in food preparation areas must wear hair restraints. All hair must be kept covered. Acceptable hair restraints include hairnets, white paper hats, and cloth chef's hats. Hair that cannot be effectively restrained by a hat must wear a hairnet. Associates who have hair that cannot be covered with a single hairnet will wear two (one for the front and one for the back).
Regarding unclean equipment and cookware and dishware
During an observation conducted on 01/13/22 at 01:15 PM, a dishwasher (staff #89) was observed to be washing dishes. The clean side of the dishwasher was observed with dirty food particles on it, including black and white solid specks and brown, bloated bread like chunks. At 01:19 PM, staff #89 set a tray onto the drying rack that had leftover food particles on the base of it. At 01:30 PM, staff #89 was observed to set a small plate onto the drying rack that had leftover soggy food crumb on it. At 01:51 PM, staff #89 was observed to set a metal pan with leftover crumbs on the top side onto the drying rack. At 01:54 PM, staff #89 set a small plate that had a food/sauce smudge on the top side of it onto the drying rack. At 02:25 PM, staff #89 was finished washing dishes and had finished cleaning the dishwashing surfaces. The same dirty food particles, including black and white solid specks and brown, bloated bread like chunks were observed still on the clean side of the dishwasher area.
An interview was conducted on 01/13/22 at 02:36 PM with the Director of Dietary Services (staff #44). Staff #44 stated that all staff have a lead trainer and all lead trainers are under him. He stated that during washing, things should be washed properly and dishware should be clean and dry. Staff #44 stated that if things are not cleaned properly, it could cause the spread of food borne illness. He stated things that are washed incorrectly need to be rewashed. Staff #44 was shown the dirty dishes and soiled clean dishwasher area and stated that the staff would be called back to rewash the dishes before they would be used to serve to residents.
A facility policy titled Washing and Sanitizing Flatware, revealed all dishes/utensils will be washed and sanitized using appropriate machine-washing procedures. Flatware should be washed in a manner that assures cleanliness and sanitation.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Arizona facilities.
- • 36% turnover. Below Arizona's 48% average. Good staff retention means consistent care.
Concerns
- • 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Brookdale Santa Catalina's CMS Rating?
CMS assigns BROOKDALE SANTA CATALINA an overall rating of 3 out of 5 stars, which is considered average nationally. Within Arizona, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Brookdale Santa Catalina Staffed?
CMS rates BROOKDALE SANTA CATALINA's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 36%, compared to the Arizona average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Brookdale Santa Catalina?
State health inspectors documented 30 deficiencies at BROOKDALE SANTA CATALINA during 2022 to 2025. These included: 30 with potential for harm.
Who Owns and Operates Brookdale Santa Catalina?
BROOKDALE SANTA CATALINA is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BROOKDALE SENIOR LIVING, a chain that manages multiple nursing homes. With 42 certified beds and approximately 34 residents (about 81% occupancy), it is a smaller facility located in TUCSON, Arizona.
How Does Brookdale Santa Catalina Compare to Other Arizona Nursing Homes?
Compared to the 100 nursing homes in Arizona, BROOKDALE SANTA CATALINA's overall rating (3 stars) is below the state average of 3.3, staff turnover (36%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Brookdale Santa Catalina?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Brookdale Santa Catalina Safe?
Based on CMS inspection data, BROOKDALE SANTA CATALINA has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Arizona. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Brookdale Santa Catalina Stick Around?
BROOKDALE SANTA CATALINA has a staff turnover rate of 36%, which is about average for Arizona nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Brookdale Santa Catalina Ever Fined?
BROOKDALE SANTA CATALINA has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Brookdale Santa Catalina on Any Federal Watch List?
BROOKDALE SANTA CATALINA is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.