Sabino Canyon Rehabilitation & Care Center

4.
-Resident #243 was admitted to the facility on August 7, 2023 with diagnoses of muscle weakness, difficulty walking, major depressive disorder, and morbid obesity.

The admission Minimum Data Set (MDS) assessment dated August 14, 2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident was moderately cognitively impaired.

An interview was conducted with resident #243 on August 22, 2023 in the room and the resident stated the water leaking from the ceiling by the bathroom door started yesterday, August 21, 2023. The resident stated she did not remember the name of the staff person she spoke with about the leak. The resident stated when she asked the staff member what they were gonna do about the leak, the staff said they could not do anything at the moment. After the interview, an observation was conducted and identified a dried water mark on the flood behind the television. Resident #243 stated there was a water damage on the ceiling before the storm. No strange smell was observed; however, the ceiling appeared to look wet with brown plaster coming off of it.

-Resident #301 was admitted to the facility on August 11, 2023 with diagnoses of polyneuropathy, restless leg syndrome, and depression.

The admission MDS assessment dated August 15, 2023 revealed the resident had a BIMS score of 10 which indicated the resident was moderately cognitively impaired.

On August 22, 2023 at approximately 8:13 AM a towel was observed to be rolled up against the window on the windowsill of resident #301 room. When asked about the purpose of the towel, the resident stated she did not know and staff had put it there earlier in the morning.

-Resident #9 was admitted to the facility on September 28, 2022 with diagnoses of kidney disease, muscle weakness, and anemia.

A review of the most recent quarterly MDS assessment dated July 7, 2023 revealed the resident had a BIMS score of 10 which indicated the resident was moderately cognitively impaired.

An observation conducted on August 22, 2023 at approximately 8:16 AM in resident #9's room identified a dry water stain on the bathroom ceiling.

-Resident #282 was admitted to the facility on January 21, 2022 with diagnoses of muscle weakness, acute osteomyelitis, and difficulty walking.

A review the quarterly MDS assessment dated August 1, 2023 revealed the resident had BIMS score of 15 which indicated the resident was cognitively intact.

An interview was conducted on August 22, 2023 at 8:29 AM with resident #282 and he stated, "when it rains, the water leaks" as he showed the HVAC that had been leaking. He stated the leaks started a few storms ago and the facility had told them they were patching the room. An observation at approximately 8:30 AM of the room, identified the HVAC vents to be black.

On August 22, 2023 at 8:04 AM two trash cans were observed to be in the 200 hallway collecting water from the ceiling.

A review of resident council meeting minutes for the past year indicated there were no discussions about water leaks in the facility prior to the current resident council meeting which was held on August 22, 2023.

Based on resident and staff interviews, review of clinical records and facility policies, and observations of current practice, the facility failed to ensure that one resident (#23) out of 19 sampled, received adequate supervision to prevent medication accidents. The deficient practice could result in the resident sustaining medication accident-related injuries.

Findings included:

Resident #57 was admitted on June 10, 2023 with diagnoses that included fracture of the sacrum, pneumocystosis, muscle weakness, chronic obstructive pulmonary disease, and depression.

A review of the MDS (minimum data set) assessment dated June 17, 2023 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact.

An observation conducted on August 21, 2023 at 11:34 AM revealed a medication cup containing 3 white elongated tablets on the resident's bedside tray table. When the resident was asked about the tablets, he stated that because he has a hard time swallowing, staff generally leave the medications with him. There were no staff present.

Additional observation occurred on August 23, 2023 at 7:32 AM. A round pill was observed in a cup on the resident's tray table. When asked, the resident stated that it was his 'Tums' medication left for him by staff.

A review of the electronic health record, including physician orders, care plan, assessments and progress notes, revealed no evidence of an order to self-administer medications or a resident assessment gauging the resident's ability to self-administer medications.

An interview was conducted on August 23, 2023 at 7:39 AM with a Licensed Practical Nurse (staff #124) who stated that staff administering medications must always observe the residents take and swallow the medication. He further stated that medications must not be left with a resident to self-administer. Staff #124 stated that he did leave the medications with resident #57 on August 21, 2023 and had intended to crush them for the resident but had forgotten. He stated that this was his error. He stated that he was uncertain which medications were left at bedside but thought they may have been Colace and vitamin C. He stated that the risk for leaving medications at bedside for this resident could be a choking hazard or that he may not take the medications as prescribed. Staff #124 stated he had not yet administered the morning medications for August 23, 2023. He reviewed the health record and was unable to identify the medication observed in the medication cup, assumed to be 'Tums' as there was no evidence of a corresponding medication entry either that morning or the previous night.

An interview was conducted with the Administrator (staff # 125) and the Director of Nursing (DON/staff #126) on August 23, 2023 at 7:42 AM. The administrator stated that when a resident wanted to self-administer any medication, they must first be assessed to determine if they are appropriate to self-administer medications, they must also have an order in place to self-administer and it must be care planned. The DON stated that nurses are expected to observe the resident and stay in the room until all medications have been taken unless a resident has been authorized to self-administered the medication. Staff #126 stated that resident #57 did not have a self-administration order for medications. She stated that the risk could include the resident not taking the medication and that staff would not know which medication had been taken by the resident. Staff #126 reviewed the resident's file and stated that even the 'Tums' would have to be documented in the system but had not been for either that morning or the previous evening.

A review of the facility's policy titled, "Self Administration of Medication" under the "Care and Treatment" section with a review by date of May 2023, revealed that if a resident wished to self-administer medications, the interdisciplinary team (consisting of the medical director or primary care physician, director of nursing or other nursing representative and social services) would assess the resident and indicated this in the chart. However, no evidence of the interdisciplinary team review was observed in the resident's chart.

Based on observations, staff interviews and facility policy, the facility failed to ensure that a safe and sanitary kitchen environment was followed in regards to a dry storage scoop and proper drying techniques.

Findings included:

An observation conducted on August 21, 2023 at 8:46 AM with the Dietary Supervisor (staff #44) revealed that a bin containing oatmeal had a scoop inside sitting on the oatmeal and metal pans were stacked together on a storage shelf in a manner which did not allow ready air flow and when separated, drops of water were found between the pans.

An observation conducted on August 23, 2023 at 8:10 AM with the Dietary Supervisor (staff #44) revealed that a bin containing oatmeal had a scoop inside sitting on the oatmeal and metal pans were stacked together on a storage shelf in a manner which did not allow ready air flow and when separated, drops of water were found between the pans. The dietary manager removed the scoop and restacked the pans loosely.

An interview was conducted on August 25, 2023 at 10:06 AM with the Dietary Supervisor (staff #44) who said that the staff are not supposed to leave the scoop in the oatmeal bin and that dishes and pans are supposed to be placed on a shelf and that they are supposed to make sure they are dry before stacking on the shelves.

A policy titled, "Food Storage" was updated November 2009 revealed that food items should be stored in accordance with good sanitary practice. This document included that dry storage will be kept free of scoops.

Based on resident and staff interviews, review of clinical records and facility policies, and observations of current practice, the facility failed to ensure that one resident (#23) out of 19 sampled, received adequate supervision to prevent medication accidents.

Findings included:

Resident #57 was admitted on June 10, 2023 with diagnoses that included fracture of the sacrum, pneumocystosis, muscle weakness, chronic obstructive pulmonary disease, and depression.

A review of the MDS (minimum data set) assessment dated June 17, 2023 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact.

An observation conducted on August 21, 2023 at 11:34 AM revealed a medication cup containing 3 white elongated tablets on the resident's bedside tray table. When the resident was asked about the tablets, he stated that because he has a hard time swallowing, staff generally leave the medications with him. There were no staff present.

Additional observation occurred on August 23, 2023 at 7:32 AM. A round pill was observed in a cup on the resident's tray table. When asked, the resident stated that it was his 'Tums' medication left for him by staff.

A review of the electronic health record, including physician orders, care plan, assessments and progress notes, revealed no evidence of an order to self-administer medications or a resident assessment gauging the resident's ability to self-administer medications.

An interview was conducted on August 23, 2023 at 7:39 AM with a Licensed Practical Nurse (staff #124) who stated that staff administering medications must always observe the residents take and swallow the medication. He further stated that medications must not be left with a resident to self-administer. Staff #124 stated that he did leave the medications with resident #57 on August 21, 2023 and had intended to crush them for the resident but had forgotten. He stated that this was his error. He stated that he was uncertain which medications were left at bedside but thought they may have been Colace and vitamin C. He stated that the risk for leaving medications at bedside for this resident could be a choking hazard or that he may not take the medications as prescribed. Staff #124 stated he had not yet administered the morning medications for August 23, 2023. He reviewed the health record and was unable to identify the medication observed in the medication cup, assumed to be 'Tums' as there was no evidence of a corresponding medication entry either that morning or the previous night.

An interview was conducted with the Administrator (staff # 125) and the Director of Nursing (DON/staff #126) on August 23, 2023 at 7:42 AM. The administrator stated that when a resident wanted to self-administer any medication, they must first be assessed to determine if they are appropriate to self-administer medications, they must also have an order in place to self-administer and it must be care planned. The DON stated that nurses are expected to observe the resident and stay in the room until all medications have been taken unless a resident has been authorized to self-administered the medication. Staff #126 stated that resident #57 did not have a self-administration order for medications. She stated that the risk could include the resident not taking the medication and that staff would not know which medication had been taken by the resident. Staff #126 reviewed the resident's file and stated that even the 'Tums' would have to be documented in the system but had not been for either that morning or the previous evening.

A review of the facility's policy titled, "Self Administration of Medication" under the "Care and Treatment" section with a review by date of May 2023, revealed that if a resident wished to self-administer medications, the interdisciplinary team (consisting of the medical director or primary care physician, director of nursing or other nursing representative and social services) would assess the resident and indicated this in the chart. However, no evidence of the interdisciplinary team review was observed in the resident's chart.

Based on observations, staff interviews and facility policy, the facility failed to ensure that a safe and sanitary kitchen environment was followed in regards to a dry storage scoop and proper drying techniques.

Findings included:

An observation conducted on August 21, 2023 at 8:46 AM with the Dietary Supervisor (staff #44) revealed that a bin containing oatmeal had a scoop inside sitting on the oatmeal and metal pans were stacked together on a storage shelf in a manner which did not allow ready air flow and when separated, drops of water were found between the pans.

An observation conducted on August 23, 2023 at 8:10 AM with the Dietary Supervisor (staff #44) revealed that a bin containing oatmeal had a scoop inside sitting on the oatmeal and metal pans were stacked together on a storage shelf in a manner which did not allow ready air flow and when separated, drops of water were found between the pans. The dietary manager removed the scoop and restacked the pans loosely.

An interview was conducted on August 25, 2023 at 10:06 AM with the Dietary Supervisor (staff #44) who said that the staff are not supposed to leave the scoop in the oatmeal bin and that dishes and pans are supposed to be placed on a shelf and that they are supposed to make sure they are dry before stacking on the shelves.

A policy titled, "Food Storage" was updated November 2009 revealed that food items should be stored in accordance with good sanitary practice. This document included that dry storage will be kept free of scoops.

Based on resident and staff interviews, review of clinical records and facility policies, and observations of current practice, the facility failed to ensure that one resident (#23) out of 19 sampled, received adequate supervision to prevent medication accidents.

Findings included:

Resident #57 was admitted on June 10, 2023 with diagnoses that included fracture of the sacrum, pneumocystosis, muscle weakness, chronic obstructive pulmonary disease, and depression.

A review of the MDS (minimum data set) assessment dated June 17, 2023 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact.

An observation conducted on August 21, 2023 at 11:34 AM revealed a medication cup containing 3 white elongated tablets on the resident's bedside tray table. When the resident was asked about the tablets, he stated that because he has a hard time swallowing, staff generally leave the medications with him. There were no staff present.

Additional observation occurred on August 23, 2023 at 7:32 AM. A round pill was observed in a cup on the resident's tray table. When asked, the resident stated that it was his 'Tums' medication left for him by staff.

A review of the electronic health record, including physician orders, care plan, assessments and progress notes, revealed no evidence of an order to self-administer medications or a resident assessment gauging the resident's ability to self-administer medications.

An interview was conducted on August 23, 2023 at 7:39 AM with a Licensed Practical Nurse (staff #124) who stated that staff administering medications must always observe the residents take and swallow the medication. He further stated that medications must not be left with a resident to self-administer. Staff #124 stated that he did leave the medications with resident #57 on August 21, 2023 and had intended to crush them for the resident but had forgotten. He stated that this was his error. He stated that he was uncertain which medications were left at bedside but thought they may have been Colace and vitamin C. He stated that the risk for leaving medications at bedside for this resident could be a choking hazard or that he may not take the medications as prescribed. Staff #124 stated he had not yet administered the morning medications for August 23, 2023. He reviewed the health record and was unable to identify the medication observed in the medication cup, assumed to be 'Tums' as there was no evidence of a corresponding medication entry either that morning or the previous night.

An interview was conducted with the Administrator (staff # 125) and the Director of Nursing (DON/staff #126) on August 23, 2023 at 7:42 AM. The administrator stated that when a resident wanted to self-administer any medication, they must first be assessed to determine if they are appropriate to self-administer medications, they must also have an order in place to self-administer and it must be care planned. The DON stated that nurses are expected to observe the resident and stay in the room until all medications have been taken unless a resident has been authorized to self-administered the medication. Staff #126 stated that resident #57 did not have a self-administration order for medications. She stated that the risk could include the resident not taking the medication and that staff would not know which medication had been taken by the resident. Staff #126 reviewed the resident's file and stated that even the 'Tums' would have to be documented in the system but had not been for either that morning or the previous evening.

A review of the facility's policy titled, "Self Administration of Medication" under the "Care and Treatment" section with a review by date of May 2023, revealed that if a resident wished to self-administer medications, the interdisciplinary team (consisting of the medical director or primary care physician, director of nursing or other nursing representative and social services) would assess the resident and indicated this in the chart. However, no evidence of the interdisciplinary team review was observed in the resident's chart.

Based on observation the facility failed to prevent the fire alarm pull station to be accessible and unobstructed. Obscuring the fire alarm pull stations from view may prevent or delay the initiating of the fire alarm system in an emergency and this has potential harm to the patients during a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.4.2.1 "Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems, unless otherwise permitted by 19.3.3.2.2 through 19.3.4.2.4." Chapter 9, Section 9.6.2.7, "Each manual fire alarm box on a system shall be accessible, unobstructed, and visible."

Findings include:

Observation made while tour on August 29, 2023, revealed a 4 foot by 4 foot table was obstructing access to the manual fire alarm pull station in the 300 dining room next to the exit door.

During the exit conference on August 29, 2023, the above finding was again acknowledged by management staff.

Based on observation the facility failed to prevent an ABC fire extinguisher from being blocked and readily accessible in the 300 hall dining room of the facility. Failing to have clear access to a fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility.

Findings included:

During a facility tour conducted on August 29, 2023, an ABC portable fire extinguisher located at the 300 hall dining room exit. A cart which had several plant pots on it was obstructing the fire extinguisher cabinet door from opening.

During the exit conference on August 29, 2023, the above findings were again acknowledged by the management team.