Desert Terrace Healthcare Center

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#20) and (#40) were free from abuse from other residents (resident #75).

Findings include:

Regarding resident #20 and resident #75

-Resident #20 was admitted to the facility on September 24, 2024, with diagnoses that included hemiplegia, urinary tract infection, gastroesophageal reflux disease, anxiety, and bipolar disorder.

Review of the Discharge Minimum Data Set (MDS) assessment dated October 5, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident had no cognitive impairment.

A behavioral care-plan initiated September 24, 2024 revealed that the resident was at risk for impaired cognitive function related to hemiplegia and hemiparesis following cerebral infarction, with a noted intervention of monitor, document, and report to provider any changes in cognitive function, decision making ability, difficulty understanding others, and mental status.

-Resident #75 was admitted to the facility on September 19, 2024, with diagnoses that included post traumatic stress disorder, anxiety, attention deficit hyperactivity disorder, substance abuse, insomnia, and depression.

Review of the Admission Minimum Data Set (MDS) assessment dated September 25, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment.

A behavioral care-plan initiated September 26, 2024 revealed the resident was at risk for trauma related to history of trauma, and post-traumatic stress disorder, which a goal of no emotional, physical, or psychological problems by the review date of December 18, 2024 and noted interventions of anticipate and meet the residents needs and resident can be triggered by loud noises so provide a calm and quiet environment.

A review of the clinical record progress notes for resident #20 dated September 30, 2024 at 12:46 a.m. revealed that the nurse knocked on resident #20's door, and upon opening resident #20 and resident #75 were raising their voices at each other. Resident #20 was out of bed moving her wheelchair and ambulating, at the same asking for her cellphone back from resident #75. Both residents continued raising their voice at each other, and resident #75 suddenly raised her voice and threatened resident #20 over the cell phone disagreement and threw the cell phone on the floor.

An interview was conducted with a Certified Nursing Assistant (CNA/staff #55) on October 10, 2024 at 2:20 p.m. The CNA reported that resident #75 has had altercations with several residents. The CNA stated that resident #75 had psyche issues and would accuse residents of stealing her things like clothes and other belongings, even though the items were donated by the facility to resident #75. The CNA concluded that resident #75 was the instigator in the incident with resident #20.

Regarding resident #40 and resident #75

-Resident #40 was admitted to the facility on September 20, 2024, with diagnoses that included acute respiratory failure, pneumonia, heart disease, congestive heart failure, insomnia, and depression.

Review of the Admission Minimum Data Set (MDS) assessment dated September 26, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment.

A review of the clinical record progress notes for resident #40 dated October 3, 2024 at 10:00 a.m. revealed that resident #40 and resident #75 were engaged in a verbal exchange in the hallway. It was then observed that resident #75 raised her leg and made contact with resident #40 in the abdomen. It concludes that the residents were separated and resident #40 wished to continue to discharge as planned.

An interview was conducted with a Certified Nursing Assistant (CNA/staff #91) on October 10, 2024 at 1:34 p.m. The CNA stated that resident #75 was alert and oriented, however she was also very behavioral. The CNA stated that she heard the resident's arguing from another room, darted out into the hallway where she witnessed resident #75 kick resident #40 in the chest. The CNA concluded that this was the first time she has seen resident #75 get physical but also stated that she had been verbally aggressive before.

An interview was conducted with a Licensed Practical Nurse (LPN/staff #110) on October 10, 2024 at 2:50 p.m. The LPN stated that resident #75 was alert and oriented but was a textbook, "druggie type of patient", and noted that she would yell out at staff and other residents. The LPN stated that resident #75 was put in a room by herself because she would cause problems any time she had a roommate. The LPN stated that resident #75 would make paranoid statements; and that, the staff would simply redirect her as best as they could.

An interview with the Director of Nursing (DON/staff #15) was conducted on September 10, 2024 at 3:16 p.m. The DON stated that resident #75 had not been at the facility long; and that, she admitted on psychiatric medications. The DON stated that the resident on arrival was asking for dosage increases on her medications that were not appropriate. The DON stated that the first incident with resident #20 raised concerns, but she thought it was an isolated incident, and that they were separated immediately. The DON then stated that the second incident involving resident #40 and resident #75 confirmed the residents were arguing in the hall, and resident #75 raised her up and made physical contact between the two. The DON concluded that after the incident they put resident #75 on 1 to 1 with staff, and eventually had her petitioned to go to a psyche facility. The DON concluded that her expectation is that residents are separated when an incident occurs and reported appropriately.

A review of facility policy titled 'Abuse: Prevention of and prohibition against' revised October of 2024 revealed that it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation. It further revealed that willful as used in this definition of abuse, means the individuals must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on clinical record review, staff and resident interviews, and a review of the facility's policy and procedures, the facility failed to ensure two residents (#90 and #123) were not subjected to abuse.


Findings included:

-Resident #90 was admitted to the facility on May 13, 2016, with diagnoses that included anxiety disorder, mood [affective] disorder, delusional disorders, depression, major depressive disorder, symptoms and signs involving cognitive functions and awareness, and hoarding disorder.

A review of resident #90's care plan dated April 7, 2022, revealed that the resident exhibited behaviors that included aggression.

A review of resident #90's Minimum Data Set (MDS) dated April 7, 2022, revealed a Brief Interview for Mental Status (BIMS) score of 4 that indicated the resident had severe cognitive impairment.

-Resident #123 was admitted to the facility on August 8, 2020, with diagnoses that included
major depressive disorder, post-traumatic stress disorder, and mood [affective] disorder. The resident was discharged on August 15, 2022.

Review of resident #123's care plan dated March 30, 2022, revealed that the resident was at risk for impaired cognitive function or impaired thought processes.

A review of resident #123's MDS dated April 4, 2022, revealed a BIMS score of 14 which indicated the resident was cognitively intact.

On May 30, 2022, the facility submitted a self-report to the SA (State Agency) regarding a resident-to-resident altercation between resident #90 and resident #123.

A review of resident #90's progress note dated May 30, 2022 at 1:20 p.m., revealed documentation that resident #90 reported that when he came out of the bathroom, he found his roommate on his side of the room going through his personal items. Staff removed the roommate from the room.

A review of resident #123's progress note dated May 30, 2022 at 1:30 p.m., revealed documentation that resident #123's roommate reported that resident #123 was found going through his personal items in his bedside table. Resident #123 stated that he was looking for his personal items that he thought his roommate had in his possession. Resident #123 stated that his roommate hit him on the head and shoulder. A skin assessment was completed and no new skin issues were noted. Resident #123 was moved to another room.

Review of the facility's investigative documentation dated June 6, 2022, revealed documentation that resident #123 stated that he thought he was on his side of the room and later stated that he was looking for items that he thought resident #90 had taken from him. The documentation also revealed that resident #90 stated that he did hit resident #123 on the shoulder but not his head because resident #123 would not stop going through this stuff.

In addition, the documentation revealed that staff #108 stated that resident #90 was heard yelling from his room. When staff #108 entered the room, resident #90 was standing in the room and resident #123 was sitting in his wheelchair. Staff #108 stated that resident #90 did not deny that he hit resident #123 and resident #90 stated he was protecting his stuff.

On September 09, 2024 at 2:09 p.m., an interview was conducted with the facility abuse coordinator/staff #50, who stated that reports and investigations of abuse would be kept by the facility for, "a while", but did not specify exactly how long but stated that longer than 12 months. Staff #50 stated all allegations of abuse would be reported to the SA, immediately within 2 hours and that identified staff would be suspended and removed from the building during the investigation.

On September 11, 2024 at 2:00 p.m., an interview was conducted with the Certified Nursing Assistant (CNA)/staff #78 who identified the types of abuse.

On September 11, 2024 at 2:00 p.m., an interview was conducted with CNA/staff #94, who stated that when abuse was witnessed or received an allegation of abuse, the first thing would be to stop the abuse, separate the residents, and when safe report to the charge nurse and the administrator.

On September 11, 2024 at 2:00 p.m., an interview was conducted with CNA/staff #99, who stated that education about abuse prevention, identification, and reporting is discussed during monthly staff meetings and annually with online training. Staff #99 also stated that if an employee is accused of abuse, the employee would be put on suspension until the investigation is done.

Interviews conducted with other staff and residents did not reveal any concerns regarding reporting of abuse.

Review of the facility policy titled "Abuse: Prevention of and Prohibition Against" dated October 2023, stated that is was the policy of the facility that each resident has the right to be free from abuse.

Based on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that medical records were documented accurately and in accordance with accepted professional standards and practices for one resident (#12) regarding vital signs and blood glucose monitoring. The deficient practice could result in inaccurate records being documented for additional residents.

Findings include:

Resident #12 was re-admitted on June 24, 2024 with diagnoses that included osteomyelitis of vertebra, sacral and sacrococcygeal regions, pressure ulcers of left buttock (stage 4), left hip (stage 4), right hip (stage 4), type 2 diabetes mellitus, and depression.

A Quarterly MDS (Minimum Data Set) assessment dated May 31, 2024 included that Resident #12 had intact cognition, required setup or clean up assistant for eating, and was incontinent of bowel/bladder.

Review of June 2024 Medication Administration Records (MAR), revealed Resident #12 was administered insulin glargine (Lantus) on June 25, 2024 and June 26, 2024, with no record of Resident #12's blood sugar results.

Review of June 2024 POC (point of care) Certified Nursing Assistant (CNA) Task documentation, revealed no evidence of vital signs performed on the evening shifts June 25, 2024 and June 27, 2024.

Regarding Vital Sign Documentation:

An interview was conducted on July 2, 2024 at 2:45 PM with CNA (staff #1), who stated that she was assigned to care for Resident #12 on the evening shift (2:00 PM - 10:00 PM) on June 28, 2024. The CNA stated that she completes documentation for all residents at the end of her shift, but did not complete documentation for Resident #12 that day.

An interview was conducted on July 3, 2024 at 10:15 AM with a Licensed Practical Nurse (LPN/staff #2), who stated that CNA's are responsible for charting resident vitals in the medical record.

An interview was conducted on July 3, 2024 at 12:20, with an LPN (staff #5) who stated the facility policy is for CNA's to complete vial signs twice a day, on the day and evening shifts, prior to the nurses' shift. The LPN stated that this is done to ensure that nurses can start medication pass immediately at the start of their shifts.

An interview was conducted on July 3, 2024 at 11:53 AM, with CNA (staff #4), who stated that the 2-10 PM shift CNA's are required to complete vitals at 2:00 PM, and to document the results in the medical record. The CNA reviewed Resident #12's medical record and stated that there was no evidence that vitals during the 2:00 PM - 10:00 PM shifts on June 25, 2024 and June 27, 2024 had been conducted. The CNA further stated that this did not meet the facility requirements for documentation of resident's vitals.

An interview was conducted on July 3, 2024 at 1:45 PM with the Director of Nursing (DON/staff #6), who stated that vitals should be conducted twice daily, and expected vitals to be conducted each nursing shift. The DON reviewed the medical record for Resident #12, and stated that there was no evidence that vitals had been obtained on June 25, 2024 and June 27, 2024 on the evening shift. The DON further stated that this did not meet her expectations and did not follow the facility policy. The DON stated the risk could include the potential to miss an acute change.

Review of the facility policy titled, Documentation and Charting, included it is the policy of the facility to provide documentation of the resident's care, treatment, response to the care, signs, symptoms, as well as progress of the resident's care.

Regarding Blood Sugar Monitoring:
An interview was conducted on July 3, 2024 at 10:15 AM, with a Licensed Practical Nurse (LPN/staff #2), who stated that orders for medications/treatments come from the referring hospital, that would include blood sugar monitoring for resident's with diagnoses of type 2 diabetes mellitus. The LPN stated that the facility policy is to check blood sugar levels prior to administering insulin, any time insulin is ordered. The LPN also stated that the facility process for insulin administration included completing a blood glucose test prior to administrating insulin, and documenting the results in the medical record. The LPN stated that the risk of not monitoring blood sugars prior to administration of insulin could result in the resident's blood sugar "bottoming-out," which could cause death. The LPN further stated that the standard of care for resident's with diabetes and insulin orders would be to check blood sugars twice a day and regularly monitor glucose levels.

An interview was conducted on July 3, 2024 at 11:07 AM, with an LPN (staff #3), who stated that the facility policy is to monitor blood glucose levels as ordered, and the standard of care is to check blood glucose levels prior to administering insulin. The LPN reviewed the medical record and stated that Resident #12 received insulin on June 25, 2024 and June 26, 2024, but she found no evidence that a blood glucose test had been performed. The LPN also stated that Resident #12's blood glucose had not been monitored since June 12, 2024. The LPN further stated that the admission nurse should have called the provider for orders to monitor blood glucose levels, because Resident #12 had an order for insulin glargine (Lantus).

An interview was conducted on July 3, 2024 at 1:45 PM with the Director of Nursing (DON/staff #6), who stated that blood glucose monitoring depends on the hospital orders and the patient. The DON further stated that insulin glargine (Lantus) is not held for low blood glucose levels, because it does not have immediate effects. The DON stated the standard of care for insulin administration would be to monitor for signs/symptoms of hypoglycemia, in lieu of physician orders for glucose monitoring.

Review of the facility policy titled, Insulin Injections, revealed insulin injections and blood glucose monitoring will only be done following physician's orders.

Lantus (insulin glargine injection) administration instructions included not to take Lantus during episodes of low blood sugar, test blood sugar levels while using insulin, such as Lantus. Individualize dosage based on metabolic needs, blood glucose monitoring, glycemic control, type or diabetes, and prior insulin use.

Based on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that medical records were documented accurately and in accordance with accepted professional standards and practices for one resident (#12) regarding vital signs and blood glucose monitoring.

Findings include:

Resident #12 was re-admitted on June 24, 2024 with diagnoses that included osteomyelitis of vertebra, sacral and sacrococcygeal regions, pressure ulcers of left buttock (stage 4), left hip (stage 4), right hip (stage 4), type 2 diabetes mellitus, and depression.

A Quarterly MDS (Minimum Data Set) assessment dated May 31, 2024 included that Resident #12 had intact cognition, required setup or clean up assistant for eating, and was incontinent of bowel/bladder.

Review of June 2024 Medication Administration Records (MAR), revealed Resident #12 was administered insulin glargine (Lantus) on June 25, 2024 and June 26, 2024, with no record of Resident #12's blood sugar results.

Review of June 2024 POC (point of care) Certified Nursing Assistant (CNA) Task documentation, revealed no evidence of vital signs performed on the evening shifts June 25, 2024 and June 27, 2024.

Regarding Vital Sign Documentation:

An interview was conducted on July 2, 2024 at 2:45 PM with CNA (staff #1), who stated that she was assigned to care for Resident #12 on the evening shift (2:00 PM - 10:00 PM) on June 28, 2024. The CNA stated that she completes documentation for all residents at the end of her shift, but did not complete documentation for Resident #12 that day.

An interview was conducted on July 3, 2024 at 10:15 AM with a Licensed Practical Nurse (LPN/staff #2), who stated that CNA's are responsible for charting resident vitals in the medical record.

An interview was conducted on July 3, 2024 at 12:20, with an LPN (staff #5) who stated the facility policy is for CNA's to complete vial signs twice a day, on the day and evening shifts, prior to the nurses' shift. The LPN stated that this is done to ensure that nurses can start medication pass immediately at the start of their shifts.

An interview was conducted on July 3, 2024 at 11:53 AM, with CNA (staff #4), who stated that the 2-10 PM shift CNA's are required to complete vitals at 2:00 PM, and to document the results in the medical record. The CNA reviewed Resident #12's medical record and stated that there was no evidence that vitals during the 2:00 PM - 10:00 PM shifts on June 25, 2024 and June 27, 2024 had been conducted. The CNA further stated that this did not meet the facility requirements for documentation of resident's vitals.

An interview was conducted on July 3, 2024 at 1:45 PM with the Director of Nursing (DON/staff #6), who stated that vitals should be conducted twice daily, and expected vitals to be conducted each nursing shift. The DON reviewed the medical record for Resident #12, and stated that there was no evidence that vitals had been obtained on June 25, 2024 and June 27, 2024 on the evening shift. The DON further stated that this did not meet her expectations and did not follow the facility policy. The DON stated the risk could include the potential to miss an acute change.

Review of the facility policy titled, Documentation and Charting, included it is the policy of the facility to provide documentation of the resident's care, treatment, response to the care, signs, symptoms, as well as progress of the resident's care.

Regarding Blood Sugar Monitoring:
An interview was conducted on July 3, 2024 at 10:15 AM, with a Licensed Practical Nurse (LPN/staff #2), who stated that orders for medications/treatments come from the referring hospital, that would include blood sugar monitoring for resident's with diagnoses of type 2 diabetes mellitus. The LPN stated that the facility policy is to check blood sugar levels prior to administering insulin, any time insulin is ordered. The LPN also stated that the facility process for insulin administration included completing a blood glucose test prior to administrating insulin, and documenting the results in the medical record. The LPN stated that the risk of not monitoring blood sugars prior to administration of insulin could result in the resident's blood sugar "bottoming-out," which could cause death. The LPN further stated that the standard of care for resident's with diabetes and insulin orders would be to check blood sugars twice a day and regularly monitor glucose levels.

An interview was conducted on July 3, 2024 at 11:07 AM, with an LPN (staff #3), who stated that the facility policy is to monitor blood glucose levels as ordered, and the standard of care is to check blood glucose levels prior to administering insulin. The LPN reviewed the medical record and stated that Resident #12 received insulin on June 25, 2024 and June 26, 2024, but she found no evidence that a blood glucose test had been performed. The LPN also stated that Resident #12's blood glucose had not been monitored since June 12, 2024. The LPN further stated that the admission nurse should have called the provider for orders to monitor blood glucose levels, because Resident #12 had an order for insulin glargine (Lantus).

An interview was conducted on July 3, 2024 at 1:45 PM with the Director of Nursing (DON/staff #6), who stated that blood glucose monitoring depends on the hospital orders and the patient. The DON further stated that insulin glargine (Lantus) is not held for low blood glucose levels, because it does not have immediate effects. The DON stated the standard of care for insulin administration would be to monitor for signs/symptoms of hypoglycemia, in lieu of physician orders for glucose monitoring.

Review of the facility policy titled, Insulin Injections, revealed insulin injections and blood glucose monitoring will only be done following physician's orders.

Lantus (insulin glargine injection) administration instructions included not to take Lantus during episodes of low blood sugar, test blood sugar levels while using insulin, such as Lantus. Individualize dosage based on metabolic needs, blood glucose monitoring, glycemic control, type or diabetes, and prior insulin use.

Based on observations, staff interviews, facility documents, and resident records, the facility failed to ensure 3 residents received medications in a timely manner.

Findings include:

1) Resident #7 admitted to the facility on 12/22/2023 with diagnoses that Osteomyelitis, Atherosclerotic Heart Disease, Anxiety Disorder, and Depression. According to the Minimum Data Set assessment completed on 12/29/2023, the Brief Interview for Mental Status revealed a score of 15 with suggested he was cognitively intact. He has an order dated 1/22/2024 for Ceftaroline Fosamil Intravenous Solution 600 MG (milligrams) intravenously two times a day for an infection of prosthetic knee joint. Review of his Medication Administration Report for January 2024, does not show any missed doses. His Ceftaroline IV medication is scheduled for 8:00 AM and 8:00 PM, with a leeway of 1 hour before and after. This means nursing staff is permitted to administer his medication between 7:00 AM to 9:00 AM, or 7:00 PM to 9:00 PM. However, on 1/2/2024, his 8:00 PM Cerftaroline dose was administered at 11:50 PM. On 1/4/2024 his 8:00 PM Cerftaroline dose was administered at 1:24 AM on 1/5/2024. On 1/5/2024 his 8:00 AM dose was administered at 10:24 AM and his 8:00 PM dose was administered at 10:19 PM. On 1/6/2024 his 8:00 PM dose was administered at 1:03 AM on 1/7/2024. On 1/7/24 his 8:00 AM dose was administered at 10:07 AM and his 8:00 PM dose was administered at 2:37 AM on 1/8/2024.

In his care plan imitated on 12/22/2023, he has goals for his left knee infection to be free from complications with the intervention to administer antibiotic as per medical doctor orders.

In a electronic Medication Administration Record (eMAR) note dated 1/1/2024 07:48 AM, it states his Ceftaroline Fosamil Intravenous Solution Reconstituted 600 MG is "on order."

A progress note dated 1/6/2024 2:25 PM revealed Nursing discussed concerns with resident "regarding medication administration and times. Resident was informed about off site pharmacy and the facilities' need to wait for delivery when he first admitted to the facility. Medication administration discussed with resident which shows that, while some doses were given late, all doses have been documented as administered. Resident verbalizes understanding and voiced no further concerns."

A subsequent eMAR note time stamped 1/12/2024 10:58 AM documents Ceftaroline Fosamil Intravenous Solution Reconstituted 600 MG "unavailable. Pharmacy notified, MD notified. Hold."

2) Resident #9 was admitted on 1/8/2024 with diagnoses that included Staphylococcal Arthritis, Left Knee
Osteoarthritis, Tachycardia, and Cervical Disc Disorder With Myelopathy. Residnet # 9 had an order dated 1/11/2024 for 1000 mg of Vancomycin HCl Intravenous Solution every 12 hours for bone and joint infection until 01/20/2024. He also had an order dated 1/15/2024 for 2 grams of Ceftriaxone Sodium Solution Reconstituted every 24 hours for infection related to tachycardia.

A review of his January MAR revealed a "7 was entered in place of administration of his Vancomycin on 1/8/2024, 1/9/2024 and 1/13/2024, as well as on 1/15/2024 for his Ceftriaxone. The chart code key indicates that a "7" means "Other/See Nurse Notes." His Vancomycin medication is scheduled every 12 hours for 8:00 AM am and 8:00 PM, with 1 hour grace window before and after. This means nursing staff is permitted to administer his medication between 7:00 AM to 9:00 AM, or 7:00 PM to 9:00 PM. On 1/13/2024, his 8:00 AM dose of Vancomycin was administered at 10:18 AM and his 8:00 PM dose was administered at 10:00 PM. Resident #9's care plan initiated on 1/8/2024 revealed goal to be free of complications related to left knee infection with intervention to administer antibiotics as per orders.

Corresponding eMAR notes for Vancomycin administration on 1/8/2024 10:19 PM reveal "awaiting arrival from pharmacy". On 1/9/2024 at 1:07 PM: "Followed up with pharmacy, medication will be delivered on 2:00 PM run, resident and MD aware", on 1/9/2024 at 8:00 PM, "New order. Not yet in from pharmacy."

On 1/13/2024 at 10:00 PM they took a "vanco trough," with a progress note on 1/14/2024 at 4:34 PM stating Vancomycin was to be held and another trough taken due to previous trough being 36.7.

Regarding Ceftriaxone, an eMAR note dated 1/15/2024 at 10:30 PM stated "awaiting from pharmacy."



3) Resident #12 was admitted on 1/4/2024 with diagnoses that included Cerebral Infarction, Hemiplegia And Hemiparesis, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, and Bipolar Disorder. According to a Brief Interview for Mental Status completed on 1/11/2024 by the interdisciplinary team, he score a 14 which indicates cognitive intactness.

He had an order dated 1/4/2024 for 2 grams of Ceftriaxone Sodium Solution Reconstituted every 24 hours for Bacteremia.

A review of his January Medication Administration Record (MAR) revealed a "7 was entered in place of administration of his Ceftriaxone on 1/4/2024, and a "10" on 1/5/2024. The chart code key indicates that a "7" means "Other/See Nurse Notes" and a "10" means hospitalized. There was no missed charting. His Ceftriaxone medication is scheduled at 2:00 PM every 24 hours, with an 1 hour grace window before and after. This means nursing staff is permitted to administer his medication between 1:00 PM and 3:00 PM. On 1/13/2024, his dose of Ceftriaxone was administered at 4:08 PM. On 1/10/2024, his dose was administered at 5:11 PM, and on 1/4/2024, it was administered at 4:08 PM.

His care plan did not reflect any goals or interventions for antibiotics. An eMAR note for 1/4/2024 at 4:08 PM stated "awaiting medications; patient just admitted to facility".

During an interview conducted on 1/16/2024 at 1:17 PM with Resident #9, he stated he does not get his antibiotics on time.

During an interview at 1:30 PM with Resident #12, he stated his medications are often late and he never gets his antibiotic on time. He states he will be told by the nurse that the pharmacy has not delivered it yet, or that there is a lot going on and they have a lot of patients.

In an interview with a Licensed Practical Nurse (LPN/Staff #34) conducted on 1/16/2024 at 12:10 PM, she stated scheduled medications can be administered on hour before or one hour after the scheduled time, or they are considered late. She stated if antibiotics are given hours later it does not make them less effective. When asked why Resident #7's Ceftriaxone was not available on 12/23/2023, 12/26/2023, 1/1/2024 and 1/12/2024, she stated it was because the pharmacy only send so much IV medications and they will have to call to have more sent out.

At 11:25 AM a chart review was completed with LPN (Staff #4) for resident #7 which revealed late administration on multiple occasions. She stated that even being given late doses, his condition would not worsen. She confirmed that he was given medications outside of parameters as it was supposed to be given within the hour before and hour after.

During an interview on 1/16/2024 at 11:30 AM with Pharmerica, the Pharmacist Technician Supervisor, (Staff #78) stated they fill a 2 day supply which is 4 doses each time. He stated they track the medication and it will be sent out automatically. He stated they do not show any days where the pharmacy missed sending refills. He stated due to the stability of the medication, they can only send 2 days at a time.

The Director of Nursing (DON/Staff #7, and the Clinical Resource Nurse, (Staff #20) were interviewed at 12:57 PM on 1/6/2024. The DON stated her expectation for administration of medications is that it should be within an hour of the scheduled time. This is for consistency and to make sure they do not get medications too close together. Regarding if it affects the effectiveness of the anti

Based on observations, staff interviews, facility documents, and resident records, the facility failed to ensure 3 residents received medications in a timely manner. The sample size was 3.

Findings include:

1) Resident #7 admitted to the facility on 12/22/2023 with diagnoses that Osteomyelitis, Atherosclerotic Heart Disease, Anxiety Disorder, and Depression. According to the Minimum Data Set assessment completed on 12/29/2023, the Brief Interview for Mental Status revealed a score of 15 with suggested he was cognitively intact. He has an order dated 1/22/2024 for Ceftaroline Fosamil Intravenous Solution 600 MG (milligrams) intravenously two times a day for an infection of prosthetic knee joint. Review of his Medication Administration Report for January 2024, does not show any missed doses. His Ceftaroline IV medication is scheduled for 8:00 AM and 8:00 PM, with a leeway of 1 hour before and after. This means nursing staff is permitted to administer his medication between 7:00 AM to 9:00 AM, or 7:00 PM to 9:00 PM. However, on 1/2/2024, his 8:00 PM Cerftaroline dose was administered at 11:50 PM. On 1/4/2024 his 8:00 PM Cerftaroline dose was administered at 1:24 AM on 1/5/2024. On 1/5/2024 his 8:00 AM dose was administered at 10:24 AM and his 8:00 PM dose was administered at 10:19 PM. On 1/6/2024 his 8:00 PM dose was administered at 1:03 AM on 1/7/2024. On 1/7/24 his 8:00 AM dose was administered at 10:07 AM and his 8:00 PM dose was administered at 2:37 AM on 1/8/2024.

In his care plan imitated on 12/22/2023, he has goals for his left knee infection to be free from complications with the intervention to administer antibiotic as per medical doctor orders.

In a electronic Medication Administration Record (eMAR) note dated 1/1/2024 07:48 AM, it states his Ceftaroline Fosamil Intravenous Solution Reconstituted 600 MG is "on order."

A progress note dated 1/6/2024 2:25 PM revealed Nursing discussed concerns with resident "regarding medication administration and times. Resident was informed about off site pharmacy and the facilities' need to wait for delivery when he first admitted to the facility. Medication administration discussed with resident which shows that, while some doses were given late, all doses have been documented as administered. Resident verbalizes understanding and voiced no further concerns."

A subsequent eMAR note time stamped 1/12/2024 10:58 AM documents Ceftaroline Fosamil Intravenous Solution Reconstituted 600 MG "unavailable. Pharmacy notified, MD notified. Hold."

2) Resident #9 was admitted on 1/8/2024 with diagnoses that included Staphylococcal Arthritis, Left Knee
Osteoarthritis, Tachycardia, and Cervical Disc Disorder With Myelopathy. Residnet # 9 had an order dated 1/11/2024 for 1000 mg of Vancomycin HCl Intravenous Solution every 12 hours for bone and joint infection until 01/20/2024. He also had an order dated 1/15/2024 for 2 grams of Ceftriaxone Sodium Solution Reconstituted every 24 hours for infection related to tachycardia.

A review of his January MAR revealed a "7 was entered in place of administration of his Vancomycin on 1/8/2024, 1/9/2024 and 1/13/2024, as well as on 1/15/2024 for his Ceftriaxone. The chart code key indicates that a "7" means "Other/See Nurse Notes." His Vancomycin medication is scheduled every 12 hours for 8:00 AM am and 8:00 PM, with 1 hour grace window before and after. This means nursing staff is permitted to administer his medication between 7:00 AM to 9:00 AM, or 7:00 PM to 9:00 PM. On 1/13/2024, his 8:00 AM dose of Vancomycin was administered at 10:18 AM and his 8:00 PM dose was administered at 10:00 PM. Resident #9's care plan initiated on 1/8/2024 revealed goal to be free of complications related to left knee infection with intervention to administer antibiotics as per orders.

Corresponding eMAR notes for Vancomycin administration on 1/8/2024 10:19 PM reveal "awaiting arrival from pharmacy". On 1/9/2024 at 1:07 PM: "Followed up with pharmacy, medication will be delivered on 2:00 PM run, resident and MD aware", on 1/9/2024 at 8:00 PM, "New order. Not yet in from pharmacy."

On 1/13/2024 at 10:00 PM they took a "vanco trough," with a progress note on 1/14/2024 at 4:34 PM stating Vancomycin was to be held and another trough taken due to previous trough being 36.7.

Regarding Ceftriaxone, an eMAR note dated 1/15/2024 at 10:30 PM stated "awaiting from pharmacy."



3) Resident #12 was admitted on 1/4/2024 with diagnoses that included Cerebral Infarction, Hemiplegia And Hemiparesis, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, and Bipolar Disorder. According to a Brief Interview for Mental Status completed on 1/11/2024 by the interdisciplinary team, he score a 14 which indicates cognitive intactness.

He had an order dated 1/4/2024 for 2 grams of Ceftriaxone Sodium Solution Reconstituted every 24 hours for Bacteremia.

A review of his January Medication Administration Record (MAR) revealed a "7 was entered in place of administration of his Ceftriaxone on 1/4/2024, and a "10" on 1/5/2024. The chart code key indicates that a "7" means "Other/See Nurse Notes" and a "10" means hospitalized. There was no missed charting. His Ceftriaxone medication is scheduled at 2:00 PM every 24 hours, with an 1 hour grace window before and after. This means nursing staff is permitted to administer his medication between 1:00 PM and 3:00 PM. On 1/13/2024, his dose of Ceftriaxone was administered at 4:08 PM. On 1/10/2024, his dose was administered at 5:11 PM, and on 1/4/2024, it was administered at 4:08 PM.

His care plan did not reflect any goals or interventions for antibiotics. An eMAR note for 1/4/2024 at 4:08 PM stated "awaiting medications; patient just admitted to facility".

During an interview conducted on 1/16/2024 at 1:17 PM with Resident #9, he stated he does not get his antibiotics on time.

During an interview at 1:30 PM with Resident #12, he stated his medications are often late and he never gets his antibiotic on time. He states he will be told by the nurse that the pharmacy has not delivered it yet, or that there is a lot going on and they have a lot of patients.

In an interview with a Licensed Practical Nurse (LPN/Staff #34) conducted on 1/16/2024 at 12:10 PM, she stated scheduled medications can be administered on hour before or one hour after the scheduled time, or they are considered late. She stated if antibiotics are given hours later it does not make them less effective. When asked why Resident #7's Ceftriaxone was not available on 12/23/2023, 12/26/2023, 1/1/2024 and 1/12/2024, she stated it was because the pharmacy only send so much IV medications and they will have to call to have more sent out.

At 11:25 AM a chart review was completed with LPN (Staff #4) for resident #7 which revealed late administration on multiple occasions. She stated that even being given late doses, his condition would not worsen. She confirmed that he was given medications outside of parameters as it was supposed to be given within the hour before and hour after.

During an interview on 1/16/2024 at 11:30 AM with Pharmerica, the Pharmacist Technician Supervisor, (Staff #78) stated they fill a 2 day supply which is 4 doses each time. He stated they track the medication and it will be sent out automatically. He stated they do not show any days where the pharmacy missed sending refills. He stated due to the stability of the medication, they can only send 2 days at a time.

The Director of Nursing (DON/Staff #7, and the Clinical Resource Nurse, (Staff #20) were interviewed at 12:57 PM on 1/6/2024. The DON stated her expectation for administration of medications is that it should be within an hour of the scheduled time. This is for consistency and to make sure they do not get medications too close together. Regarding if it affects the eff

Based on observation the facility failed to maintain rated doors for hazardous area. Failing to maintain rated doors and maintain the the self-closing hardware on the door and frame to a hazardous room could cause harm to patients and/or staff in time of a fire if the door does not close, latch secure and seal.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Chapter 8, 8.7.1. 1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: 1. Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3 2. Protecting the area with automatic extinguishing systems in accordance with Section 9.7 3. Applying both 8.7.1.1 (1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43. Section 8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3/4-hour fire protecting rating and shall be self or automatic closing in accordance with 7.2.1.8. Section 7.2.1.8.1 A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self or automatic closing in accordance with 7.2.1.8.2.

Findings include:

Observations made while on tour on October 26, 2023, revealed the following;

1) the rated door for the clean side laundry room had a 1/2 gap on the upper handle side of the door and excessive gap on the lower handle side of the door
2) the rated doors for the kitchen had a 1/2 gap on the upper handle side of the door and excessive gap on the lower handle side of the doors

During the exit conference on October 26, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to fill penetrations in fire/smoke barriers in the facility. Failing seal the penetrations, holes and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients and/or staff in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations made while on tour on October 26, 2023, revealed the following;

1) above the drop ceiling in the therapy gym several penetrations were seen on the fire wall. Some of the penetrations were cut through the double sheet of drywall
2) above the drop ceiling in the dining room on the fire wall which connected to the kitchen was an approximately 3 inch by 8 inch hole cut through the drywall. There was a blue data line running through the hole

During the exit conference conducted on October 26, 2023, the above findings were again acknowledged by the management team.

Based on record review and interview the facility failed to provide fire drill documentation for two (2) drill for the same shift for 2023. Failing to conducted the fire drills in accordance with the life safety code to familiarize staff with conditions under an actual fire can result in harm to patients and/or staff during a an actual fire or emergency situation.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

Findings include:

Based on record review and interview on October 26, 2023, revealed the facility failed to provide documentation that fire drills were completed for the following;

1) first quarter third shift 2023
2) third quarter third shift 2023

During the exit conference conducted on October 26, 2023, the above findings were again acknowledged by the management team.

Based on record review and staff interview the facility failed to ensure the required annual load bank test of the emergency generator was completed as required. Failure to test the emergency generator as required could result in harm to patients and/or staff during emergency system failure.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 8, Section 8.4.2.3 "Diesel powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 20 continuous minutes and at not less than 75 percent of the EPS kW rating for 1 continuous hour for a total test duration of not less the 1.5 continuous hours.

Findings include:

Based on record review and staff interview on October 26, 2023, revealed on February 3, 2023 vendor Valleywide Generator Service Inc. reported the generator fuel injector pump was worn and was needing to be replaced. The company attempted the annual load bank and discontinued after a little over an hour. The facility provided documentation dated September 29, 2023 from Summit Trades and Services LLC for a proposal for a new generator. No other documentation was provide showing the fuel injector pump had been replaced.

During the exit conference conducted on October 26, 2023, the above findings were again acknowledged by the management team.

Based on observation, the facility failed to ensure that staff did not use of extension cords and power strips for appliances. The use of daisy chained power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area.

Findings include:

Observations made while on tour on October 26, 2023, revealed the following;

1) in the HR office a refrigerator was seen plugged into a power strip
2) in the business office a white extension cords was seen plugged into the wall and had other cords plugged into it

During the exit conference conducted on October 26, 2023, the above findings were again acknowledged by the management team.

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents.

Findings include:

A review of the personnel file for the Activities Director (staff #33) revealed staff #33 was hired on July 11, 2022.

Further review of staff #33's personnel file revealed she completed the Arizona State Board of Nursing approved Nurse Aide Training Program on December 16, 2022.

Additionally, an undated receipt indicated that she completed and submitted a CNA (Certified Nursing Assistant) application which has not yet been approved.

Additional review of staff # 33's personnel file revealed a receipt for Activities Professional Course enrollment dated July 10, 2023.

A job description for Activities Supervisor signed by staff #33 on August 24, 2023 indicated the essential duties and responsibilities of the position was to plan, develop, organize, implement, evaluate, and direct the activities programs of the facility. Under qualifications, the education and/or experience indicated that the member must be a qualified therapeutic recreation specialist or an activities professional who is licensed by this state and is eligible for recertification a s recreation specialist or as an activities professional or must behave, as a minimum two years' experience in a social or recreational program within the last five years, one of which was a full-time in a patient activities program in a health care setting. Under certificates and licenses portion, it indicated that the member be licensed or registered, in the State in which practicing or completed a training course approved by the State.

An interview was conducted with staff #33 on October 19,2023 at 11:02 a.m., staff #33 stated she does not have her certification as a qualified therapeutic specialist or as an activities professional but is currently enrolled in a program. Staff #33 stated she is the only facility staff in charge of activities and there is no corporate oversight for activities that she has to report to. Furthermore, she stated that she is strictly in charge of activities.

The facility policy titled "Verification of Licenses" revised April 2004 indicated that it is the policy of the company to verify that all employees in positions which require licensure or certification, have a current license or other authorization to practice in the state in which they work.

The facility policy titled "Employment Applications" revised January 2022 noted that the facility requires applicants for employment to complete an employment application and that it used to obtain information regarding the applicant's identification and qualifications for employment.

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional.

Findings include:

A review of the personnel file for the Activities Director (staff #33) revealed staff #33 was hired on July 11, 2022.

Further review of staff #33's personnel file revealed she completed the Arizona State Board of Nursing approved Nurse Aide Training Program on December 16, 2022.

Additionally, an undated receipt indicated that she completed and submitted a CNA (Certified Nursing Assistant) application which has not yet been approved.

Additional review of staff # 33's personnel file revealed a receipt for Activities Professional Course enrollment dated July 10, 2023.

A job description for Activities Supervisor signed by staff #33 on August 24, 2023 indicated the essential duties and responsibilities of the position was to plan, develop, organize, implement, evaluate, and direct the activities programs of the facility. Under qualifications, the education and/or experience indicated that the member must be a qualified therapeutic recreation specialist or an activities professional who is licensed by this state and is eligible for recertification a s recreation specialist or as an activities professional or must behave, as a minimum two years' experience in a social or recreational program within the last five years, one of which was a full-time in a patient activities program in a health care setting. Under certificates and licenses portion, it indicated that the member be licensed or registered, in the State in which practicing or completed a training course approved by the State.

An interview was conducted with staff #33 on October 19,2023 at 11:02 a.m., staff #33 stated she does not have her certification as a qualified therapeutic specialist or as an activities professional but is currently enrolled in a program. Staff #33 stated she is the only facility staff in charge of activities and there is no corporate oversight for activities that she has to report to. Furthermore, she stated that she is strictly in charge of activities.

The facility policy titled "Verification of Licenses" revised April 2004 indicated that it is the policy of the company to verify that all employees in positions which require licensure or certification, have a current license or other authorization to practice in the state in which they work.

The facility policy titled "Employment Applications" revised January 2022 noted that the facility requires applicants for employment to complete an employment application and that it used to obtain information regarding the applicant's identification and qualifications for employment.