Splendido At Rancho Vistoso

Based on clinical record review, interviews, review of facility policies and the State Agency (SA) complaint tracking system, the facility failed to use a two-person transfer, as identified by the comprehensive care plan, resulting in the resident #1's fall with injury. The deficient practice could result in increased risk of injury to the resident.

Findings include:

Resident #1 was admitted to the facility on February 23, 2022 with diagnoses of unspecified dementia, degenerative disease of nervous system and repeated falls.

A review of a Minimum Data Set (MDS) assessment dated July 10, 2024 revealed a staff assessment for mental status indicating resident #1 had a memory problem with both short-term memory and long-term memory. It was also assessed that resident #1's cognitive skills for daily decision making to be moderately impaired. The same MDS assessment also indicated resident #1 was entirely dependent on staff for assistance or the assistance of 2 or more helpers required with sit to stand and bed-to-chair transfer. The MDS also revealed the resident was receiving hospice care.

A review of the physician's orders revealed the following orders; Hoyer lift for transfers only, which was dated March 22, 2024.

A review of a comprehensive care plan revealed a focus on the resident's risks of falls due to his use of psychotropic medications and fall risk score. An intervention was initiated on March 25, 2024 that indicated resident #1 was a two person assist with Hoyer lift with transfers.

A review of the facility's assessment titled, "Assessment Criteria for Safe Resident Handling and Movement," dated July 5, 2024 indicated resident #1 was not weight bearing as they did not have any bilateral upper-extremity strength. The same assessment also indicated resident #1 was a 2-person transfer by staff with a full body lift with full sling.

A review of the progress notes for resident #1 revealed an entry dated September 2, 2024 that was created by Licensed Practical Nurse (LPN/Staff #147). The note revealed that staff #147 was summoned to resident #1's room by another staff member. The note continues to indicate that resident #1 was sitting on the floor with a CNA and that the "CNA stated she slid him down to the floor when trying to transfer to (wheelchair)". The note indicated that staff #147 and three other staff members assisted the resident into the wheelchair and vitals were taken.

A review of another progress note for resident #1 which was dated September 3, 2024 and was created by LPN/Staff #53. The note indicated resident #1 was complaining of pain when he moved in bed and during peri-care. At this time, the resident was assessed and it was noted that there was bruising to the lateral right knee with some swelling. The note indicates that a new order for increased morphine and an x-ray was received.

A review of the physician's orders revealed an order for an X-ray to the right knee and hip due to increased pain caused by a fall which was dated September 3, 2024.

A review of a third progress note for resident #1, dated September 5, 2024 which was written by Registered Nurse (RN/Staff #138), revealed the results of the x-ray showed a "comminuted distal perihardware fracture". The note also indicated that the medical doctor, hospice, and resident #1's spouse was notified of the results.

A review of the intake information submitted by the facility to the SA complaint tracking system revealed a facility self-report was made on September 4, 2024 which stated resident #1 was being assisted by a Certified Nursing Assistant (CNA) (referring to staff #26) when resident #1 "slid down with (the) CNA to the floor". At the time of the self-report, the facility was still awaiting results of the x-ray.

A review of the intake information submitted by an anonymous reporter to the SA complaint tracking system on September 6, 2024 revealed resident #1 had a fall on September 2, 2024 when being transferred by a CNA (staff #26). This is the same event that was identified in the facility self-report. The information also indicated resident #1 complained of pain from the right knee to the right hip and received an x-ray on September 4, 2024. The report indicated the x-ray revealed a fractured right knee.

An interview was conducted on September 10, 2024 at 10:30 AM, via phone, with staff #26. Staff #26 indicated that she has received training on resident transfer methods from the facility. Staff #26 also indicated that she usually gets updated resident information during shift change however, she indicated that she does not get a lot of information that she feels she needs. Based on her experience, the shift change report is quick and "sometimes they will say to just check in with the nurse on the floor". Staff #26 indicated they were familiar with resident #1 and she indicated that in the past she would use the "bear hug" (stand pivot transfer) and she was not aware that he was to be using a Hoyer lift for transfers. Staff #26 continued to explain that she was transferring resident #1 by the "bear hug" and then his legs were giving out and so staff slid the resident down to the floor. Staff #26 indicated resident #1 went down on his right side and she called for a co-worker (staff #57) who was walking by. During the interview, staff #26 had indicated this shift was her first shift back from an extended absence as she had not worked since June of 2024.

An interview was conducted with Certified Nursing Assistant (CNA/Staff #57) on September 10, 2024 at 10:51 AM. Staff #57 explained that she utilizes the Kardex to identify how a resident is transferred and the facility provides training on transfer methods which includes the gait belt, Hoyer and Saralifts. Staff #57 indicated that updated resident information is shared with her during shift change and for any information that is not provided to her, she will look at the Kardex for additional information. Staff #57 indicated that on September 2, 2024 she was walking another resident to the dining hall when she passed the room of resident #1 and saw staff #26 with the resident in his room and at that time, she could not see resident #1's position. She indicated that she asked staff #26 if she needed assistance because resident #1 was a Hoyer transfer and staff #26 responded that she did not. Staff #57 indicated that after she had assisted the other resident to the dining room, she walked back down the hallway and at that time staff #26 asked for help. Staff #57 indicated that staff #26 explained that resident #1 did not fall but slid down. Staff #57 then went to retrieve staff #147 and staff #116 (CNA) for assistance.

An interview was conducted with staff #116 on September 10, 2024 at 11:18 AM. Staff #116 explained that resident transfer methods are listed on the Kardex or the shift cheat sheet that she uses. She indicated the cheat sheet has basic resident information on there such as their diagnoses and transfer methods. Staff #116 stated that the cheat sheet is available for all CNAs in a binder at the nurses' station. Staff #116 explained that she was working on September 2, 2024 when staff #147 asked for her help with resident #1 and she observed him in his room with half of his body on the floor. Staff #116 stated that staff #26 told her that the resident did not fall but slid down. Staff #116 revealed the resident was in a lot of pain and was very agitated however the resident did not identify where the pain was. After the fall, 15-minute neuro checks were implemented according to staff #116.

A phone call was placed to staff #147 on September 10 at 11:53 AM but was not returned during the course of the investigation.

An interview was conducted with the Director of Nursing (DON/Staff #99) on September 10, 2024 at 1:31 PM. Staff #99 indicated that it w

Based on clinical record review, interviews, review of facility policies and the State Agency (SA) complaint tracking system, the facility failed to use a two-person transfer, as identified by the comprehensive care plan, resulting in the resident #1's fall with injury.

Findings include:

Resident #1 was admitted to the facility on February 23, 2022 with diagnoses of unspecified dementia, degenerative disease of nervous system and repeated falls.

A review of a Minimum Data Set (MDS) assessment dated July 10, 2024 revealed a staff assessment for mental status indicating resident #1 had a memory problem with both short-term memory and long-term memory. It was also assessed that resident #1's cognitive skills for daily decision making to be moderately impaired. The same MDS assessment also indicated resident #1 was entirely dependent on staff for assistance or the assistance of 2 or more helpers required with sit to stand and bed-to-chair transfer. The MDS also revealed the resident was receiving hospice care.

A review of the physician's orders revealed the following orders; Hoyer lift for transfers only, which was dated March 22, 2024.

A review of a comprehensive care plan revealed a focus on the resident's risks of falls due to his use of psychotropic medications and fall risk score. An intervention was initiated on March 25, 2024 that indicated resident #1 was a two person assist with Hoyer lift with transfers.

A review of the facility's assessment titled, "Assessment Criteria for Safe Resident Handling and Movement," dated July 5, 2024 indicated resident #1 was not weight bearing as they did not have any bilateral upper-extremity strength. The same assessment also indicated resident #1 was a 2-person transfer by staff with a full body lift with full sling.

A review of the progress notes for resident #1 revealed an entry dated September 2, 2024 that was created by Licensed Practical Nurse (LPN/Staff #147). The note revealed that staff #147 was summoned to resident #1's room by another staff member. The note continues to indicate that resident #1 was sitting on the floor with a CNA and that the "CNA stated she slid him down to the floor when trying to transfer to (wheelchair)". The note indicated that staff #147 and three other staff members assisted the resident into the wheelchair and vitals were taken.

A review of another progress note for resident #1 which was dated September 3, 2024 and was created by LPN/Staff #53. The note indicated resident #1 was complaining of pain when he moved in bed and during peri-care. At this time, the resident was assessed and it was noted that there was bruising to the lateral right knee with some swelling. The note indicates that a new order for increased morphine and an x-ray was received.

A review of the physician's orders revealed an order for an X-ray to the right knee and hip due to increased pain caused by a fall which was dated September 3, 2024.

A review of a third progress note for resident #1, dated September 5, 2024 which was written by Registered Nurse (RN/Staff #138), revealed the results of the x-ray showed a "comminuted distal perihardware fracture". The note also indicated that the medical doctor, hospice, and resident #1's spouse was notified of the results.

A review of the intake information submitted by the facility to the SA complaint tracking system revealed a facility self-report was made on September 4, 2024 which stated resident #1 was being assisted by a Certified Nursing Assistant (CNA) (referring to staff #26) when resident #1 "slid down with (the) CNA to the floor". At the time of the self-report, the facility was still awaiting results of the x-ray.

A review of the intake information submitted by an anonymous reporter to the SA complaint tracking system on September 6, 2024 revealed resident #1 had a fall on September 2, 2024 when being transferred by a CNA (staff #26). This is the same event that was identified in the facility self-report. The information also indicated resident #1 complained of pain from the right knee to the right hip and received an x-ray on September 4, 2024. The report indicated the x-ray revealed a fractured right knee.

An interview was conducted on September 10, 2024 at 10:30 AM, via phone, with staff #26. Staff #26 indicated that she has received training on resident transfer methods from the facility. Staff #26 also indicated that she usually gets updated resident information during shift change however, she indicated that she does not get a lot of information that she feels she needs. Based on her experience, the shift change report is quick and "sometimes they will say to just check in with the nurse on the floor". Staff #26 indicated they were familiar with resident #1 and she indicated that in the past she would use the "bear hug" (stand pivot transfer) and she was not aware that he was to be using a Hoyer lift for transfers. Staff #26 continued to explain that she was transferring resident #1 by the "bear hug" and then his legs were giving out and so staff slid the resident down to the floor. Staff #26 indicated resident #1 went down on his right side and she called for a co-worker (staff #57) who was walking by. During the interview, staff #26 had indicated this shift was her first shift back from an extended absence as she had not worked since June of 2024.

An interview was conducted with Certified Nursing Assistant (CNA/Staff #57) on September 10, 2024 at 10:51 AM. Staff #57 explained that she utilizes the Kardex to identify how a resident is transferred and the facility provides training on transfer methods which includes the gait belt, Hoyer and Saralifts. Staff #57 indicated that updated resident information is shared with her during shift change and for any information that is not provided to her, she will look at the Kardex for additional information. Staff #57 indicated that on September 2, 2024 she was walking another resident to the dining hall when she passed the room of resident #1 and saw staff #26 with the resident in his room and at that time, she could not see resident #1's position. She indicated that she asked staff #26 if she needed assistance because resident #1 was a Hoyer transfer and staff #26 responded that she did not. Staff #57 indicated that after she had assisted the other resident to the dining room, she walked back down the hallway and at that time staff #26 asked for help. Staff #57 indicated that staff #26 explained that resident #1 did not fall but slid down. Staff #57 then went to retrieve staff #147 and staff #116 (CNA) for assistance.

An interview was conducted with staff #116 on September 10, 2024 at 11:18 AM. Staff #116 explained that resident transfer methods are listed on the Kardex or the shift cheat sheet that she uses. She indicated the cheat sheet has basic resident information on there such as their diagnoses and transfer methods. Staff #116 stated that the cheat sheet is available for all CNAs in a binder at the nurses' station. Staff #116 explained that she was working on September 2, 2024 when staff #147 asked for her help with resident #1 and she observed him in his room with half of his body on the floor. Staff #116 stated that staff #26 told her that the resident did not fall but slid down. Staff #116 revealed the resident was in a lot of pain and was very agitated however the resident did not identify where the pain was. After the fall, 15-minute neuro checks were implemented according to staff #116.

A phone call was placed to staff #147 on September 10 at 11:53 AM but was not returned during the course of the investigation.

An interview was conducted with the Director of Nursing (DON/Staff #99) on September 10, 2024 at 1:31 PM. Staff #99 indicated that it was his 5th day working at the facility at the time of the interview. When asked

Based on observation, clinical record, staff interviews and facility policy, the facility failed to ensure that medications were administered as ordered by the physician for 1 resident (#21).

Findings include:

Resident #21 was admitted on April 26, 2023 with diagnose of personal history of transient ischemic attack, cerebral infarction, and cardiac septal defect.

A care plan dated April 14, 2023 included that the resident has Cerebral Vascular Accident and history of transient ischemic attack with an intervention of giving medications as ordered by the physician.

A physician's order dated June 24, 2023 included Aspirin Oral Tablet Chewable (Aspirin), Give 81 mg by mouth one time a day for deep vein thrombosis prophylaxis.

An observation was conducted on October 19, 2023 at 7:32 AM of a Registered Nurse (RN/staff #32) administering a 81mg enteric coated aspirin to resident #21

An interview was conducted on October 19, 2023 at 10:41 a.m. with the RN (staff #32) who said that she gave him an enteric coated aspirin. She checked the orders and said it should have been a chewable aspirin. She said that was the card that was missing so she just used house supply, but the house supply was enteric coated.

An interview conducted on October 20, 2023 at 10:28 AM with the Director of Nursing (DON/staff #44) said that her expectation for provider orders is that they be followed. She said that enteric coated aspirin does not meet the order and that the administration did not meet her expectation.

A policy titled 6.0 General Dose Preparation and Medication Administration revised January 1, 2013 revealed that facility staff should verify that the medication name and dose are correct.

Based on record review, staff interviews, and policy review, the facility failed to ensure a background check was completed prior to an employee working onsite.

Findings include:

A review of employee personnel files, on October 19th, 2023, indicated staff # 85 did not have a valid fingerprint card. In place of a fingerprint card, a photocopy of staff's previous employment as a security guard was on file.

An interview was conducted on October 19th, 2023 at 1:27 PM with Human Resources (Staff #111). Staff #111 stated they were new to the State of Arizona and upon their hire, they did an audit on employee files and found several employees with recently expired fingerprint clearance. HR stated In employee's case, they discovered there was no fingerprint card on file so they requested that staff #85 apply for a fingerprint card. When asked for the copy of the application, it was discovered the application did not have an application number so there was no way for the facility to confirm the status of the application. When asked if the staff #85 is still currently working onsite, HR confirmed they were as of today but they would remove staff #85 immediately until his background check is fully completed.

An interview was conducted on October 20th, 2023 AT 8:08 AM with the facility administrator (staff #121) in their office. When asked what their expectation was in regards to background checks for new employees, they stated that a new hire should have a copy of the fingerprint card on file or an application pending prior to working at the facility. Staff #121 stated they had assumed that staff #85's background check was done correctly because they observed a checkmark next to the fingerprint box without looking at the employee personnel file.

A review of the policy titled, "Pre-Employment Screening" with an effective date of June 14, 2007, indicated the Human Resources representative will be responsible to ensure the background check form is completed. It also indicates that if any applicant is not able to complete a background check they will not be hired by the company.

Based on observation, clinical record, staff interviews and facility policy, the facility failed to ensure that medications were administered as ordered by the physician for 1 resident (#21). This practice could result in decreased deep vein thrombosis prophylaxis.

Findings include:

Resident #21 was admitted on April 26, 2023 with diagnose of personal history of transient ischemic attack, cerebral infarction, and cardiac septal defect.

A care plan dated April 14, 2023 included that the resident has Cerebral Vascular Accident and history of transient ischemic attack with an intervention of giving medications as ordered by the physician.

A physician's order dated June 24, 2023 included Aspirin Oral Tablet Chewable (Aspirin), Give 81 mg by mouth one time a day for deep vein thrombosis prophylaxis.

An observation was conducted on October 19, 2023 at 7:32 AM of a Registered Nurse (RN/staff #32) administering a 81mg enteric coated aspirin to resident #21

An interview was conducted on October 19, 2023 at 10:41 a.m. with the RN (staff #32) who said that she gave him an enteric coated aspirin. She checked the orders and said it should have been a chewable aspirin. She said that was the card that was missing so she just used house supply, but the house supply was enteric coated.

An interview conducted on October 20, 2023 at 10:28 AM with the Director of Nursing (DON/staff #44) said that her expectation for provider orders is that they be followed. She said that enteric coated aspirin does not meet the order and that the administration did not meet her expectation.

A policy titled 6.0 General Dose Preparation and Medication Administration revised January 1, 2013 revealed that facility staff should verify that the medication name and dose are correct.

Based on observations, staff interviews, and policy review, the facility failed to ensure that cleaning clothes were stored in accordance with professional standards and that a beard nets were worn by two staff member. The deficient practice could result in placing residents at risk for food-borne illnesses.

Findings include:

A kitchen observation was conducted on October 17, 2023 at 8:40 AM. The observation revealed a dry cleaning rag on the top shelf of the central food preparation area adjacent to the plating area. Two additional rags were observed on a shelf above the sink in the main kitchen area, directly on top of a sealed bag of pita pocket bread. The executive chef took pictures of each identified rag and its placement.

An interview was conducted immediately thereafter with the executive chef, staff #110, who stated that the expectation was the cleaning rags are to be stored underneath the counters and not on food preparation or storage areas. He stated that the risk could include a potential for infection or foodborne illness.

A kitchen observation was conducted on October 17, 2023 at 8:50 AM. Staff #90, cook and executive chef, staff #110, were both observed without a beard net in the kitchen area. Staff #110 had approximately 2 centimeters of facial hair present; whereas staff #90 had a full-grown beard approximately 6 centimeters in length. Both staff members were observed in the kitchen and neither had a beard net in place at the time.

An interview was conducted on October 17, 2023 at 8:55 AM, with staff #110, executive chef. Staff #110 stated he understood that staff #90 should have been wearing a beard net; however, he stated that he was under the impression that he (staff #110) did not require a beard net because his beard was relatively short. He stated that he understood that the risk still existed for hair to fall into the food regardless of the length of the beard.

A kitchen observation was conducted on October 18, 2023 at 10:47 AM. A stained cleaning rag was observed on the food preparation counter. The rag was observed for approximately 5 minutes while staff continued to walk past it. No one removed it. When the sous chef, staff #31 was asked about the cleaning rag, she stated that the rag should not be there and removed it. She stated it was left there earlier when she was transferring a hot tray.

An interview was conducted on October 19, 2023 with server, staff #67, who stated that the expectation is that hair nets and beard nets are to be worn anytime that staff are in the kitchen.

An interview was conducted on October 19, 2023 at 12:30 PM, with both the executive chef, staff #110 and sous chef, staff #31. Both stated that the expectation is that beard nets are worn when facial hair is present and that cleaning rags, either dry or wet, not be stored on food preparation or storage surfaces.

An interview was conducted on October 19, 2023 at 12:42 PM, with the administrator, staff #121. Staff #121 stated that the expectations are that sanitary practices should be conducted properly and following procedures regarding the placement of cleaning rags. She stated that not storing the rags accordingly could result in an infection control risk. She further stated that both hair and beard nets are to be worn at all times in the kitchen. She stated that the risk could include getting hair into the food that is being served to residents and staff.

A review of facility kitchen and cleaning related policies revealed the presence of the following policies: cleaning dishes/ dish machine, cleaning and sanitizing the dining room, food storage and refrigeration management policy, culinary experience center safety-noting that culinary team members receive routine training on safety topics, kitchen equipment cleaning and sanitizing, and food temperatures; however, none of these policies showed evidence that of the hair or beard net requirements. Additionally, the food storage and refrigeration management policy, revised March 2023, revealed that food, chemicals and supplies should be stored in a manner that protects quality and the safety of food.

Based on record review and staff interview, the facility failed to participate in a community based exercise in 2022-2023. Failure to provide policy and procedures for the training and testing program may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency.

Findings include:

Based on record review and staff interview on October 25, 2023, revealed the facility failed to provide documentation of participation of the following;

1. Participate in a full-scale exercise (FSE) that is community-based.
2. Conduct an additional exercise that may include, but is not limited to the following: (A) A second FSE that is individual, facility-based. (B) A tabletop exercise.

During the exit conference on October 25, 2023, the above finding was again acknowledge by the management team.