Ahwatukee Post Acute

Inspectors wroteNumber of residents sampled:3Number of residents cited:3The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 3 of 3 sampled residents (#142, #147, and #150). The deficient practice could result to residents not being able to access an advocate who can inform them of their options and rights related to discharges. Based on closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for three discharged residents (#142, #147, and #150). [...]

Inspectors wroteNumber of residents sampled:6Number of residents cited:3The facility failed to ensure three residents necessary medications were ordered and available for use. Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for three residents (#5), (#43), and (#7). The deficient practice could result in not receiving medications that are physician ordered and necessary.

Inspectors wroteBased on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that their abuse policy was implemented regarding major injury that one resident (#5) sustained. The deficient practice could result in other facility policies not being followed.

Inspectors wroteBased on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to report a major injury that one resident (#5) sustained. The deficient practice could result in other injuries of unknown origin to residents.

Inspectors wroteBased on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to investigate a major injury that one resident (#5) sustained. The deficient practice could result in other injuries of unknown origin to residents not being investigated thoroughly.

Inspectors wroteBased on clinical record review, observations, staff interviews, and review of policy and procedure, the facility failed to protect the residents' (#128, #161 #15 and #14) rights to be free from abuse by another resident (#15, #11, #17). The deficient practice could result in residents not protected from further abuse.

Inspectors wroteBased on clinical record reviews, staff interviews, State Agency (SA) intake database and review of facility documentation, policies and procedures, the facility failed to have evidence that an allegation of abuse for two residents (#174, #125) and misappropriation of narcotics for three residents (#134, #135, #136) were thoroughly investigated. The deficient practice could result in further abuse and misappropriation of narcotics not prevented and appropriate actions not taken.

Inspectors wroteBased on closed clinical record review, staff interviews, review of facility documentation, policy and procedures, and through observation of current practice. the facility failed to adequately provide activity of daily living (ADL) care for two residents (#127 and #137). The deficiency could result in residents not maintaining good personal hygiene.

Inspectors wroteBased on record review, staff interviews, resident interview, review of facility documentation and policy, and through observation of current practice the facility failed to ensure care and services related to pressure ulcer was provided for one resident (#171). The deficient practice could result in new or worsened pressure injuries.

Inspectors wroteBased on closed record review, staff interviews, resident interview, review of facility documentation and policy and the 2010 Clinical Practice Guidelines for Clostridium difficile (C-diff) Infection in Adults, the facility failed to ensure infection prevention and control practices related to C-diff precautions were implemented for one resident (#123). The deficient practice could result in transmission of infection to residents and staff.

Inspectors wroteBased on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure that residents representatives were notified of significant changes in condition for one resident (#120). The deficient practice could result in resident representatives not being informed of the change and decisions regarding treatment.

Inspectors wroteBased on observation, interviews and policy review, the facility failed to ensure that one resident's medications were administered as ordered by the provider based on standards of practice for two resident's (#68, #35), medications are not left unattended at the bedside for one resident (#40), and medications are not left unattended on the floor. The deficient practice could result in residents not receiving prescribed does of medications, and residents taking medications that are not ordered. The facility census was 89, and the sample was 18 residents. -Regarding Fluticasone Nasal Spray A medication administration task observation was conducted on August 1, 2023 at 7:20 AM with a Licensed Practical Nurse (LPN/staff #29). At the medication cart the LPN prepared mediation for Resident #35, that included Fluticasone Propronate Nasal Spray. [...]

Inspectors wroteBased on clinical record review, staff interviews and policy and procedure, the facility failed to ensure consistent treatments were provided to one resident (#82) with pressure ulcers. The deficient practice could result in worsening of pressure ulcers. The facility census was 89, and the sample was 18 residents. Resident #82 was admitted on [DATE] with diagnoses that included atrial fibrillation, leukemia, type 2 diabetes mellitus, pressure ulcer of buttock, adult failure to thrive, depression, need of assistance with personal care. Review of the clinical record revealed the resident currently had six wounds: [...]

Inspectors wroteBased on review of the clinical record, interviews and facility policy, the facility failed to ensure an as needed psychotropic medication was monitored appropriately. The deficient practice could cause prolonged usage of medications intended for an as needed basis without appropriate monitoring.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe and sanitary kitchen; six ventilation exhausts above clean dishware and food prep areas were unclean, food storage for the kitchen area and three nourishment refrigerators were not monitored, maintained and documented for safe food handling. The census was 89. The deficient practice could result in residents becoming ill.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and review of policy, the facility failed to ensure that 1 out of 18 sampled residents' (#72) needs and preferences were addressed, regarding his wheelchair. The deficient practice could result in residents' needs and/or preferences not being addressed.

Inspectors wroteBased on observations, resident and staff interviews, clinical record review, and policy, the facility failed to ensure that one resident (#40) received ADL (activity of daily living) care related to getting resident out of bed consistently. The sample size was 18. The deficient practice could result in residents not receiving care-planned ADLs and not maintaining mobility.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that individualized activities were consistently offered to one resident (#40). The facility census was 89, and the sample was 18 residents. The deficient practice could result in resident's not consistently being provided activities to meet their interest and to support their physical, mental and psychosocial well-being.

Inspectors wroteBased on observations, staff interviews, clinical record review, and policy and procedure, the facility failed to ensure hydration care and services were provided and documented for one resident (#62). The sample size was 18. The deficient practice places residents at risk for potential dehydration.

Inspectors wroteBased on observations, staff interviews, and review of policy, the facility failed to ensure their system of medication records enabled accurate reconciliation and accounting for all controlled substances. The deficient practice could result in misappropriation of residents' medications. The facility census was 89, and the sample was 18 residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure that medications were labeled according to professional standards, and that expired medications were not available for resident use. The census was 98, and the sample was 18 residents. The deficient practice could result in expired medications being administered to residents, or resident's receiving the wrong medication.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure expired glucometer controls were not available for use. The census was 98, and the sample was 18 residents. The deficient practice could result in inaccurate blood glucose test results.

Inspectors wroteBased on observation, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during wound treatment for one resident (#82). The census was 89 residents, and the sample was 18. The deficient practice could result in transmission of infection, or exposing the wound to other organisms.

Inspectors wroteBased on staff interview, facility policy, and review of the Center for Disease Control (CDC) recommendations, the facility failed to ensure that their Infection Preventionist have completed the specialized training in Infection Prevention and Control. The deficient practice could result in improper infection prevention practices within the facility.

Inspectors wrote-Resident #44 was admitted to the facility on [DATE] with diagnoses that included Methicillin Resistant Staphylococcus Aureus infection, intraspinal abscess and granuloma, and diabetes. Review of the clinical record revealed a Smoking Evaluation dated April 12, 2022 that the resident required supervised smoking. A Resident Smoking Responsibility Agreement and a Resident Smoking policy dated April 14, 2022, signed by the resident, included documentation of the resident's understanding and agreeing to comply with the facility smoking policy. However, review of the admission MDS assessment dated [DATE] revealed the section J1300 (Current Tobacco Use) was coded no for current tobacco use. An interview was conducted on June 6, 2022 at 12:06 PM with resident #54, who stated he is a smoker and that he is allowed to smoke outside in the smoking area. [...]

Inspectors wroteBased on observations, clinical record reviews, interviews, and facility documentation and policy, the facility failed to ensure that 3 residents (#238, #2 and #7) received adequate assistance with Activities of Daily Living (ADL). The sample size was 8. The deficient practice could result in resident needs being unmet.

Inspectors wroteBased on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure thorough skin assessments were conducted for one resident (#44) and that two residents (#238 and #397) were consistently provided adequate wound care. The sample size was 2. The deficient practice could result in delayed treatment and healing of skin wounds.

Inspectors wroteBased on resident, family, and staff interviews, facility documentation, facility assessment, and policy review, the facility failed to ensure that there was sufficient nursing staff to meet the needs of the residents. The deficient practice could result in residents' needs not being met.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policy, the facility failed to ensure two residents (#78 and #54) and/or their representatives were informed of the risks and benefits of psychotropic medications prior to receiving the medications. The sample size was 6 residents. The deficient practice could result in residents and/or their representatives not being fully informed of the risks and benefits of psychoactive medications.

Inspectors wroteBased on observations, clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure that housekeeping services necessary to maintain a safe and clean environment were provided for two residents (#69 and #77). The deficient practice could result in residents not having a safe and clean environment.

Inspectors wroteBased on clinical record reviews, interviews, the State Agency (SA) database, and facility documentation and policy, the facility failed to ensure an allegation of abuse was reported timely to the SA for one resident (#439) and failed to report the results of an investigation to the SA within the required timeframe for one resident (#238). The sample size was two residents. The deficient practice could result in further allegations and investigations of abuse and neglect not being reported.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that one resident (#39) with a diagnosis of a serious mental illness was referred to the appropriate State-designated mental health or intellectual disability authority for review once the resident's stay exceeded 30 days. The sample size was 3, residents. The deficient practice could result in necessary specialized services not being provided for residents that need it.

Inspectors wroteBased on clinical record review, staff interviews and review of facility documentation, the facility failed to ensure that Preadmission Screening and Resident Reviews (PASRR) were completed accurately and timely for two residents (#2 and #78). The sample size was 3 residents. The deficient practice could result in specialized services not being identified and provided to residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#397) received adequate pressure ulcer care. The sample size was two residents. The deficient practice could result in residents developing pressure ulcers or worsening of pressure ulcers.

Inspectors wrote-Resident #19 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, age-related osteoporosis without current pathological fracture, and osteoarthritis. An activities of daily living (ADL) care plan revised on June 26, 2021, revealed an intervention to implement and deliver a restorative program as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 4, indicating the resident had severe cognitive impairment. The assessment also revealed the resident had no functional limitation in range of motion or impairment of the upper extremities (shoulder, elbow, wrist, and hand). Review of the physician order summary revealed an order late entry for March 26, 2022 for occupation therapy to evaluate and treat, and for skilled occupational therapy 3 times a week for 4 weeks for therapy exercise and orthotic fitting. [...]

Inspectors wroteBased on clinical record review, observation, resident and staff interviews, and policy review, the facility failed to follow a physician order for bladder training for one resident (#47) who had an indwelling catheter. The deficient practice could result in residents having indwelling catheters unnecessarily.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident's (#7) medical record was accurate regarding advance directives. The sample size was 20. The deficient practice could result in residents' medical records not being accurate.