Dr Guy Gorman Sr Care Home

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that residents were evaluated for the need and safety for the use of bed rails prior to the installation/use of rails, failed to document alternatives to bed rails were attempted prior to the use of bed rails, failed to document reasons for failure of alternatives, and failed to advise residents and/or Resident Representatives (RR) of the risks and/or benefits of rail use with informed consent signed prior to the installation of bed rails for three of three residents (Resident (R) 14, R33, and R57) reviewed for bed rail use of 50 census residents. In addition, the facility had failed to evaluate the need and safety of bed rail use for all residents in the facility. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to submit mandatory staffing information based on the payroll data journal and other verifiable and auditable data as required. This placed residents at risk for inaccurate staffing information.

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 5 currently employed sampled Certified Nursing Assistant (CNA)(3, 21, 26, and 6) reviewed for training completed the required 12 hours of annual in-service education based on their hire dates. The facility also failed to ensure CNA26 and CNA6 received annual abuse, dementia, and infection control training. This placed residents at risk for receiving care from unskilled staff and increased risk for abuse, neglect and diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to notify a Resident's Representative Party (RP) when the resident experienced a change in condition for two of seven residents (Resident (R) 3 and R4) reviewed for changes out of a total sample of 18 residents. The failure to notify an RP for family member of a change in condition and/or transfer could lead to an inability to support their family member during a time of illness. This failure had the potential to affect any of the fifty-current residents that might have a change in condition and/or a transfer to another facility for evaluation.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the Centers for Medicare and Medicaid Services within the required time frame for 1 of 2 sampled residents (R)(4) reviewed for abuse. This failure placed residents at risk for abuse.

Inspectors wroteBased on observation, interview and record review, facility failed to have documented evidence of thorough investigation, including preventing further potential abuse while the investigation of the alleged violation was in progress, of alleged abuse for 1 of 2 sampled residents (R) (R4) reviewed for abuse. Without thorough investigations, the facility could not prevent or prohibit further abuse. These failures placed residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure required documentation for discharge was present in the medical record for 1 of 2 sampled residents (Resident 51), when there was no physician documented reason for discharge. This placed the resident at risk of being discharged from the facility without a physician's assessment to ensure all treatment options were explored which may have allowed resident to remain in the facility.

Inspectors wroteBased on interview and record review, the facility failed to transmit required Minimum Data Set (MDS-assessment tool) resident assessment data to the Centers for Medicare & Medicaid Services (federal agency that provides health coverage) within the required timeframe for 2 of 6 sampled residents (R) (R53 and R57) reviewed for timeliness in transmitting discharge Minimum Data Set (MDS-an assessment tool). This placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one of three sampled residents (Resident (R) 37) for pressure ulcers. The failure to accurately code/assess the resident's condition had the potential to affect the care planning for the resident to receive all required services.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's plan of care were revised when diet texture was changed, glasses were no longer available, transfer needs changed, and foot fracture was sustained for 1 of 18 sampled residents (R) (R4) whose care plans were reviewed. This failure increased the risk for unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a registered nurse worked eight consecutive hours for 1 of 203 days reviewed for staffing. This placed residents at risk for lack of nursing assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's drug regimen was free from unnecessary drugs for 1 of 5 sampled resident (R) (R7) reviewed for unnecessary medication use. R7 received anti-hypertensive medications that did not meet physician's ordered blood pressure parameters. This failure placed residents at risk for adverse side effects such as hypotension, dizziness, and falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure records were complete and accurate for 1 of 5 sampled residents (R)(R7) reviewed for unnecessary medication use. This placed residents at risk for incomplete clinical records.

Inspectors wroteBased on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required participants for 2 of 4 quarters reviewed for participation. This failed practice placed residents at risk for quality and infection control deficiencies, adverse events, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases when staff did not change gloves during 1 of 2 sampled resident (R) (4) personal care observation when going from dirty tasks to clean tasks. This placed residents at risk for the spread of infection and its associated discomfort and decline in physical condition.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure two of five residents (Resident (R) 6 and R56) reviewed for immunizations had been provided with education and the opportunity to decline or receive an updated pneumococcal conjugate vaccine (PCV20 or PCV21). This failure had the potential to affect the residents' ability to decrease the possibility of serious pneumococcal infection and potential hospitalization.

Inspectors wroteBased on interview and record review the facility failed to offer training on its compliance and ethics program for 5 of 5 sampled staff (Certified Nursing Assistant) (CNA)(3, 21, 26, 6, and 19) reviewed for training. This placed residents at risk for non-compliant and unethical treatment.

Inspectors wrote* For Resident 207: R207 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a condition that causes a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life, with no specific diagnosis) and wedge compression fracture (a type of vertebral fracture that occurs when the front of the vertebra collapses, giving the bone a wedge shape) of unspecified lumbar vertebra (lower back), initial encounter for closed fracture. A limited physical mobility and self-care deficit care plan initiated on [DATE] had a goal which indicated the resident required assistance with ADLs (Activities of Daily Living). Interventions included PT/OT (Physical Therapy/Occupational Therapy) evaluation and treatment as ordered. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect (R106) and failed to protect residents' right to be free from physical abuse by another resident for (R)(R2 and R27) for 7 sampled residents reviewed for abuse as evidenced by: 1. Failed to ensure resident-centered care and treatment was provided in accordance with professional standards of practice to 1 of 6 sampled residents (R) (R106) reviewed for accidents. Licensed Practical Nurse (LPN) 6 failed to conducted neuro checks to assess for neurological changes and ensure timely interventions after R106's unwitnessed fall, 2. Failed to provide adequate supervision for 1 of 6 sampled residents (R106) reviewed for accidents to prevent recurrent falls when one to one staffing was recommended but not provided, 3. [...]

Inspectors wroteBased on interview and record review the facility failed to demonstrate they had implemented any performance improvement activities for any of their identified concerns. Failure to evaluate problem areas systemically and identify, and test solutions has the potential for resident quality of life to negatively impact all residents.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and resident's representative(s) before transfer to the hospital for 4 of 4 sampled residents (R) (R106, R20, R158 and R21) reviewed for hospitalization. These failures did not afford residents and/or their representatives to make informed decisions about transfers and prohibited access to an advocate who could inform resident/representative of their options and rights. This failure had the potential to affect all facility-initiated transfers or discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed hold notice to the resident or resident's representative(s) before transfer to the hospital for 4 of 4 sampled residents (R) (R106, R20, R158 and R21) reviewed for hospitalization and had an overnight hospital stay. This failure placed resident/representatives at risk for not having a clear understanding of the length of time the bed can be held, the cost associated with the bed hold and/or any other requirements which had the potential for stress/anxiety associated with the potential return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the required Minimum Data Set (MDS-assessment tool) resident assessment data for 6 of 16 sampled residents (R) were accurate as of the Assessment Reference Date (ARD) as evidenced by: 1. R33, R41, R17, R15 medications were inaccurate, 2. R38's wound was inaccurate. 3. R31's restorative care was inaccurate These failure increased the residents' risk for having unmet health care needs. Findings 1. inaccurate medication coding: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and or implement a comprehensive care plan for two of 16 sampled residents (R31 and R16). * R31: The Physical Therapist (PT) was not included in the care planning process, and their input and recommendations for knee brace related to knee buckling, and trapeze for mobility were not incorporated into the care plan. Staff were unaware of PT recommendations for transfer and mobility care, and did not implement transfer care as care planned and recommended by PT. The care plan did not include if R31 had refused to use any of the PT's recommendations. Additionally, the [NAME] used by the Certified Nursing Assistants (CNA) for awareness of the care plan did not include the use of a sit to stand lift and was outdated. [...]

Inspectors wroteBased on interview, record review, and policy, the facility failed to ensure that wound care was provided in accordance with the comprehensive care plan and professional standards of practice for one of two residents reviewed (Resident (R) 17). The deficient practice increased the risk for pain, infection and rehospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient staffing to meet resident care needs on 7 of 16 days when resident (R) R106 fell and there were less than three required Certified Nursing Assistant on duty, as outlined in the Facility Assessment. This placed resident at risk for delayed or unmet care needs and lack of supervision to prevent falls and resident to resident altercations.

Inspectors wroteBased on interview and record review the facility failed to ensure 2 of 6 sampled staff reviewed for competencies had documented competencies as evidenced by charge nurse did not complete any trainings in past two years, including fall prevention and Certified Nursing Assistant (CNA) working the floor had an expired CPR certificate. These failures placed residents at risk for unmet and unsafe care needs.

Inspectors wroteBased on interviews, review of records, and policy, the facility failed to ensure one of two residents reviewed for dental concerns (Resident (R) 38) received routine dental care. The deficient practice resulted in delayed dental services.

Inspectors wroteBased on observations, interviews, and review of policy, the facility failed to ensure food was stored in accordance with appropriate guidelines. Specifically, 1. A box of frozen blueberries was not left in the freezer open and undated, 2. A scoop was not left in the powdered sugar bin, 3. Expired baking soda was not left on the pantry shelf available for resident use, 4. Refrigerator temperatures/temperature logs were maintained for facility refrigerators, and 5. Staff did not keep personal food items in the resident's refrigerator. The facility census was 53. The deficient practice could increase the risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff completed mandatory QAPI (Quality Assurance and Performance Improvement) training as part of its QAPI program. The deficient practice placed residents at risk for receiving care from staff who did not understand the goals and various elements of the program, including their role in communicating concerns, problems, or opportunities for the facility's improvement to the facility's QAA (Quality Assessment and Assurance) Committee.

Inspectors wroteBased on interview and record review, the facility failed to ensure five of five currently employed sampled Certified Nursing Assistants (CNAs) or Licensed Nursing Assistants (LNA) (CNA16, LNA2, CNA13, CNA9, CNA8) completed the required 12 hours of annual in-service education based on their hire dates. The facility also failed to ensure CNA16 received annual abuse and dementia training and LNA2 received annual infection control training. These failed practices had the potential to negatively affect the competency of the NAs, placed residents at risk for receiving care from unskilled staff and increased risk for abuse, neglect, unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 16 sampled residents (R) (R27) was treated with respect and dignity and received care in an environment that promoted maintenance or enhancement of his or her quality of life. R27 was fed by staff standing over him. This failed practice had the potential to negatively affect the resident's self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure background check for criminal history was completed prior to caring for vulnerable adults for 1 of 9 sampled staff (Licensed Practical Nurse (LPN)6) reviewed for background check. This failure placed residents at risk for receiving care from unqualified staff and at risk of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse was reported to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for 1 of 7 sampled residents (R) (R27) reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse.

Inspectors wroteBased on interview and record review, the facility failed to transmit required Minimum Data Set (MDS-assessment tool) resident assessment data to the Centers for Medicare & Medicaid Services (federal agency that provides health coverage) within the required timeframe for 2 of 2 sampled residents (R) (R10 and R30) reviewed for timeliness in transmitting discharge Minimum Data Set (MDS-an assessment tool). This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to update or correct the Preadmission Screening and Resident Review (PASARR) and notify the state mental health authority for 1 of 1 sampled resident (R) (R29) reviewed for Pre-admission Screening and Resident Review (PASRR) that had a mental health condition or an inaccuracy with current level I form. This failure placed the resident at risk for unmet mental health services necessary to obtain the resident's highest level of functioning and psychosocial well-being.

Inspectors wroteBased on interview, record review, and policy the facility failed to update/revise the comprehensive care plan for one of two residents (R)17 reviewed for pressure ulcers (PU). The deficient practice had the potential to negatively impact the provision of care and services for R17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of two residents review for pressure ulcers received care consistent with professional standards when Resident 35's (R35) wound care assessments were not completed weekly, and care planned intervention of a multi-podus boot (an orthopedic device) was not implemented. This had the potential for R35's pressure ulcers to worsen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 sampled resident (R) (R24) reviewed for urinary catheter received treatment and services to prevent urinary tract infections when staff failed to ensure urinary drainage bag spigot/spout did not touch the inside of the urinal to prevent contamination and failed to develop individualized and specific clinical indications for changing the urinary and bag instead of changing at routine fixed intervals. These failures placed the resident at increased risk for urinary tract infections and its associated complications.

Inspectors wroteBased on interview, record review, and policy, the facility failed to ensure that 1 out of 6 residents (R) reviewed for timeliness of physician's visits (R207), was seen by a physician at least once every 30 days for the first 30 days after admission. This deficient practice had the potential to affect resident care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident 158 (R158) did not receive duplicate anticoagulant therapy unnecessarily when they failed to ensure the physician intended R158 to be treated with two different anticoagulants. This placed R158 at higher risk of bleeding side effects.

Inspectors wroteBased on interview and record review the facility's assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was not conducted with input from the required individuals stated in the regulation. This failure placed residents at risk for unmet care needs if their assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases when gloves were not changed between residents during 1 of 3 staff (Licensed Practical Nurse 2) medication pass observations. This failure increased the resident risk for infections and its associated discomfort and decline in physical condition.

Inspectors wroteBased on interview and record review the facility failed to ensure infection control practices were implemented to protect vulnerable residents during a COVID-19 (Coronavirus, an infectious disease caused by the SARS-CoV-2 virus) outbreak. The facility failed to notify the local Navajo Nation Health Department, potentially limiting assistance from outside resources, and failed to directly protect residents when they did not ensure symptomatic and/or COVID-19 positive staff did not work in the facility. This deficient practice and system wide failure may have contributed to the extent of the outbreak where thirty-one (31) residents developed COVID-19 infections while residing in the facility, five (5) of which required hospitalization for their symptoms. 1. The facility did not report the COVID-19 outbreak to the Arizona Department of Health and/or the Navajo Nation Health Department. 2. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to ensure seven residents (Resident (R) 99, R98, R24, R3, R39, and R36) received care and treatment in accordance with professional standards of practice. 1. The facility failed to perform Accuchecks (finger stick blood sugar checks) per the physician's orders for eight days while continuing to administer scheduled insulin to R99; 2. and failed to notify R98's Physician to obtain an order for Accuchecks after the resident was admitted to the facility with an order for insulin. 3. The facility failed to perform neuro checks after R39, R24, and R36 had sustained unwitnessed falls. 4. Additionally, the facility failed to ensure skin assessments and wound measurements were completed per the facility's policy for R3. [...]

Inspectors wroteBased on interview, job description review and document review, the facility failed to ensure a Registered Nurse (RN) was placed in the position of Director of Nursing (DON) services. This deficient practice had the potential to affect the care and nursing services provided to all 50 residents.

Inspectors wroteBased on observations, interview, and policy review, the facility failed to ensure food was served and stored in a manner to prevent the potential spread of food borne illness to all 23 residents on the Men's unit and to all residents who were served bread for two meals observed during the survey. Dietary staff failed to adhere to proper glove use when handling ready to eat food. The refrigerator on the Men's Unit was too warm and the temperatures were not adequately monitored.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to to establish a process in which the infection control policies and procedures were updated at least annually. In addition, the facility failed to provide indwelling urinary catheter care in a manner to prevent infection for one (Resident (R) 29) of two sampled residents reviewed for indwelling urinary catheters. The deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to implement an antibiotic stewardship program that promoted safe usage of antibiotics and collect outcome data for one (Resident (R) 99) of one sampled resident reviewed for antibiotic stewardship. In addition, the facility failed to review their antibiotic stewardship policy and procedure annually. This failure placed all residents at risk for antibiotic resistance and poor outcomes.

Inspectors wroteBased on interview and record review the facility failed to develop a Compliance and Ethics Program.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to report misappropriation of personal property, injuries of unknown source, and allegations of abuse to their administrator and/or the Centers for Medicare & Medicaid Services (CMS) immediately, but not later than two hours for four of 11 sampled residents reviewed for abuse/neglect and injuries of unknown injuries (Resident (R)17, R22, R99 and R45). Failing to report timely has the potential to delay facility actions to protect residents from further potential abuse while the allegation is investigated.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to investigate an injury of unknown origin for one resident (Resident (R) 1) of four residents reviewed for injury of unknown origin. In addition, the facility failed to implement their abuse policy and take steps to protect residents from the potential of further abuse by removing the alleged perpetrator from resident care, pending investigation for four residents (R3, R16, R17 and R45) of 11 residents reviewed for abuse. This failure had the potential to contribute to further abuse or psychosocial harm for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident and/or the resident representative was provided with written transfer notices upon emergent transfer to the hospital for four out of five residents reviewed for hospitalization (Resident (R)15, R6, R298, and R36) out of a total sample of 17 residents. This had the potential for Residents and/or their representative to be unaware of their rights.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure four out of five sampled residents reviewed for hospitalization out of a total sample of 17 residents (Resident (R) 15, R6, R298, and R36) were provided with bed hold notices upon emergent transfer to the hospital.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for five out of 17 sampled residents (Resident (R) 24, R19, R3, R42, and R43), creating the potential for a lack of appropriate care and services.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure three of three Certified Nursing Aide (CNA)35, CNA67, and CNA96) completed the required training annually.

Inspectors wroteReview of the facility demographic sheet revealed R7 was admitted on [DATE]; diagnoses included diabetes. A current physician order read, Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously at bedtime for Lowering Blood Sugar . During an observation of medication administration with Licensed Nurse (LN) 15 on 09/13/23 at 7:35 PM, LN15 prepared 30 units of Insulin Glargine at the medication cart in the hallway outside of R7's room. R7 was wheeling their wheelchair toward their room. Observed LN15 raise R7's shirt exposing their abdomen and inject the insulin while in the hallway outside of R7's room. Following the injection LN15 was asked if she usually gave injections in the hallway. She stated, I didn't realize I did that. She confirmed injections should be given in privacy. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure one resident (Resident (R) 17) of 17 sampled residents were free misappropriation of property by staff. This deficient practice had the potential to allow staff to take advantage of residents for personal gain.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to identify and complete a significant change in status Minimum Data Set (MDS) assessment for two (Residents (R) 3 and R36) in a total sample of 17. The facility failed to assess R3 for increased behaviors and declining cognition, and R36 for a significant decline in their physical condition which impacted their ability to perform activities of daily living (ADLs). This had the potential for care and services needed for R3 and R36 to reach their highest practical well-being not to be identified, assessed, planned, and provided.

Inspectors wroteBased on record review, interview, review of the Resident Assessment Instrument (RAI) manual and policy review, the facility failed to ensure that two residents (Resident (R) 2, and R4), out of 17 sampled residents', and one unsampled resident's (R46) Minimum Data Set (MDS) assessments were transmitted in a timely manner.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one of two sampled residents recently admitted to the facility (Resident (R) 98), out of a sample of 17 residents, was provided with the written summary of the baseline care plan following admission. R98 stated she did not know what the services and treatments for her care entailed.

Inspectors wroteBased on record review and interview, the facility failed to develop a care plan for the problem of dehydration for one of one resident (R )15 in the sample of 17. Specifically, the resident was admitted to the hospital on two occassions for diagnosis of dehydration.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one out of four residents reviewed for nutrition (Resident (R)15), out of a total sample of 17 residents, received sufficient fluids to ensure adequate hydration. R15, who was on a physician ordered fluid restriction, was hospitalized twice, and noted to be dehydrated in June and July 2023. Failures included a lack of reassessment following hospitalization with dehydration, not monitoring fluid intake records, and not putting together a plan to ensure adequate hydration status.

Inspectors wroteBased on interview and record review the facility failed to ensure an as needed (PRN) antipsychotic medication order was limited and prescribed for only 15 days for R43, one of five residents reviewed for unnecessary medications.