Fountain Hills Post Acute

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medication was acquired, received, and administered according to physician orders for one of three sampled residents (#2). The deficient practice could result in a resident not receiving medication as ordered by the physician.-

Inspectors wroteBased on clinical record review, resident and staff interviews, hospital records, facility documentation, policies and procedures, the facility failed to ensure physician-ordered diets were followed and implemented for 2 of 10 sampled residents (#9 and #12). This deficient practice resulted in resident #9 choking and requiring hospitalization.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure that an allegation of sexual abuse made by one (Resident #3) of three sampled residents was immediately reported to the administrator and to the appropriate state agency within the required timeframes (within 2 hours for allegations involving abuse or serious bodily injury), as required. This deficient practice had the potential to place residents at risk for ongoing abuse and delayed protective interventions. Findings Include:Resident #3 was admitted [DATE], with diagnoses including metabolic encephalopathy, traumatic brain injury history, depression, anxiety disorder, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medication was administered and stored according to policy for two of four sampled residents (#4 and #2). The deficient practice resulted in residents accidentally ingesting medication. Findings Include:-Regarding Resident #4:Resident #4 was admitted to the facility on [DATE], with diagnoses that included hyperlipidemia, anemia, type 2 diabetes mellitus, chronic pain syndrome, pressure ulcer of right buttock, and pressure ulcer of right ankle. An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #14 had a brief interview for mental status (BIMS) score of 14, indicating intact cognition. [...]

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for one resident (#9). The deficient practice could result in harm to the residents, and/or visitors who have access to medications.

Inspectors wroteBased on record review, facility documentation, staff and resident interviews, and facility policy and procedures, the facility failed to protect the right of one resident(#10) to be free from abuse by staff. The deficient practice could result in residents being abused.

Inspectors wroteBased on review of clinical records and policy, observations, and staff interviews the facility failed to ensure a complete anti-seizure medication regimen was administered to Resident # 295 within accepted professional standards of practice. The deficient practice of incomplete medication administration does not align with accepted professional standards of practice and may result in undesirable quality of care. Findings Include: Resident # 295 was admitted on [DATE] with diagnoses of burn of unspecified degree of buttock, essential hypertension, and unspecified convulsions. The most recent admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. On admission, Resident # 295 had the following anti-seizure medication regimen: [...]

Inspectors wroteBased on review of clinical records and policy, observations, and staff interviews the facility failed to ensure cautionary slippery-floor safety signs were present near a hazardous area for Resident #295. The deficient practice of reduced safety measures may result in a higher likelihood of accidental falls. Findings Include: Resident #295 was admitted on [DATE] with diagnoses of burn of unspecified degree of buttock, muscle weakness, abnormalities of gait and mobility, and unspecified convulsions. The most recent admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Care plan initiated on January 19, 2024, revealed a goal for Resident #295 was not to sustain serious injury due to risk for falls related to impaired mobility. [...]

Inspectors wroteBased on the clinical record reviews, resident and staff interviews, facility document, and facility assessment, the facility failed to ensure that there was sufficient nursing staff to meet the needs of multiple residents (#s 11, 19, 27, 85, 129, and 180). The census was 27. The deficient practice could result in residents' care needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#21) was informed in advance of the risks and benefits of psychoactive medications. The sample size was 2. The deficient practice could result in residents and/or their representatives not being made aware of the risks and benefits of psychoactive medications.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure the provider received notification of an unwitnessed fall regarding one resident (#84). The sample size was 12. The deficient practice could result in delayed care.

Inspectors wroteBased on clinical record review, staff interviews, State Agency (SA) database, review of facility records, and review of policies and procedures, the facility failed to report an allegation of abuse regarding one sampled resident (#130), to the law enforcement agency within the required time frame. The deficient practice could result in more reasonable suspicions of crime not being reported.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, the State Agency (SA) database, and policy review, the facility failed to ensure that an allegation of abuse was investigated regarding one sampled resident (#130). The deficient practice could result in further allegations of abuse not being investigated.

Inspectors wroteBased on clinical record review, resident and staff interviews, and review of policies, the facility failed to ensure two sample residents (#3 & #14) were consistently provided care and services to maintain acceptable parameters of nutritional status. The deficient practice could result in residents with unplanned weight loss and dehydration.

Inspectors wroteBased on clinical record review, staff interviews, and policy reviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one resident (#19) by failing to ensure there was a physician order and ongoing care and monitoring for the use of a CPAP (continuous positive airway pressure) machine and not providing oxygen as ordered. The sample size was 2. The deficient practice could result in residents not having an order for the use of a CPAP machine and not receiving oxygen as ordered.

Inspectors wroteBased on observations, staff interviews, the CDC (Centers for Disease Control and prevention) and policy review, the facility failed to ensure visual alerts were posted to ensure everyone was aware of the recommended infection control practices in the facility. The deficient practice could result in the spread of infection.

Inspectors wroteBased on observations, family and staff interviews, clinical record review, and review of policy, the facility failed to ensure the call light for one resident (#84) was appropriately placed within the resident's reach. The sample size was 12. The deficient practice could result in residents not having the means to communicate with staff and not receiving care or services in a timely manner.