Life Care Center of Yuma

Inspectors wroteBased on clinical record reviews, staff and resident interviews, review of facility documentation, and policy and procedures, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of the four sampled residents (#2 and #3). The deficient practice could result in the resident being in an unsafe environment. Findings Include:- Regarding Resident #2:Resident #2 was admitted on [DATE], with a diagnosis of cerebral edema, dysphagia, aphasia, dysarthria, restlessness and agitation, stimulant abuse, hypertension, anemia, and repeated falls. An annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #2 was cognitively intact with no physical or verbal behaviors. [...]

Inspectors wroteBased on observation, clinical record review, interviews, and facility policy and procedures, the facility failed to ensure the care plan regarding anticoagulant therapy was established for one resident (Resident #9). The deficient practice may result in absence of person-centered goals or safeguarding against adverse events related to medication therapy.

Inspectors wroteBased on record review, staff interviews, facility documentation and policy review, the facility failed to ensure controlled medications were recorded, stored, and reconciled accurately for one Resident (#1). The deficient practice could result in the inability to establishes a system of records of receipt and disposition of controlled drugs.

Inspectors wroteBased on record review, staff interviews, facility documentation and policy review, the facility failed to ensure safe and secure storage of controlled medication for one Resident (#1). The deficient practice could result in unsafe handling of controlled medication.

Inspectors wroteBased on record review, staff interviews, facility documentation and policy review, the facility failed to ensure medication records were completed, or safeguarded against loss or destruction. The deficient practice could lead to incomplete medical records in accordance to professional standards.

Inspectors wroteBased on clinical record review, interviews, and facility policy and procedure, the facility failed to ensure that an allegation of sexual abuse was reported to the State Agency within the required time frame for one resident (# 684). This deficient practice can result in allegations of abuse not being reported.

Inspectors wroteBased on clinical record review, interviews, and review of facility documentation and policies, the facility failed to ensure that the facility policy was implemented regarding restricting access to residents following an allegation of abuse by a staff. This deficient practice placed the resident at risk and has the potential to violate the resident's right to safety and prevent further harm.

Inspectors wroteBased on clinical record review, interviews and facility policy review, the facility failed to ensure their policy was followed for abuse and injury of unknown origin for three residents (#66, #54 and #89). The deficient practice could lead to other policies not being followed potentially placing residents at harm.

Inspectors wroteBased on clinical record review, interviews and facility policy review, the facility failed to thoroughly investigate an injury of unknown origin and a resident to resident altercation for three residents (#66, #54 and #89). The deficient practice could lead to thorough investigations not being completed and sent to the State Agency potentially placing residents at harm.

Inspectors wroteBased on clinical record review, interviews and facility policy review, the facility failed to ensure residents care plans were updated and revised on four residents (#15, #66, #54 and #89). The deficient practice could result in the medical records not being complete and accurate, resulting in the resident not receiving the proper care or interventions.

Inspectors wroteBased on clinical record review, interviews and facility policy review, the facility failed to ensure accurate medical documentation was completed on four residents (#72, #54, #66 and #89). The deficient practice could result in the medical records not being complete and accurate.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#27) was not neglected and her basic needs were being met regarding assistance with bathing, nail clipping, hair washing, and monitoring the condition of her skin. The facility also failed to assess the resident's needs after falls and update the care plan with new interventions as needed. The deficient practice could result in further incidents of resident neglect.

Inspectors wroteBased on observation, staff interviews, and policy review, and review of current facility practice, the facility failed to ensure care plan was developed and implemented to meet the assessed need for one resident (#78). The deficient practice could result in the resident receiving the care they need.

Inspectors wroteBased on personnel file review, staff interviews, facility assessment and policy review, the facility failed to ensure one Certified Nursing Assistant (CNA /staff #64) had the cardiopulmonary resuscitation (CPR) certification to provide nursing and related services. The deficient practice could result in staff not able to to safely meet resident needs during an emergency. Sample size was one. Facility census was 81.

Inspectors wroteBased on observations, staff interviews, and the facility policy and procedures, the facility failed to maintain a clean kitchen; and failed to ensure food items were dated when opened. The deficient practice could result in residents having food-borne illness.

Inspectors wroteBased on observations, staff interviews, and facility policy review and the Centers for Disease Control and Prevention (CDC), the facility failed to ensure infection control standards related to enhanced barrier precautions were followed for one resident (#78) with catheter and wound. The deficient practice could result in transmission of multi-drug resistant organisms.

Inspectors wrote-Resident #337 was admitted to the facility on [DATE] with diagnoses that included digestive surgery, sepsis due to enterococcus, and encounter for surgical aftercare following surgery on the digestive system. Review of hospital records, dated February 11, 2022 included discharge instructions for wound care which noted that there was use of a wound vacuum (VAC) for the resident's surgical wound. The admission nursing note dated February 12, 2022 included that the resident was admitted with a diagnosis of small bowel obstruction related to hernia surgery and the resident had an extensive debridement hernia repair. The note included the resident was admitted with a wound VAC in place. The resident's skin integrity care plan, initiated on February 12, 2022, included that the resident had a break in skin integrity. [...]

Inspectors wroteBased on facility documentation, interviews, and policy, the facility failed to ensure that staff were tested for COVID-19 at the required frequency. This deficient practice could lead to the spread of COVID-19.

Inspectors wroteBased on clinical record reviews, facility documentation, interviews and policy, the facility failed to ensure that an allegation of resident to resident abuse was thoroughly investigated for two residents (#24 and #51). The deficient practice could result in other residents being abused.

Inspectors wroteBased on clinical record review, interviews, and policy, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) process for one resident (#3). The deficient practice could result in residents not receiving needed services.

Inspectors wroteBased on clinical record review, interviews, and policy, the facility failed to develop a bowel care plan for one resident (#65). The deficient practice could result in residents not receiving needed care.

Inspectors wroteBased on clinical record review, interviews, and policy, the facility failed to administer pain medications within ordered parameters for one resident (#65). The deficient practice could result in residents' receiving too much pain medication.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy reviews, the facility failed to ensure treatments were provided as ordered for one sampled resident (#7) with a pressure ulcer. The deficient practice resulted in the resident not receiving consistent treatment for a pressure ulcer.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure physician's orders were followed regarding catheter size for one sample resident (#7). The deficient practice could result in residents not having the size catheter ordered by the physician.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure review, the facility failed to ensure one of 22 residents' (#32) medical record was complete. The deficient practice could result in residents' clinical records not being complete.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one of six sampled residents (#32) was informed of the risks and benefits of a psychotropic medication prior to the administration of the medication. The deficient practice could result in residents/representatives not being information of the risks and benefits of taking psychoactive medications.

Inspectors wrote-Resident #320 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included cellulitis of the left lower limb, type-2 diabetes mellitus, and peripheral vascular disease. An advance directive form dated [DATE] signed by the resident revealed the resident had chosen to be a Full Code. Review of the physician's order dated [DATE] revealed the following advance directive order: Do Not Resuscitate (DNR) with limited interventions. An interview was conducted with the Assistant Director of Nursing (ADON/staff #6) on [DATE] at 9:55 am. She stated the residents sign their code status on admission and the order will be entered in Point Click Care (PCC). The ADON stated the advance directive form has to be redone when the resident returns to the facility after hospitalization. [...]

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to ensure the required discharge information was documented and a discharge order was entered for one of three sampled residents (#69). The deficient practice could result in discharge requirements not being completed.

Inspectors wroteBased on clinical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure that a baseline care plan was developed for one sampled resident (#66) regarding the use of oxygen. The deficient practice may result in residents not being provided the services and person-centered care necessary to meet his/her needs.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a care plan was developed for hearing and the use of hearing aids for one resident (#20). The sample size was 16. The deficient practice could result in residents use of hearing aids not being reflected in the care plan.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one of two sampled residents (#2) received the necessary services to maintain good grooming and hygiene. The deficient practice could result in grooming and hygiene needs of residents not being met.

Inspectors wroteBased on observation, clinical record review, staff and resident interviews, and policy review, the facility failed to ensure one resident (#43) was served food that accommodated the resident's food allergies. The census was 62. The deficient practice could result in residents receiving food that they are allergic to.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure infection control standards were followed regarding tracheotomy care for one resident (#2) and catheter care for one resident (#7). The deficient practice could result in the spread of infection.