Prescott Nursing and Rehab Community

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene prior to administering medication to R7, R2, R8, and R9. This affected 4 out of 4 residents (R) reviewed for medication errors out of a sample of 9. This was evidenced by: The facility policy titled Hand Washing/Hand Hygiene, dated 1/2025, states in part: Practicing Hand Hygiene is a simple effective way to prevent infections by preventing the spread of germs. Wash hands and other skin surfaces when:2. After removing gloves or other personal protective equipment3. After care of each resident.4. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 5 residents (R) reviewed were free from chemical restraints. (R21)R21 was prescribed a hypnotic medication. There is no indication nonpharmacological interventions were tried prior to initiating the medication. The facility did not complete a sleep assessment, care plan, or monitor R21's sleep. R21 denied insomnia or history of sleep concerns. R21 is not informed that R21 is taking a psychotropic for sleep.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the residents remain free of possible accidental hazards. Facility did not determine the correct mechanical full body lift (Hoyer) sling size and ensure staff were applying the correct size Hoyer sling to prevent accidents for 3 of 7 residents (R) reviewed. (R7, R37, R44). Facility developed a plan of care for R37 that listed the use of an xl (x-[NAME] large) Hoyer sling when a large sling should be used per manufacturer's guidelines. Certified Nursing Assistants (CNAs) used a medium Hoyer sling to transfer R37. Facility developed a plan of care for R44 that listed use of an xl sling when a large Hoyer sling should be used per manufacturer's guidelines. CNAs used a medium Hoyer sling to transfer R44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received the appropriate treatment and services to prevent complications for 1 of 1 resident (R) receiving nutrition through tube feedings (enteral nutrition) (R26). The facility did not ensure standards of practice were conducted by ensuring proper gastrostomy tube (G-tube) placement before administering medications via G-tube. The facility policy titled, Care and Treatment of Feeding Tubes, last reviewed 04/03/25 states under the section of Policy Explanation and Compliance Guidelines, .6.licensed nurses, will monitor and check that the feeding tube is in the right location (a). Tube placement will be verified before beginning a feeding and before administering medications. On 05/12/26, Surveyor reviewed R26's medical record. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 14 residents. (R4 and R7)-Certified Nursing Assistant (CNA) E did not place barrier between floor and graduate when emptying R4's Foley catheter bag.-CNA D did not sanitize the mechanical lift after transferring R6, nor prior to using mechanical lift to transfer R7. CNA D and CNA E used the EZ stand lift for R4's transfer from bed to wheelchair and did not sanitize after use. The facility policy titled, Cleaning/Disinfecting Resident-Care items and Equipment, reviewed on 01/20225 states, . Reusable items are cleaned and disinfected between residents . The facility procedure titled, Emptying a Urinary Drainage Bag Competency, states, . 4. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (R) reviewed. (R33) R33 was not given enteral feeding nutrition as ordered; instead R33 received twice as much as ordered resulting in vomiting and aspiration, requiring suctioning and transfer to hospital on [DATE] where R33 expired on [DATE]. The facility's failure to properly monitor, assess, and correctly follow physician (MD) orders and treatments for enteral feeding resulted in resident receiving twice as much enteral feeding as ordered and created a finding of Immediate Jeopardy (IJ) that began on [DATE]. The state agency notified Nursing Home Administrator (NHA) A of the immediate jeopardy on [DATE] at 3:00 PM. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not prepare, store or distribute foods in a sanitary manner. The facility practices had the potential to affect all 29 residents. Kitchen staff did not complete monitoring of sanitation chemicals used to clean kitchen surfaces. Food items stored in the resident refrigerator on the unit were beyond use by dates. This is evidenced by: Facility policy titled, Sanitation Terminology, with a revised date of 01/25, states in part: Quaternary Solutions: a)Use of quat for food contact surfaces bucket: Add quat to water and test concentration in the water by using test strip. It should read 150-400 PPM on the chart. Facility dietary guideline posted on resident refrigerator titled, Unit Fridge, with no date, states in part: Sandwiches made from dietary expires 3 days after preparation. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 29 residents (R). -The facility did not have an infection surveillance process in place for a GI outbreak in March 2025. -Staff did not follow Enhanced Barrier Precautions (EBP) of wearing personal protective equipment (PPE) when providing IV medication administration for R236, when providing catheter care and positioning for R22, and when providing resident cares for R11.

Inspectors wroteBased on interview and record review, the facility did ensure notification in writing to the resident or resident representative, and the Office of the State Long-Term Care Ombudsman of residents' transfer or discharge from facility per regulation requirements. The facility practice affected 5 out of 5 residents (R) reviewed for the Office of the State Long-Term Ombudsman notice (R11, R1, R33, R22, R2), and 4 of 5 residents reviewed for transfer notice (R11, R1, R33, R22).

Inspectors wroteBased on interviews and record reviews, the facility did not notify provider as indicated for blood sugars outside of desired parameters for 1 of 12 residents, (R) R7, reviewed. This is evidenced by: Facility policy titled, Notification of Change, with a reviewed date of 01/2025 states in part: The resident's physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death .Some physicians may require different notification parameters for conditions such as blood glucose or other conditions. Please follow the physician's order in these cases. R7 was admitted to the facility on [DATE] with a pertinent diagnosis of diabetes mellitus type 2. [...]

Inspectors wroteBased on interview and record review, the facility did not provide written notice of bed-hold policy to the resident or their representative for 1 of 5 residents (R) reviewed for hospitalization. (R22) This is evidenced by: Facility's policy titled Bed Hold with the reviewed date of 01/25, documented in part, 1. The facility Social Worker or designee will provide a copy of the bed hold policy to the resident and/or the resident representative at the time of admission and again prior to a transfer due to hospitalization or therapeutic leave. The signed copies will be maintained in the resident's financial or personal file .3. In the event of an emergency transfer to a hospital, the facility social worker or designee will attempt to contact the resident or resident representative within 24 hours of the transfer and determine whether to hold the resident's bed. [...]

Inspectors wroteBased on interview and record review, the facility did not implement an effective discharge plan with a focus on identifying resident's need and an effective transition to post discharge care for 1 of 1 resident (R) who were ordered for discharge from the facility, R26.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 2 of 12 residents (R) (R1, R24) reviewed. Staff did not remove sutures per provider orders for R24 or implement hospital discharge orders upon readmission for R24. Facility did not enter and administer physician orders for R1.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 2 of 3 residents (R24 and R11) reviewed for high risk of Pressure Injury (PI) development received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. - R24 is high risk for the development of PIs and has a stage 3 PI to the right heel. R24 was observed for 2 hours and 58 minutes in which she was lying in bed without staff offering or attempting to reposition and heels were not elevated as ordered. -Staff did not perform proper hand hygiene when applying topical prescriptions to R24's wound bed during wound dressing change. -Staff did not sanitize bedside tables for R24 and R11 during wound dressing change. This is evidenced by: Example 1 According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that services for a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, for 1 of 1 resident (R) R14 reviewed for respiratory assessment related to medication administration. R14 was administered a nebulizer treatment without a lung assessment completed prior to and after treatment. Evidenced by: Facility's policy titled Med Pass read in part, M. Nebulizer treatment administration.6. Assess pulse, respiratory rate, breath sounds, pulse oximetry before beginning treatment .12. Monitor patient's pulse, respiratory rate, breath sounds and pulse oximetry post treatment and as ordered by physician . According to the National Library of Medicine (2021), the standard of nursing care expected with small volume nebulizer treatment includes: [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of steroid inhaler to meet the needs for 1 of 1 resident (R) reviewed, R14. This is evidenced by: Facility's policy titled Med Pass read in part, M. Nebulizer treatment administration.14. If inhaled medication included steroids, have patient rinse mouth and gargle with warm water after treatment . R14 was admitted to the facility on [DATE] with a pertinent diagnosis of chronic respiratory failure. R14's orders included: 01/30/25: Budesonide suspension for nebulization; 0.5 mg/2 ml; amt: 0.5 mg; inhalation Special Instructions: Administer 1 neb twice per day for shortness of breath twice per day. Please rinse mouth with water after use. Do not swallow. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure they were monitoring the effectiveness of psychotropic drugs for 2 of 4 residents (R) (R14, R21). The facility did not complete behavior monitoring as outlined in the comprehensive care plan to determine adequate indication for use of antidepressant medications (duloxetine and buproprion) for R14. R21 receives trazodone, an antidepressant medication, for sleep with no adequate indication for use and no sleep hygiene care plan with non-pharmacological interventions to promote sleep. This is evidenced by: The facility policy, titled Behavioral Health Services, dated 1/2025, states: 7. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 39 residents (R). The facility had a sick employee with respiratory symptoms on duty delivering direct resident care. Improper hand hygiene was observed during wound care and personal care for R1 and R5. Facility laundry services had dirty linens on the floor and personal items were stored in a clean linen area. Staff carried soiled linens in the hallway without containing them in a plastic bag.

Inspectors wroteBased on observation, the facility did not close the privacy curtain to provide privacy during personal care to the resident's abdominal/groin area for 1 of 1 sampled resident (R18). This is evidenced by: R18 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic neuropathy, unspecified, dysphagia, oral phase, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, retention of urine, and unspecified, muscle weakness (generalized). R18's Minimum Data Set assessment, dated 11/12/23, indicates R18 has a Brief Interview for Mental Status (BIMS) score of 99 (severe cognitive impairment)-resident unable to complete interview. On 02/12/24 at 9:15 AM, Surveyor observed R18. Surveyor observed R18 in bed lying on his back with the head of the bed rolled up. Surveyor attempted to interview R18, with no response. [...]

Inspectors wroteBased on record review, observation and interview, the facility did not ensure to develop and implement a comprehensive individualized care plan to meet the needs of the residents (R). R18's care plan was not developed for intermittent urinary catheterization and for incontinence of bladder and bowel. This occurred for 1 of 13 sampled residents (R18). This is evidenced by: R18 was admitted to the facility on [DATE] and has a diagnosis of retention of urine. R18's Minimum Data Set assessment, dated 11/12/23, Section H: Bowel and bladder indicates R18 is intermittingly catheterized, is frequently incontinent of bladder and continent of bowel. Currently R18 is not continent of bowel. On 02/13/24 at 2:42 PM, Surveyor reviewed R18's current comprehensive care plan. R18 did not have a care plan for intermittent urinary catheterization or urinary and bowel incontinence. [...]

Inspectors wroteBased on record review and interview, the facility did not review and revise the fall comprehensive care plan for 1 of 3 sampled residents (R) R239.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure prescription medications were administered by qualified staff. Surveyor observed Certified Nursing Assistant apply prescribed Nystatin powder to a resident's (R) skin for 1 of 1 observation. (R5)

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure that 3 of 6 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. (R1, R3, and R6) R1 did not receive regular assistance with toileting or personal care. R3 did not receive regular assistance with personal care or repositioning every 2 hours as care planned. R6 did not receive regular assistance with turning and repositioning or bathing and personal cares

Inspectors wroteBased on observation, interview and record review, the facility did not provide care and services in accordance with professional standards of practice for 3 of 3 residents (R). (R18, R1, R3). R18 did not have cares provided as care planned and had reoccurring moisture associated skin damage (MASD) to the buttocks. The facility did not ensure R1 had heart failure assessed. R3 did not receive skin care to prevent breakdown to the right hand.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure residents with limited range of motion (ROM) received services to maintain or prevent further reduction in ROM for 1 of 1 resident (R) R3 reviewed. This is evidenced by: R3 was admitted to the facility on [DATE] with diagnoses including, in part, Lennox-gastaut syndrome (LGS), dysphagia, heart failure, and hypertension. Provider note on 02/15/24 states in part, That adults with LGS have multiple types of seizures that vary among individuals. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the environment remained free of hazards for 1 of 1 Resident (R) who smokes.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 1 sampled resident (R18) maintained acceptable parameters of nutrition. R18 has experienced a continual weight loss, meal assistance or alternatives to meals were not provided, daily weights were not completed. The last updated intervention for nutrition was 1/11/24. This is evidenced by: R18 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic neuropathy, unspecified, dysphagia, oral phase, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, retention of urine, and unspecified, muscle weakness (generalized). history of cancer in prostate, UTI recurrent with hydronephrosis. [...]