Prescott Valley Nursing & Rehabilitation

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that residents were provided copies of their personal and medical records upon written request within the required timeframe for one resident (#82). The deficient practice could result in resident rights being violated.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three sampled residents (#82). The deficient practice could result in harm to the resident.

Inspectors wroteNumber of residents sampled: 21Number of residents cited: 17The facility failed to ensure residents right to personal privacy and confidentiality of his or her medical recordsBased on record review, staff interviews, review of facility documentation and policy, the facility failed to protect residents' right to personal privacy and confidentiality of his or her personal and medical records. The deficient practice could result in an unauthorized access to residents' personal and medical records.

Inspectors wroteBased on record review, staff interviews, review of facility documentation and policy, the facility failed to provide a written notice notifying one resident (#71 and #73) upon transfer to an acute care hospital setting of the bed hold which specifies the duration of bed-hold including reserve payment, and the facility failed to send notification of transfer of discharged residents to the representative of the Office of the State Long-Term Care Ombudsman.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure 7 residents (#1, #7, #49, #2, #25 and #18 were) with diagnosis of serious mental illness were referred for PASARR (Pre-admission and Resident Review) Level II evaluation. The deficient practice could result in residents not receiving the services according to their assessed needs.

Inspectors wroteBased on clinical record review, staff interviews and review of facility policy, the facility failed to ensure medications were administered following the parameter set for 2 of 5 sampled residents (#2 and #52). The deficient practice could result in resident not receiving the appropriate treatment they need.

Inspectors wroteBased on observations, staff interviews and facility policy review, the facility failed to ensure that a treatment cart was kept locked when unsupervised and unattended. The deficient practice could result in unauthorized staff and residents having access to medications and residents receiving the wrong medication.

Inspectors wroteNumber of residents sampled:Number of residents cited:FFTE THAT 5 STAFF MEMBERS HAVE COMPLETED RESIDENT RIGHTS TRAINING.Based on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#37, #5, #27, #16, and #56) are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. The deficient practice could result in staff not being familiar with residents' rights.

Inspectors wroteNumber of residents sampled:Number of residents cited:FFTE THAT 5 STAFF MEMBERS HAVE COMPLETED RESIDENT RIGHTS TRAININGBased on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#37, #5, #27, #16, and #56) are educated on abuse, neglect, exploitation, and misappropriation of resident's property. The deficient practice could result in staff not being familiar with the prevention and reporting of abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteNumber of residents sampled:Number of residents cited:FFTE THAT 5 STAFF MEMBERS HAVE COMPLETED IC TRAINING Based on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#37, #5, #27, #16, and #56) are educated on infection control and prevention. The deficient practice could result in staff not being familiar with process and procedures for the control and prevention of infection.

Inspectors wroteNumber of residents sampled:Number of residents cited:FFTE THAT 5 STAFF MEMBERS HAVE COMPLETED BEHAVIORAL HEALTH TRAININGBased on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#37, #5, #27, #16, and #56) received behavioral health training. The deficient practice could result in staff not being equipped to provide residents with behavioral health care and services.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure 1 of 5 sampled resident (#2) or resident representative was informed of the risks and benefits, options, and alternatives related to the use of a psychotropic medication prior to its administration. The deficient practice could result in resident not able to exercise his right to choose an option he prefers.

Inspectors wroteNumber of residents sampled: 21Number of residents cited: 1The facility failed to ensure that one resident (#63) was free from abuseBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#63) to be free from abuse by another resident (#22). The deficient practice could result in further abuse of residents and appropriate action not taken.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure there was adequate indication, non-pharmacological interventions and monitoring of behaviors and side effects related to the use of antipsychotic medication for 1 of 5 sampled residents (#2). The deficient practice could result in unnecessary use of antipsychotic medication for the resident.

Inspectors wroteNumber of residents sampled: 21Number of residents cited: 1The facility failed to ensure that abuse policy was implementedBased on clinical record, staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database the facility failed to implement their policy regarding conducting thorough investigation of abuse allegation and protecting residents from further abuse for one resident (#63). The deficient practice could result in abuse continuing and not being prevented.

Inspectors wroteNumber of residents sampled: 21Number of residents cited: 1The facility failed to ensure that an allegation of abuse was reportedBased on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to conduct and submit an investigation report for an allegation of abuse for one resident (#3). The deficient practice could result in abuse allegations not being investigated and reported.

Inspectors wroteNumber of residents sampled: 1Number of residents cited: 1Based on clinical record review, staff interviews, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure an MDS (Minimum Data Set) significant change in status assessment (SCSA) was completed for one sampled resident (#2) related to hospice admission. The deficient practice could result in resident not comprehensively assessed and needs not being met.

Inspectors wroteBased on observations, staff interview and review of facility policy, the facility failed ensure infection control standards were followed by staff during meal service; and, failed to ensure hand hygiene was performed between residents during medication administration. The deficient practice could result in food-borne illness and transmission of infection to residents and staff.

Inspectors wroteNumber of residents sampled:Number of residents cited:TFFTE THAT ONE STAFF MEMBER HAD CURRENT CPR TRAINING Based on documentation, staff interviews, and facility policies the facility failed to ensure that one staff member (#1) was had current CPR (Cardiopulmonary Resuscitation) training consistent with their role. The deficient practice could result in staff being qualified/trained to provide CPR when needed by residents.

Inspectors wroteBased on observation, interviews, review of clinical record, and facility policy, the facility failed to ensure adequate supervision consistent with the resident's needs was provided to one resident (#3) to prevent an accident of spilling a hot liquid beverage. The deficient practice resulted in the resident sustaining a burn.-

Inspectors wroteBased on interviews, review of clinical record, and facility policy, the facility failed to ensure a resident was assessed timely and that a provider was notified timely of a change of condition for one resident (#3). The deficient practice resulted in the resident having a delay of care for treatment of a burn.-

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure a baseline care plan was developed and implemented timely for one resident (#20). The deficient practice could lead to decreased communication and coordination between interdisciplinary team members, leading to a decreased quality of care for a resident.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure a care plan was updated for three residents (#18), (#25), and (#149). This deficient practice could result in resident's care plans not being updated as necessary.

Inspectors wroteBased on clinical documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#30 and #28) were allowed to choose their bedtime. The deficient practice could result in the rights and personal choices of the residents being denied.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure two resident's (#37 and #26) had a Level I PASRR (pre-admission screening and resident review form) screening. The sample size was 2. The deficient practice could result in resident's not receiving needed care in the facility.

Inspectors wroteBased on observations, staff interviews, manufacturer directions and policy review, the facility failed to ensure that food was stored in accordance with professional standards for food safety, and counters and equipment were properly sanitized to prevent cross contamination. The deficient practice could result in loss of freshness and nutritive value and the risk of foodborne illness.

Inspectors wroteBased on clinical record review, review of facility documentation, staff interviews and review of facility policy, the facility failed to ensure one sampled resident's (#48) right to be free from misappropriation of medication by a staff member. The deficient practice could result in resident's not receiving ordered medications.

Inspectors wroteBased on staff interviews, clinical record review, facility record review, review of the State Agency database and review of facility policy and procedure, the facility failed to ensure that an allegation of misappropriation/drug diversion involving one resident (#48) was reported to Law Enforcement within the required time frame. The deficient practice could result in delayed law enforcement intervention.

Inspectors wroteBased on staff interviews, clinical record review, facility record review, review of the State Agency database and review of facility policies and procedures, the facility failed to ensure that an allegation of misappropriation/drug diversion involving one resident's (#48) property was reported to the state agency within the required time frame. The deficient practice could result in further abuse allegations not being reported timely to the State Agency.

Inspectors wrote-Resident #47 was admitted to the facility on [DATE] with diagnoses that included myocardial infarction, atherosclerotic heart disease of the native coronary artery with unspecified angina pectoris, chronic obstructive pulmonary disease, chronic kidney disease, depression, anxiety disorder, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Review of the nursing notes revealed the resident was sent to the hospital on June 9, 2022 following complaints of 10/10 pain for abdominal distention. The discharge MDS assessment dated [DATE] revealed the resident's discharge was unplanned and that return was anticipated. A subsequent health status note dated June 10, 2022 indicated the resident was admitted to the hospital for pancreatitis. [...]

Inspectors wroteBased on clinical record review, facility documentation, staff interview, and review of policy, the facility failed to notify one sampled resident (#100)/representative of the facility bed hold policy including reserve bed payment, at the time of transfer/discharge. The deficient practice could result in residents not being informed of their bed hold rights.

Inspectors wroteBased on clinical record review, staff interview, and facility policy and procedure, the facility failed to ensure that a care plan was developed for one sampled resident (#23) regarding wound care/skin integrity. The deficient practice could result in care issues not being addressed in residents' plan of care.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure one resident (#44) was free from accident hazards and received adequate supervision to prevent accidents. The sample size was 4. The deficient practice could result in residents being injured.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure Medication Regimen Reviews (MRRs) were completed on a monthly basis by the pharmacist for one resident (#9). The sample size was 5. The deficient practice could result in gradual dose reductions not being done or unnecessary medications being administered.

Inspectors wroteBased on clinical record reviews, staff interviews, and review of facility policy, the facility failed to ensure there was monitoring for target behaviors and adverse side effects, and failed to provide non-pharmacological interventions prior to medication use for one resident (#14) on psychotropic medications. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure an advanced directive was accurately documented for one resident (#197). The sample size was 2. The deficient practice could result in residents receiving services which are not in accordance with their wishes.

Inspectors wroteBased on facility documents, the Center for Disease Control and Prevention (CDC) information, staff interview, and the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure one staff (#91) was tested for COVID-19 at the required frequency. The deficient practice could result in possible spread of the COVID-19 virus.