Rim Country Health & Retirement Community

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#34) was free from abuse by another resident (#50). The deficient practice could result in residents being physically and emotionally harmed. Findings Include:-Regarding Resident #50 Resident #50 was readmitted to the facility on [DATE], with diagnoses that included suicidal ideations, displaced fracture of the right lower leg, effusion of the right ankle, chronic pain syndrome, anxiety disorder, muscle weakness, hypertension, seizures, type 1 diabetes, major depressive disorder, insomnia, and spastic hemiplegia affecting the left nondominant side. A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. [...]

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to complete notifications involving abuse for two residents (# 15 and #23). The deficient practice resulted in allegations of abuse not being reported, not investigated and residents not protected from further abuse. The resident #15 was admitted on [DATE] for a planned respite stay while a patient with Arizona Care Hospice, and discharged to his home on 7/8/2025 with diagnoses that included: atherosclerotic heart disease and vascular dementia. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed completion of only section A. A review of the hospice admission packet revealed that the resident was admitted to the facility from Arizona Care Hospice for a respite stay while home health services were established. [...]

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to develop and implement policies and procedures for the documentation and reporting of alleged violations involving abuse for one resident (#23). The deficient practice resulted in allegations of abuse not being reported, not investigated and residents not protected from further abuse.

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one resident (#6) to be free from abuse by another resident (#4). The deficient practice could lead to ongoing abuse leading to harm of residents.

Inspectors wroteBased on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure two residents (#20 and #22) were not physically abused in a resident to resident altercation. The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: -Regarding Resident #20: Resident #20 was re-admitted to the facility November 18, 2024, with diagnoses that included anxiety disorder, insomnia, flaccid hemiplegia affecting left side, dysphagia, difficulty in walking, dysarthria, and acquired absence of left leg below the knee. A quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for two residents (#20 and #22) regarding assessment following an incident of abuse. The deficient practice could result in care team members not being adequately informed regarding the status of residents and lead to missed or delayed care. Findings Include: -Regarding Resident #20: Resident #20 was re-admitted to the facility November 18, 2024, with diagnoses that included anxiety disorder, insomnia, flaccid hemiplegia affecting left side, dysphagia, difficulty in walking, dysarthria, and acquired absence of left leg below the knee. [...]

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one of one sampled residents (#5) was safe to self-adminster medication. The deficient practice could result in a medication overdose. Resident #5 was initially admitted on [DATE], with a diagnoses of bipolar disorder, shortness of breath, and major depressive disorder. Review of the clinical record revealed no evidence of a medication self-administration order for: Floonase Propionate 50 MCG/ACT suspension [NAME] Ellipta Aerosol Power 100-25 MCG Review of the clinical record revealed no evidence of a medication self-administration assessment. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. [...]

Inspectors wroteBased on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure necessary blood pressure medications were administered according to provider orders for one resident (#30). This deficient practice could result in side effects leading to negative resident outcomes. Findings Include: Resident #30 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, anxiety disorder, and gastro-esophageal reflux. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) was not conducted because residents is rarely or never understood. The staff assessment of cognitive patterns for this resident revealed that the resident has both short and long term memory problems and his daily decision making skills are noted as severely impaired. [...]

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure kitchenware were following professional standards of practice. The deficient practice could result in residents becoming ill.

Inspectors wroteBased on clinical record review, staff and caregiver interviews, and policy and procedures, the facility failed to ensure medications were securely stored in accordance with professional standards for one resident (#10). The deficient practice resulted in resident hospitalization.

Inspectors wroteBased on documentation, interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#21) did not abuse another resident (#32). The deficient practice could result in residents being physically and/or emotionally injured.

Inspectors wroteBased on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #2 was free from abuse from resident #1. The deficient practice could result in residents experiencing emotional and mental trauma from abuse.

Inspectors wroteBased on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #1's care plan was updated to accurately reflect the resident's care. The deficient practice could result in residents not getting the appropriate care they need.

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#9) were free from physical abuse resulting in injury by other residents (resident #23). The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#50) to be free from physical abuse by another resident (resident #99). The deficient practice could result in resident not protected from further abuse.

Inspectors wroteBased on record review, interviews, facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure one resident (#10) was free from abuse from a staff member. The deficient practice could lead to further abuse of residents.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policy and procedures, and the State Survey Agency database, the facility failed to develop and implement their policy on abuse reporting and investigation for one resident #67. The deficient practice could result in abuse continuing and not being prevented.

Inspectors wroteBased on review of the clinical record, facility documentation, review of the State Agency database, staff interviews, and review of policy and procedure, the facility failed to ensure two allegations of abuse were thoroughly investigated and prevent further potential abuse and take appropriate corrective action for two residents. The deficient practice could lead allegations of abuse not being investigated and abuse occurring in the facility. Findings Include: Regarding resident #67 and resident #66 -Resident #67 was admitted to the facility on [DATE] with diagnoses that included visual disturbance, schizoaffective disorder, bipolar disorder depressed severe with psychotic features, generalized anxiety disorder, major depressive disorder, insomnia, difficulty walking, and aphasia. Resident #67 was discharged home on [DATE]. [...]

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and facility policies and procedures, the facility failed to allow one resident the right to exercise his rights without coercion or interference or coercion from the facility and to be supported by the facility in the exercise of his rights. The deficient practice could result in other residents not being able to exercise their rights.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that two residents (#36, #68) were free from abuse from another resident. The deficient practice could result in other residents being abused.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, review of policy and procedures, and the State Survey Agency database, the facility failed to ensure an allegation of resident to resident abuse was reported within the required timeframe to the State Agency for one resident (#67). The deficient practice could result in further allegations of abuse not being reported in a timely manner as required.

Inspectors wroteBased on staff interviews, review of facility documentation, policy and procedures, the facility failed to implement their policy on abuse reporting and investigation for four residents (#15, #218, #220, and #221). The deficient practice could result in abuse continuing and not being prevented.

Inspectors wroteBased on review of the clinical record, facility documentation, review of the State Agency database, staff interviews and review of policy and procedure facility failed to ensure two allegations of abuse and two injuries of unknown origin were fully investigated. The deficient practice could result in allegations of abuse and injuries of unknown origin not being investigated and abuse/neglect occurring in the facility.

Inspectors wroteBased on clinical record review, staff interviews and facility policy and procedures, the facility failed to revise and update care plans to include non-pharmacological interventions for psychotropic medications for three residents (#52, #5, #24). The deficient practice could result in resident needs not being met.

Inspectors wroteBased on observation, staff interviews, and review of policy, the facility failed to ensure that professional standards of practice were followed during medication administration when staff left medications at the bedside unattended and did not assure that the resident (#10) took an inhaled medication according to physician's orders, that medications are not left unattended on the medication cart, and a medication was left unlocked and unattended. The deficient practice could result in residents not receiving the prescribed dose of medication and resident's having access to unprescribed medications.

Inspectors wroteBased on staff interviews and facility documentation, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Inspectors wroteBased on observations, staff interviews, and review of policy and procedures, the facility failed to ensure infection control standards were maintained regarding hand hygiene. The deficient practice could result in transmission of infection.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policies and procedures, the facility failed to ensure two residents (#220, #221) were not neglected resulting in injury of unknown origin. The deficient practice could result in residents suffering from preventable injuries due to neglect.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure an order for hospice was obtained for one resident #54. The resident census was 68, and the sample was 17. The deficient practice could result in residents not receiving the treatment and care based on their needs. Resident #54 was re-admitted on [DATE] with diagnoses that included major depressive disorder, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, and dementia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident received hospice as a resident. Review of a Hospice notes dated March 20, 2023 that revealed the resident was transferred to the facility. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure appropriate services for mental or psychological difficulty for one resident (#60).

Inspectors wroteBased on observations, staff interviews, review of records, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for one resident (#31). The medication error rate was 10%. The deficient practice could result in further medication errors.

Inspectors wroteBased on observations, interviews and policy review the facility failed to ensure the carrots served during lunch were warm and palatable. This deficient practice has the potential for residents who disliked a meal to experience dissatisfaction with their meals or to experience a nutritional problem. While on steam table, the temperature of the foods prepared for lunch was measured with registered dietician (staff #68) On June 7, 2023 11:18 AM for the following foods: pot roast was 157 degrees, potatoes was 150 degrees, sautéed carrots was 148 degrees, gravy was 150 degrees and mechanical soft potatoes were 160 degrees. At 11:32 AM the temperature of mechanical soft meat was 142 degrees. A test tray was prepared for survey team on June 7, 2023. At 12:38 AM trays were passed by various staff members until reaching the room farthest away from the kitchen. [...]

Inspectors wroteBased on resident and staff interviews, observation, the facility assessment, facility documentation, and review of policy and procedure, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. The deficient practice resulted in resident needs not being met and/or not being met timely.

Inspectors wroteBased on facility documentation, staff interviews, the glucometer manual, and facility documentation, the facility failed to ensure that quality control testing was consistently completed on the glucometers. The deficient practice could result in not being aware of glucometers that were not functioning properly and therefore providing inaccurate blood glucose level results for residents.

Inspectors wroteBased on observations, clinical record review, facility documents, resident and staff interviews, and policy reviews, the facility failed to ensure that unit freezer temperatures were monitored and adaptive equipment was cleaned in a sanitary manner for one resident (#1). The deficient practice has the potential to cause foodborne illness.

Inspectors wroteBased on observations, facility documentation, staff interviews, and review of the Centers for Disease Control (CDC) guidelines and facility policy, the facility failed to ensure staff donned required Personal Protective Equipment (PPE) upon entering resident rooms on Transmission-Based Precautions (TBP), that staff donned the required PPE during conducting Covid-19 testing, and that staff completed the screening process prior to beginning their shift. The deficient practice could result in the spread of infection to residents and staff.

Inspectors wroteBased on facility documentation, staff interviews, and review of policy and procedures, the facility failed to implement their policy to ensure that 2 employees had received at least one dose of COVID-19 vaccine, after having been granted a temporary delay, and that one employee received a second of COVID-19 vaccine. The deficient practice may result in further staff not being vaccinated for COVID-19.

Inspectors wroteBased on clinical record reviews, staff interviews, and review of facility policy, the facility failed to ensure two residents (#36 and #34) were informed in advance of the risks and benefits of proposed treatment with psychotropic medications. The sample size was 5. The deficient practice could result in residents receiving high risk medications without education, their knowledge, or consent.

Inspectors wroteBased on clinical record review, facility documentation, staff and responsible party interviews, and review of policy and procedure, the facility failed to ensure that one sampled resident (#58) was free from staff to resident abuse. The deficient practice could result in further resident abuse.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that the risks and benefits were explained prior to the use of bedrails, and that the use of bedrails was ordered and monitored appropriately for one sampled resident (#58). The deficient practice may result in improper use of bedrails.

Inspectors wroteBased on facility documentation, clinical record review, staff interviews, and review of policy, the facility failed to implement their policy regarding reporting an allegation of abuse for one sampled resident (#58). The deficient practice could result in further abuse allegations not being reported in a timely manner.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, the State Survey Agency database, and review of policy and procedures, the facility failed to ensure an allegation of staff to resident abuse was reported in the required timeframe to the State Agency for one sampled resident (#58). The deficient practice could result in further allegations of abuse not being reported as required.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to prevent further potential abuse, by failing to remove a staff member from providing direct care to residents regarding an allegation of abuse for one sampled resident (#58), and failed to submit the results of the facility investigation regarding the abuse to the State Survey Agency. The deficient practice could result in further abuse and results of investigations not being sent to the State Agency within the required timeframe.

Inspectors wroteBased on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for one resident (#58). The sample size was 21. The deficient practice could result in residents' MDS assessments not being accurate.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure one resident (#53) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The sample size was 2. The deficient practice could result in necessary specialized services not being provided for residents who need it.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedures, the facility failed to develop a comprehensive person-centered care plan for one resident (#23) to include risk for pressure ulcer formation. The sample size was 21. The deficient practice could result in a plan of care that did not meet the resident's needs.

Inspectors wroteBased on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure the comprehensive care plan was revised to include skin breakdown for one resident (#23). The sample size was 21. The deficient practice could result in inaccurate/incomplete plans of care for residents.

Inspectors wroteBased on observation, clinical record reviews, staff interviews, and review of facility policy and procedures, the facility failed to ensure resident rights were followed during medication administration regarding two residents (#49 and #32). The deficient practice could result in adverse effects and residents receiving unnecessary medications.

Inspectors wroteBased on observation, clinical record review, facility documents, staff interviews, and policy review, the facility failed to provide one sampled resident (#1) the necessary services to maintain good grooming and personal hygiene. The deficient practice could result in residents' hygiene needs not being met.

Inspectors wroteBased on observation, clinical record review, facility documents, staff interviews, and policy review, the facility failed to provide an ongoing program of activities for one sampled resident (#24). The deficient practice could result in residents not being provided activities.

Inspectors wroteBased on clinical record review, observation, staff interviews and review of policy and procedure, the facility failed to ensure that one sampled resident (#23) received the necessary care and services to prevent pressure ulcers and to treat acquired pressure ulcers. The deficient practice could result in formation or worsening of pressure ulcers.

Inspectors wroteBased on the clinical record review, staff interviews and policy reviews, the facility failed to ensure one resident (#20) weight was obtained as ordered. The sample size was 2. The deficient practice could result in residents with unplanned weight loss.

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility policy and procedures, the facility failed to ensure two residents (#32 and #34) were provided pain management consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. The sample size was 6. The deficient practice could result in residents' pain not being managed.

Inspectors wroteBased on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#36) was free of unnecessary drugs, by failing to administer medications according to parameters as ordered by the physician. The sample size was 5. The deficient practice could result in residents receiving unnecessary medications.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#34) was free of an unnecessary medication, by failing to ensure the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for a psychotic medication. The sample size was 5. The deficient practice could result in residents receiving medications that are not necessary.

Inspectors wroteBased on observations, review of the clinical records, staff interviews and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered to two residents (#56 and #12). The error rate was 7.69%. The deficient practice could result in further medication errors.

Inspectors wroteBased on personnel file reviews, staff interviews, and policy review, the facility failed to provide evidence that 1 out 10 sampled staff (#27) was provided training for abuse, neglect, and exploitation as per their policy. The deficient practice could result in staff not being knowledgeable of how to prevent, identify, investigate, and report allegations of abuse.