Sabino Canyon Rehabilitation & Care Center

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure the advanced directive/code status for 1 resident (#133) out of 135 residents was recorded in the medical record in a timely manner. The deficient practice could result in residents not receiving services according to their wishes.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to execute and document the transfer/discharge process in accordance with the regulation and facility policy for 1 of 21 sampled residents (#3). The deficient practice could result in incomplete and inaccurate medical records for residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that the discharge Minimum Data Set (MDS) assessment was completed and accurate for 1 of 21 sampled residents (#3). The deficient practice could result in incomplete and inaccurate medical records for residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that resident medical records were completed accurately for two of two residents (#19 & #42) regarding Minimum Data Set (MDS) assessment and pain medication administration record. The universe was 104. The deficient practice could result in incomplete documentation in resident medical records.

Inspectors wroteBased on observations, staff interviews, and a review of facility policy and procedures, the facility failed to ensure that infection control standards were maintained when using reusable medical equipment to obtain resident vital signs and that enhanced barrier precautions were followed. The deficient practices could result in the spread of infection to residents.

Inspectors wroteBased on clinical record reviews, interviews, and review of facility policies, the facility failed to ensure a discharge summary was completed for one resident (#64). The deficient practice could result in an unsafe discharge for residents.

Inspectors wroteBased on clinical record reviews, interviews, and review of facility policies, the facility failed to ensure that a resident's discharge rights were honored during a discharge appeal. The sample size was 3. The deficient practice could result in the resident not being able to receive services to support their recovery.

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in life-threatening injuries.

Inspectors wroteThe facility failed to ensure a durable medical equipment (DME), wheelchair, in compliance with a provider's order was provided upon discharge to meet one resident's (#11) basic need for safe discharge. The deficient practice could place residents not meeting their highest practical level of medical, physical and psychosocial well-being while at home. Based on closed record review, staff interviews, review of facility's documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a durable medical equipment (DME), wheelchair, in compliance with a provider's order was provided upon discharge to meet one resident's (#11) basic need for safe discharge. The deficient practice could place residents not meeting their highest practical level of medical, physical and psychosocial well-being while at home.

Inspectors wrote4. -Resident #243 was admitted to the facility on [DATE] with diagnoses of muscle weakness, difficulty walking, major depressive disorder, and morbid obesity. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident was moderately cognitively impaired. An interview was conducted with resident #243 on August 22, 2023 in the room and the resident stated the water leaking from the ceiling by the bathroom door started yesterday, August 21, 2023. The resident stated she did not remember the name of the staff person she spoke with about the leak. The resident stated when she asked the staff member what they were gonna do about the leak, the staff said they could not do anything at the moment. [...]

Inspectors wroteBased on resident and staff interviews, review of clinical records and facility policies, and observations of current practice, the facility failed to ensure that one resident (#23) out of 19 sampled, received adequate supervision to prevent medication accidents. The deficient practice could result in the resident sustaining medication accident-related injuries.

Inspectors wroteBased on observations, staff interviews and facility policy, the facility failed to ensure that a safe and sanitary kitchen environment was followed in regards to a dry storage scoop and proper drying techniques.

Inspectors wroteBased on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure one resident (#35) was consistently provided the necessary treatment and services to promote the healing of pressure ulcers. The sample size was 2 residents. The deficient practice could result in delayed healing of pressure ulcers.

Inspectors wroteBased on observations, staff interviews, manufacturer instructions, and review of policy, the facility failed to ensure appropriate infection control protocol was followed during point-of-care glucose testing. The deficient practice increases the risk for transmission of infectious disease and/or bloodborne pathogens.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure prompt efforts were made to resolve one sampled resident's (#205) grievance about missing clothing. The deficient practice could result in resident grievances not being resolved promptly.

Inspectors wroteBased on clinical record review, staff interview, facility documentation, and policy reviews, the facility failed to ensure services met professional standards of quality regarding medication administration for one resident (#205). The sample size was 5. The deficient practice could result in residents not receiving physician ordered medications.

Inspectors wroteBased on staff interviews, clinical record review, and review of policy and procedures, the facility failed to ensure one resident (#35) was not administered unnecessary medications, by failing to ensure medications were administered in accordance with physician orders. The sample size was 5 residents. The deficient practice increases the risk for residents to receive medications that may not be necessary.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy and procedure, the facility failed to ensure that advanced directives were available and correct for 2 residents (#156 & #164). The sample size was 7. The deficient practice could result in residents receiving services not in accordance with their wishes.