Sante of North Scottsdale

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews, the facility failed to ensure that adequate supervision and interventions were provided to one resident (#2) to prevent elopement from the facility. The deficient practice resulted in one resident leaving the building without notice, and could result in other residents going missing and/or getting injured.

Inspectors wroteBased on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that resident (#22) was given a safe place to store valuable personal belongings and personal/medical information for safe keeping in her room to prevent personal property from being misappropriated. The deficient practice could result in residents' property being misappropriated.

Inspectors wroteBased on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to complete a thorough investigation regarding an allegation of misappropriation for one resident (#22). The deficient practice could result in the misappropriation of the residents' property.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#2) received treatment and care in accordance with professional standards of practice regarding anticoagulant therapy. The deficient practice could lead to risk of bleeding in residents on anticoagulant therapy.

Inspectors wroteBased on clinical record review, interviews, and policy review, the facility failed to ensure medications were administered as ordered for two of 17 sampled residents (#272 and #277). The deficient practice could result in resident not receiving the required treatment they need. The facility census was 69.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that opioid medication orders for two residents (Resident #4 and #38) were administered following the physician ordered parameters. The deficient practice could result in inaccurate administration of opioid medication, with the potential of over medicating resident's with opioid medication.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure target behaviors, side effects and effectiveness related to psychotropic medications were monitored for three residents (#42, #1 and #23). The sample size was 6. The deficient practice could result in complications.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to follow infection control standards on enhanced barrier precautions (EBP) for 3 of 3 sampled residents (#23, #26, and #24). The deficient practice could lead to spread of infections.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one Resident # 42 was informed of the risks and benefits related to use of psychotropic medication for one resident (#42). The deficient practice could result in residents not having the choice to refuse proposed treatment plans as well as to be informed of potential adverse side effects of receiving psychotropic medications.

Inspectors wroteBased on observations, clinical record review, interviews, and facility policy review, the facility failed to ensure that communication deficit was addressed with interventions to accommodate needs and abilities for one resident (#327) . The sample size was one of one. The deficient practice could result in a care plan that did not meet the resident's needs. Findings Include: Resident #327 was admitted on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis affecting the right side, and encephalopathy. The hospital speech therapy note dated August 27, 2024 revealed that the resident had impaired cognition, dysphagia (swallowing disorder), and dysarthria (speech disorder); and that, the resident had moderate dysarthria impacting overall intelligibility at conversational level. [...]

Inspectors wroteBased on observations, clinical record review, interviews, and facility policy review, the facility failed to ensure that one resident's (#327) communication deficit was addressed in the baseline care plan. The sample size was one of one. The deficient practice could result in a care plan that did not meet the resident's needs. Findings Include: Resident #327 was admitted on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis affecting the right side, and encephalopathy. The hospital speech therapy note dated August 27, 2024 revealed that the resident had impaired cognition, dysphagia (swallowing disorder), and dysarthria (speech disorder); and that, the resident had moderate dysarthria impacting overall intelligibility at conversational level. Strategies included were for the resident to slow rate of speech and over-articulate sound to improve intelligibility. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure treatment cart was not left unlocked and unsupervised; and, failed to ensure there were no expired medications readily available for resident use in the treatment cart. The deficient practice could result in the potential for unauthorized non-medical trained individuals to have access to treatment medications with risk of misusage and related risk of allergic reactions.

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility documentation and policy review, the facility failed to ensure oxygen therapy was safely monitored for one resident (#3). The deficient practice could result in high carbon dioxide content in the resident's blood that can lead to respiratory acidosis or death.

Inspectors wroteBased on observations, staff interviews, and facility policy and procedures, the facility failed to ensure that three staff (#118, #200, and #203) maintained infection control standards prior to entering and exiting a resident's room on isolation precautions. The deficient practice could result in the spread of COVID-19 infection.

Inspectors wroteBased on clinical record review, staff interviews, and policy reviews, the facility failed to ensure that a baseline care plan regarding pain management was developed for one resident (#311). The sample size was 5. The deficient practice could result in baseline care plans not addressing residents' pain.

Inspectors wroteBased on staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#161) weight was obtained and adequately monitored. The sample size was 4 residents. The deficient practice could result in delayed identification of residents with weight loss.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#311) received pain management services consistent with professional standards of practice. The sample size was 5. The deficient practice could result in unmanaged pain for residents.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that services met professional standards of practice regarding medication administration resulting in a significant medication error for one sampled resident (#50). The deficient practice resulted in the resident receiving another resident's medication.