The Center at Tucson

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure that a care plan related to food preference for one resident (#17) was implemented. The deficient practice could place resident at risk for malnutrition.

Inspectors wroteBased on clinical record review, resident and staff interviews and facility policy review, the facility failed to ensure that the preference for a gluten free diet for one resident (#17) was honored. The deficient practice could result in resident's food preferences not accommodated and places the resident at risk for nutritional complications.

Inspectors wroteBased on review of facility documentation, State Agency (SA) Licensing database, and staff interview, the facility failed to ensure written notification of a change in administrator was made to the SA at the time of the change. The deficient practice could result in inaccurate contact information in the SA licensing database.

Inspectors wroteBased on clinical record review and facility documentation, family/staff interviews and policy and procedure, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for one resident (#84).

Inspectors wroteBased on clinical record reviews, facility documentation, staff interviews, family interview and policy and procedures, the facility failed to ensure that allegations of misappropriation of resident property were reported to the State Agency and that the results of the investigations were submitted to the State Agency within the required time frame for one resident (#84).

Inspectors wrote-Resident #70 was admitted to the facility on [DATE] with diagnoses of arteriovenous malformation of the digestive system vessel, gastrointestinal hemorrhage, and cognitive communication deficit. A physician's order dated January 7, 2022 included for Apixaban (Anticoagulant) Tablet 5 mg, Give 5 mg by mouth two times a day for coronary artery disease. A Care Plan dated January 7, 2022 included the resident is at risk for bleeding related to the use of anticoagulant/blood thinner medication. Interventions included administering blood thinner per physician orders and monitoring frequently for signs and symptoms of bleeding (extensive bruising, tarry stools, bloody stools, bloody urine, nose bleed, bleeding gums, etc.). A physician's order dated January 10, 2022 included for Anticoagulation Medication Monitoring: [...]

Inspectors wrote-A breakfast dining observation was conducted on February 1, 2022 at 8:38 a.m. on the second-floor hallway. A Certified Nursing Assistant (CNA/staff #18) was observed pouring coffee and juices from the meal cart parked in front of a room located near the nurses' station. Staff #18 was observed to place the uncovered beverages on the meal tray, walk the entire length of the hallway, enter a resident's room and serve the tray to the resident. -Additional dining observations were conducted on February 1 and 8, 2022 between 8:30 a.m. and 8:45 a.m. on the 200 hallways at breakfast. Several staff who were helping to serve the breakfast trays were observed to pour milk, orange juice, coffee, apple juice and cranberry juice from the meal cart parked in front of one resident's room, and deliver the uncovered beverages on the tray to residents' rooms located at the end of the hall. [...]

Inspectors wroteBased on observations, staff interviews, facility documentation, and review of policies and procedures, the facility failed to ensure that one staff (#14) and one vendor (#1) were consistently screened for COVID-19 upon entry to the facility, and that one staff (#52) performed appropriate hand hygiene during wound care. The deficient practice could result in the spread of infection.

Inspectors wroteBased on observations, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#13) was treated with dignity and respect. The sample size was 3. The deficient practice could result in residents not being treated with dignity and respect.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was notified as ordered when one resident's (#39) blood sugar level was outside parameters. The sample size was 5. The deficient practice could result in delayed medical care.

Inspectors wroteBased on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one of two sampled residents (#129) was reported to the State Agency. The deficient practice could result in allegations of abuse not being reported as required.

Inspectors wroteBased on clinical record review, staff interviews, review of policy and procedure and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two residents (#138 and #81). The sample size was 24. The deficient practice could result in additional MDS assessments that do not accurately reflect residents' status and could result in data that is not accurate for quality monitoring.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#24) was provided incontinence care in accordance with professional standards of practice. The sample size was 3. The deficient practice could result in residents' not receiving incontinence care timely.

Inspectors wroteBased on observations, clinical record review, resident, family member and staff interviews, and policy and procedure, the facility failed to ensure one resident (#24) consistently received appropriate treatment and care as ordered by the physician for edema control. The sample size was 2. The deficient practice could result in residents with edema not being provided treatment and services ordered by the physician.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure timely assessments and consistent treatments were provided to one resident (#56) with pressure ulcers. The sample size was 2. The deficient practice could result in worsening of pressure ulcers.

Inspectors wroteBased on clinical record review, resident family and staff interviews, and policy and procedure, the facility failed to ensure one resident (#38) received the necessary assessments related to urinary catheters to restore bladder continence. The sample size was 4. The deficient practice could result in possible urinary complications and bladder continence not being restored.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure interventions were implemented timely for one resident (#77) with malnutrition and weight loss. The sample size was 4. The deficient practice places residents at risk for nutritional decline.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure that one resident (#70) was assessed for pain in accordance with the physician's orders. The sample size was 5. The deficient practice could result in residents' pain not being assessed.

Inspectors wroteBased on clinical record review, resident and staff interviews, and review of policy and procedure, the facility failed to ensure that an antibiotic medication was obtained and available timely for one sampled resident (#132). The deficient practice could result in medications not being available for residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure consistent monitoring was conducted for one resident (#70) receiving a psychotropic medication. The sample size was 5. The deficient practice could result in residents receiving psychotropic medications not being monitored for side effects and effectiveness.

Inspectors wroteBased on clinical record review, staff interviews, observation, and policy review, the facility failed to ensure that one sampled resident's food preferences were honored (#70). The deficient practice could result in residents' food preferences not being honored.

Inspectors wroteBased on facility documentation, interviews, and policies, the facility failed to inform two residents/representatives (#74 and #7) that a resident had tested positive for COVID-19 within the required time frame and failed to provide evidence other residents and their families/representatives were informed. The deficient practice could result in residents and their families/representatives not being aware of new COVID-19 cases in the facility and the actions implemented to reduce the risk of transmission.