Center at Tucson, LLC

Based 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. Findings include: Review of the list of current facility staff revealed that staff #114 was listed as the Administrator. A copy of an email confirmation dated February 2, 2024 from the State nursing care institution administrator (NCIA) board revealed that they received the administrator's notice of appointment. The personnel file for the administrator revealed a hire date of February 25, 2024. A review of the monthly quality assurance meeting sign sheets from January through June 2024 revealed that the staff #114 signed in as the administrator. Review of the SA licensing database revealed that the administrator (staff #114) was not the administrator on record. An interview was conducted on August 16, 2024 at 11:14 a.m. with the administrator (staff #114) who stated that she became the administrator of the facility on February 25, 2024; and that, a notification regarding an administrator change was made to the State NCIA board. However, the administrator was not able to say whether a notification was made to the SA as well. Further, the administrator stated that the expectation was that a notification of the Administrator change was to happen within 30 days of the change; and, if that did not take place, she would be at risk of losing her license and the facility would be out of compliance.

Based 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. Findings include: Resident #17 was admitted July 13, 2024 with diagnoses of fractured right femur with closed fracture with routine healing, type 2 diabetes mellitus, and cognitive communication deficit. The physician order dated July 13, 2024 included for a diet order of regular diet, regular texture and thin consistency. The social history note dated July 15, 2024 included that the resident appeared to be alert, oriented to person, place, time and situation. The nutrition assessment dated July 15, 2024 revealed the resident followed a gluten free diet. The nutrition care plan dated July 19, 2024 included the resident had a potential and/or was at risk for inability to maintain nutrition. Interventions included resident food preferences, food selections, portion sizes honored via selective menu per resident request and to provide food in a form that is acceptable and culturally acceptable. An admission Minimum Data Set (MDS) assessment dated July 20, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS assessment did not code for any nutritional approaches; and, nutritional status did not trigger for care planning. The social services progress note dated July 25, 2024 included the resident had a BIMS score of 15 indicating the resident had intact cognition. A late entry physician progress note dated July 25, 2024 included the resident was alert and oriented. Plan was to maximize nutrition and mobility. The diet roster by wing dated August 15, 2024 revealed that resident #17 had regular diet and regular texture. Despite documentation of a gluten-free diet preference, the clinical record revealed no evidence that this diet preference was implemented. During an interview conducted on August 14, 2024 at 9:41 a.m. resident #17 stated that he was gluten free but would pasta and bread. he resident stated that the facility should have gluten free food. An interview was conducted on August 15, 2024 at 2:15 p.m. with the kitchen manager (staff #56) who stated that they have the diet order from the speech therapist or the hospital printed out. from their dietary printer. He stated that the dietician evaluates the residents' preferences and allergies, sends the information to the kitchen printer and it gets printed to their diet roster, which was a sheet of paper that tells him the residents' food textures, allergies, preferences, and dislikes. In an interview with the registered dietician (RD/staff #400) conducted on August 15, 2024 at 2:23 p.m., the RD that the residents are interviewed for food preferences by their dietary technicians who would then communicate this to the dietary staff/department and the RD. She stated that the MNA or nutritional assessment was followed up by the

Based 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. Findings include: Resident #17 was admitted July 13, 2024 with diagnoses of fractured right femur with closed fracture with routine healing, type 2 diabetes mellitus, and cognitive communication deficit. The physician order dated July 13, 2024 included for a diet order of regular diet, regular texture and thin consistency. The nutrition assessment dated July 15, 2024 revealed the resident followed a gluten free diet. Review of the clinical record revealed no evidence of a physician order for a gluten-free diet for resident #17. The nutrition care plan dated July 19, 2024 included the resident had a potential and/or was at risk for inability to maintain nutrition. Interventions included resident food preferences, food selections, portion sizes honored via selective menu per resident request and to provide food in a form that is acceptable and culturally acceptable. An admission Minimum Data Set (MDS) assessment dated July 20, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS assessment did not code for any nutritional approaches; and, nutritional status did not trigger for care planning. The social services progress note dated July 25, 2024 included the resident had a BIMS score of 15 indicating the resident had intact cognition. A late entry physician progress note dated July 25, 2024 included the resident was alert and oriented. Plan was to maximize nutrition and mobility. Review of the diet roster by wing dated August 15, 2024 revealed that resident #17 had regular diet and regular texture. During an interview conducted on August 14, 2024 at 9:41 a.m. resident #17 stated that he was gluten free but would pasta and bread. he resident stated that the facility should have gluten free food. An interview was conducted on August 15, 2024 at 11:00 a.m. with cook (staff #93) who stated that if a resident had a preference or was on a gluten free diet, this will be honored. The cook stated that in order to honor the resident's preference, the kitchen staff must be made aware by either the nursing staff or the RD (Registered Dietitian). The cook stated that the dietician evaluates the resident's preferences and allergies; and, this information is then sent to the kitchen and it gets printed out to the kitchen's diet roster, which is a sheet of paper that tells him their residents' food textures, allergies, preferences, and dislikes. An interview was conducted on August 15, 2024 at 2:47 pm with registered nurse (RN/staff #401) who stated that the appropriate diet order or information for a new resident was taken from the hospital verbal report, discharge orders, packet received from the hospital and from the speech therapist. The RN stated that resident preferences and/or allergies were