Life Care Center of Paradise Valley

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on a review of the facility's Emergency Preparedness Plan, record review, and staff interviews, it was determined that the facility failed to participate in required emergency drills. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency.Â

Based on observation, it was determined that the facility failed to maintain the sprinkler heads and ensure that all parts of the sprinkler system were in accordance with the UL Listing. Failing to maintain sprinkler heads and damaged/missing escutcheon plates, which are part of the U.L. Listing of the sprinkler assembly, could allow heat and smoke to affect other areas of the building. This could cause harm to the patients.

Based on observation and staff interviews, the facility failed to ensure that the electrical breaker for the fire alarm system has visual markings to distinguish it from other breakers. Failure to properly identify/mark the fire alarm system could lead to harm of residents and staff in an emergency.

Based on observation, the facility failed to maintain a special locking exit door located on the 2nd floor of the facility. Failing to provide manual release of the exit doors could cause harm to patients and/or staff in an emergency

Based on observation and interview, the facility failed to provide corridor doors in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.6, 19.3.6.3, and 19.3.6.3.10. This deficient practice could affect approximately 14 of the 110 residents.Â

Based on observation, it was determined that the facility failed to fill penetrations in multiple smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to all residents and staff in the event of a fire.Â

Based on record review and staff interview, it was determined that the facility failed to ensure that their Emergency Preparedness plan incorporated documentation to include the emergency and standby power systems. Failure to implement the emergency and standby power systems plan during an emergency could lead to harm.