Osborn Health and Rehabilitation

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Smoke Deficiencies

Install an approved automatic sprinkler system.

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.

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

Ensure services provided by the nursing facility meet professional standards of quality.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Smoke Deficiencies

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

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Based on observation, the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer, which will cause harm to the patients and/or staff.

Based on observation and interview with staff, it was determined that the facility failed to provide a safe means of egress out of the emergency exit doors. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.Â

Based on observation, the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer, which will cause harm to the patients and/or staff.

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the Administrator failed to ensure that three residents (resident #272, #273, #369) were provided nursing services to assist in maintaining their highest practicable well-being. In regards to resident #272, findings include: Resident #272 was initially admitted on December 16, 2022 with diagnosis of Hypertension, Diabetes Mellitus, Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke, Hemiplegia or Hemiparesis, Schizophrenia. Resident #272 was discharged on December 30, 2023. A review of a quarterly Medicare Minimum Data Set (MDS) assessment dated April 16, 2024, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. A review of a progress note created on June 27, 2024 @ 2PM revealed Resident #272's involvement in the incident, indicating that the incident occurred. A review of the intake information for AZ00198684 revealed that the Facility Reported Incident (FRI) was submitted on June 27, 2024 at 3:36PM. This review revealed that Resident # 272 and Resident #273 exchanged verbal profanities to each other, indicating resident #272's involvement in the incident. A review of a progress note titled 'Change of Condition' created on June 28, 2023 at 1:04PM revealed that Resident #272 underwent daily monitoring for the next 30 days, following the verbal altercation, indicating that the incident occurred. An interview was conducted on October 9, 2024 at 1:21PM with the Director of Nursing (DON/Staff # 66), who stated the expectations and their understanding of the facilities abuse policy. Staff #66 identified abuse as, "any form of physical, emotional, verbal, sexual, misappropriation, seclusion and neglect.". Staff #66 then stated that the process of reporting and investigating allegations is to report to the Department of Health Services within 2 hours of notification, then they have 5 days to provide the investigation results back to the Department of Health Services, Staff #66 also reported that additional parties of notification include Adult Protective Services, law enforcement, the provider, and any families/Power of Attorney's. Staff #66 stated that the impact of abuse on the residents could include, "the overall psychosocial wellbeing of the resident". Staff #66 then stated that in regards to the incident that took place on July 27, 2023 between Resident #272 and Resident #273, that she could not re-call the incident and would need to review the full investigation notes provided by their predecessor. Staff #66 reported their conclusion of the full investigation notes, and stated that their immediate response was to separate the two residents, to put into effect 'Change of Condition' monitoring, and, to complete medication assessments and psychiatric evaluations for both Resident # 272 and Resident #273. Staff #66 reported that Resident # 272 and Resident #259 refused a room c

Based on observations, interviews, facility documentation, and review of facility policy, the facility failed to ensure appropriate treatment and services for activities of daily living were provided, according to residents' preferences and to meet residents' needs, for Residents #320 and #322. -Regarding Resident #320: Resident #320 was admitted into the facility on October 01, 2024, with diagnoses that included pigmentary retinal dystrophy, sepsis, urinary tract infection, pneumonia, and adult failure to thrive. Review of Resident #320's care plan dated October 01, 2024 revealed that the resident had a focus for an activities of daily living (ADL) self-care performance deficit, with an intervention in place for "1:1 assistance with meals: Resident is blind". A review of the resident's physician's orders revealed an order in place dated October 01, 2024, for "1:1 Assistance with meals; Resident is blind." Review of the Speech Therapy Evaluation and Plan of Treatment dated October 02, 2024 revealed that the "resident is legally blind" and that the resident requires supervision/ assistance 50-75% of the time at meal time due to swallowing safety. A review of the Brief Interview for Mental Status (BIMS) assessment that was completed on October 02, 2024, revealed Resident #320 had a score of 14, indicating intact cognition. Upon review of the progress notes, a Social Services Summary note dated October 04, 2024, revealed that Resident #320 eats meals with 1:1 staff assist in her room. A Weekly Clinical Interdisciplinary Team (IDT) Review note dated October 08, 2024, revealed nursing to provide assist with meals. A follow-up review of the resident's care plan revealed that the care plan had been adjusted. Under the focus of ADLs, the resident still had the intervention in place for "1:1 assistance with meals: Resident is blind". However, under the focus of "4.2% significant weight loss x 5 days", the resident had a new intervention dated October 09, 2024, that "Patient & family would like to encourage resident to eat independently prior to assist". Review of the resident's clinical record revealed there was no evidence of documentation in the progress notes prior to October 10, 2024, regarding updates to Resident #320's status of 1:1 assistance during mealtimes. A Therapy progress note dated October 10, 2024, revealed that "Patient status changed from 1:1 assist to set up for meal times. Patient is able to independently manage meals after set up. Husband prefers to feed wife when he is present mainly at lunch time as this is his daily routine in the home. Patient manages her daily routine with verbal cues". An observation was conducted on October 08, 2024 at 7:56 AM, of Resident #320 in her room. There was no signage outside the room or inside the room indicating that the resident was blind. An interview was conducted at this same time with the resident, who stated that "I don't have central vision, I'm not able to read" and "I can't see anything on

Based on observation, staff interviews, review of the manufacturer instructions and policy review, the facility failed to ensure that one medication in a medication cart was labeled, with an open date. Findings include: An observation of the medication administration was conducted with a Registered Nurse (RN/Staff #147) on October 9, 2024 at 4:23PM. Staff #147 was observed administering a Tuberculin PPD Step 2, which was not marked with an open date. An interview was conducted on October 9, 2024 at 4:30PM with staff #147, who stated that the Tuberculin PDD should have been dated when it was opened, and that this particular medication will have an expiration date of 28 days from opening. A review of the Center of Disease Control guidelines pertaining to 'Mantoux tuberculin skin test,' revealed the expectations to review vial labels to make sure that the vial contains the tuberculin that you wish to choose, and that the label should indicate the expiration date. Revealing that if a vial has been open more than 30 days, or the if the expiration date has passed, then the vial should be thrown away and a new vial should be used. With the expectation that the new vial is expected to reflect the open date and as well as the initials of the individual who opened the vial.

Based on observation and interviews, the facility failed to provide automatic sprinkler protection for the roof overhang at the southwest corner of the facility. This overhang is over four feet in width. Failing to provide automatic sprinklers to all areas of the facility could cause harm to residents and/or staff in time of a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater." (1.) NFPA 13, Standard for the Installation of Sprinkler Systems" NFPA 13, Section 8.15.7 Exterior roofs, Canopies, Porte-Cochers, Balconies, Decks or Similar Projections. Section 8.15.7.1 Unless the requirements of 8.15.7.2,8.15.7.3 , or 8.15.7.4 are met sprinklers shall be installed under exterior roofs, canopies,Porte-cocheres, balconies decks, or similar projections exceeding 4 ft in width. Findings include: Observations made while on tour on October 16, 2024, revealed that the roof overhang at the southwest corner of the building was not sprinklered. The overhang was greater than four feet in width and appeared to be constructed of combustible (wood) materials. Management staff acknowledged during the facility tour and exit conference on October 16, 2024, that the roof overhang at the southwest corner of the building was not sprinklered.