Sandstone of Tucson Rehab Centre

Based on document reviews and interviews, failed to maintain, review, and update the Emergency Preparedness (EP) Plan annually. Failure to develop an emergency plan may cause harm to the patients and staff during an emergency and failure to ensure the EP plan was reviewed annually poses a potential risk that all required revisions to the plan will not be recognized and revised as needed.

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, 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 staff and residents.

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 38 of the 116 residents plus staff in the event of a fire. Â

Based on observation, it was determined that the facility failed to properly fill penetrations of the fire/smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the fire/ smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients and staff in the affected area at the time of a fire.

Based on observation, the facility failed to provide a protective guard on light bulbs located throughout the facility. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.Â

The facility failed to ensure an allegation of abuse for one resident (#4) was reported to the State Agency (SA) within the timeframe established by regulations. The deficient practice could lead to continued abuse of residents.

Based on review of the clinical record, interviews, and review of the facility’s policies and procedures, the facility failed to protect the rights of one resident (#6) to be free from abuse from another resident (#9). The deficient practice could lead to sustaining injuries.

The facility failed to ensure a signed consent was obtained before starting a new psychotropic medication for one resident, #4. The deficient practice could lead to a resident’s responsible party not being informed of the risk and benefits of a resident's medications.Â

The facility failed to ensure an allegation of abuse for one resident (#4) was reported to the State Agency (SA) within the timeframe established by regulations. The deficient practice could lead to continued abuse of residents.

Based on review of the clinical record, interviews, and review of the facility’s policies and procedures, the facility failed to protect the rights of one resident (#6) to be free from abuse from another resident (#9). The deficient practice could lead to sustaining injuries.

The facility failed to ensure a signed consent was obtained before starting a new psychotropic medication for one resident, #4. The deficient practice could lead to a resident’s responsible party not being informed of the risk and benefits of a resident's medications.Â

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to maintain documentation that an alleged violation related to the allegation of financial misappropriation of property for one resident (#333) by another resident (#91) was thoroughly investigated.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect one resident (#511) rights in a manner that promotes enhancement of the resident’s quality of life by having her own cell phone to access persons and services outside the facility. The deficient practice could lead to residents’ rights being violated.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#911) to be free from physical abuse by another resident. The deficient practice could result in further abuse of residents and appropriate action not taken.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#333) to be free from financial misappropriation/exploitation of resident property by another resident (#111). The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to maintain documentation that an alleged violation related to the allegation of financial misappropriation of property for one resident (#333) by another resident (#111) was thoroughly investigated. The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#191), which provides instructions to meet the resident’s immediate needs. The deficient practice could result in resident's treatments and needs not appropriately addressed.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to review and revised the care plan for one resident (#191) after each fall incident. The deficient practice could place the resident at risk for more falls.

 Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to identify elopement risks, and plan for effective supervision for resident one of three sampled residents (#888) related to risk factors for cognitively intact residents, and to ensure that one resident (#511) was supervised during activity sessions, and that activities were conducted safely. The deficient practice could result in avoidable accidents.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#191), which provides instructions to meet the resident’s immediate needs.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#911) was not subjected to physical abuse by another resident. Â

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#333) to be free from financial misappropriation/exploitation of resident property by another resident (#111). Â

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect one resident (#511) rights in a manner that promotes enhancement of the resident’s quality of life by having her own cell phone to access persons and services outside the facility.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to review and revised the care plan for one resident (#191) after each fall incident.Â

Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to identify elopement risks, and plan for effective supervision for resident one of three sampled residents (#888) related to risk factors for cognitively intact residents, and to ensure that one resident (#511) was supervised during activity sessions, and that activities were conducted safely.Â

Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the resident’s (#10) rights to be free from abuse by another resident (#5). This deficient practice could result in further incidents of resident to resident abuse. Â

Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the resident’s (#10) rights to be free from abuse by another resident (#5). Â

Based on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect The rights of one resident (# 07) to be free from verbal and physical abuse by another resident (#33).  This deficient practice has the potential to violate the resident’s right to safety and prevent further harm. The sample size was 5. The facility census was 122.   Â

Based on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect The rights of one resident (# 07) to be free from verbal and physical abuse by another resident (#33).  This deficient practice has the potential to violate the resident’s right to safety and prevent further harm. The sample size was 5. The facility census was 122. Â

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the rights of 2 of 8 sampled residents (Resident #2 and #6) to be free from abuse by another resident (Resident # 1 and #5). The deficient practice could result in other residents being abused.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the rights of 2 of 8 sampled residents (Resident #2 and #6) to be free from abuse by another resident (Resident # 1 and #5). The deficient practice could result in other residents being abused.

Based on clinical record review, resident and staff interviews, and review of policy, the facility failed to protect the rights of four residents (#25, #23, #49, #51) to be free from abuse by other residents (#20, #33, #45). The deficient practice could result in the facility failing to provide sufficient protection to prevent resident to resident abuse.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure appropriate interventions were implemented in accordance with professional standards.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff.  This deficient practice could result in further incidents of resident to resident abuse.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff. This deficient practice could result in further incidents of resident to resident abuse.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff.  This deficient practice could result in further incidents of resident to resident abuse.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure appropriate interventions were implemented in accordance with professional standards. This deficient practice could result in further injury.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff. Â