Sante of Chandler

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Assessment and Care Planning Deficiencies

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

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Based on observation and document review, the facility failed to ensure the patient corridors were in good working condition. Failing to maintain doors could cause harm to patients and/or staff during an emergency

Based on observation, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#269) was assessed to determine clinical appropriateness to self-administer medications. The deficient practice could result in medications not being taken as ordered. Findings include: Resident #269 was admitted to the facility on May 25, 2024 with diagnoses that included chronic respiratory failure with hypoxia, congestive heart failure and asthma. Review of the physician order summary revealed an order dated May 25, 2024 for albuterol sulfate HFA (hydrofluoroalkane) inhalation 2 inhalation inhale orally every 6 hours as needed for cough, azelastine HCL (hydrochloride) nasal solution 1 spray in both nostrils one time a day for allergies, Budesonide-Formoterol Fumarate Inhalation Aerosol 2 inhalation inhale orally two times a day for interstitial lung disease rinse mouth and throat after use, and Latanoprost Ophthalmic Solution 0.005% Instill 1 drop in both eyes one time a day for glaucoma. Further review of the physician order revealed no order for the resident to self-administer medications. During an observation on May 28, 2024 at 9:46 A.M. in resident #269's room, a light blueish inhaler and a nasal spray was observed on the resident's over the bedside table and an eye drop was observed on top of the round table in his room. There were no staff present. At 9:52 A.M. licensed practical nurse (LPN/staff #76) was asked to come in resident #269's room and he identified the items as an inhaler, nasal spray, and an eye drop. Review of clinical records revealed no documentation that the resident was assessed by the interdisciplinary team (IDT) as a candidate to self-administer. Review of the care plan revealed no evidence that self-administration of medication was part of resident's care planning. An interview was conducted on May 30, 2024 at 10:29 A.M. with LPN (staff #57). The LPN stated that when administering medications, she makes sure that it is the right patient, route, dose, and documentation. Further, the LPN stated that she does not leave the medications with the resident but instead observes the resident take the medication. The LPN said the reason for that was the patient might not take the medication or somebody might come and take it from the resident. The LPN said she could be written up if she left the medication with the resident. An interview was conducted on May 31, 2024 at 10:01 A.M. with the Director of Nursing (DON/staff #143). The DON stated that a doctor's note or order was required in order for residents to self-administer medication. In addition, the DON stated that the resident would require an assessment by a nurse to self-administer a medication and if they can the medications were locked up in the resident's room and the staff would hold the key. The DON further stated that medications are not supposed to be left at the bedside without a doctor's order or assessment. The potential risk for lea

Based on observations, interviews, and policy review, the facility failed to ensure that services met professional standards of practice during medication administration using a pill cutter. The deficient practice could result in cross-contamination of medications. Findings include: During an observation of medication administration on May 30, 2024 at 8:33 A.M. the licensed practical nurse (LPN/staff #3) was observed cutting the large pills she identified as hydralazine, vitamin C, and amlodipine using a white pill cutter. After breaking the pills, she returned the pill cutter in the top drawer of the medication cart without first cleaning it. An interview was conducted on May 30, 2024 at 9:14 A.M. with an LPN (staff #3). The LPN stated that there was only one pill cutter in the drawer and that she was not familiar with the process after using it to cut medications. An interview was conducted on May 30, 2024 at 9:19 A.M. with the Director of Nursing (DON/staff #143). The DON stated that to cut big pills, a pill cutter was used and the medication was given to the resident one at a time. She stated that there was a pill cutter in the medication cart. Further, the DON stated that after using the pill cutter to cut a medication the nurse had to wipe it with a tissue or clean it with bleach wipes before putting it back in the medication cart. In addition, the DON said that the risk for not cleaning the pill cutter was that medication left in the pill cutter can mix with other medications and possibly cause an interaction. The DON said her expectation was for staff to clean a pill cutter after each use.

Based on observation, interviews, and records review the facility failed to ensure 1 of 1 sampled resident (#57) received appropriate indwelling catheter care and treatment. The deficient practice could result in residents developing complications related to indwelling catheter. The findings include: Resident #57 was admitted to the facility on May 6, 2024 for diagnoses of fracture of sacrum, low back pain, chronic obstructive pulmonary disease, atrial fibrillation, and long-term use of anticoagulants. The admission Minimum Data Set (MDS) assessment dated May 12, 2024 revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment also coded the resident had an indwelling catheter. Review of the physician order dated May 11, 2024 revealed the following orders: -Catheter size 16 French/10 cubic centimeters balloon for diagnosis of retention/failed void trial -Catheter care as needed for catheter maintenance. -Catheter care every shift, every day and night shift for catheter maintenance. -Change catheter for dislodgement/clogging as needed for catheter maintenance. Review of the care plan for the use of an indwelling Foley catheter revealed the resident had an altered elimination related to urinary retention with failed voiding trial. Interventions included routine catheter care every shift and as needed. An observation of catheter care was conducted on May 30, 2024 at 1:13 P.M. with certified nursing assistant (CNA/staff #108). During the catheter care, the outside of the tube had a collection of a white substance, approximately 2 inches from the penile meatus. The CNA (staff #108) applied pressure to remove the white substance. The CNA used a clean white wash cloth with soap and water to cleanse the resident's penis and groin. After cleaning the resident, the used white wash cloth was slightly brown. After the catheter care, the resident asked the CNA to be repositioned. An interview was conducted on May 30, 2024 at approximately 1:30 P.M. with resident #57 after the catheter care observation. The resident stated that catheter care had not been completed prior to the observation nor was it done daily. An interview was conducted on May 30, 2024 at 1:31 P.M. with a CNA (staff #108) regarding the catheter care she completed. According to the CNA, based on the buildup on the catheter tubing and her observation of the resident's perineal area, the resident had not had catheter care today or within the last 12 hours. The CNA stated that the resident was at risk for urinary tract infection (UTI) if catheter care was not done daily. The CNA verified the resident's medical record and identified that no other CNAs had performed catheter care yet that morning. The physician order for catheter care every shift, every day and night shift for catheter maintenance was transcribed in the Treatment Administration Record and revealed that on May 30, 2024, catheter care had been documented as completed b

Based on observations, staff interviews, and policy review, the facility failed to ensure food was served in accordance with professional standards for food service safety. The deficient practice could result in foodborne illnesses. Findings include: During an observation for lunch preparation on May 30, 2024 at 11:46 A.M. dietary staff #59 was using a food thermometer to check the temperature of a chicken for a chicken sandwich while the sandwich was on top of a white cutting board. At 11:47 A.M. the staff left the thermometer on top of the white cutting board used to cut the chicken sandwich. At 11:51 A.M. another staff (#36) was observed entering the kitchen and proceeded to scoop soup from a pot using a ladle without performing hand hygiene. After scooping the soup, the staff (#36) then attempted to open a plastic bag before washing her hands in the kitchen sink then left the kitchen with the container of soup. At approximately 11:55 A.M. an interview was conducted with staff #36 and she stated that she should have washed her hands before she scooped the soup from the pot. During a continuous observation of lunch preparation, staff #144 was observed leaving the kitchen and walking towards the dining area while holding a Styrofoam container. At 12:07 P.M. staff #144 came back in the kitchen without performing hand hygiene and proceeded to the tray line where the food trays were lined up. Staff #144 then opened the refrigerator door and removed milk cartoons out of the refrigerator without performing hand hygiene. At 12:09 P.M. staff #144 then washed his hands. During a dining room observation on May 30, 2024 at 12:14 P.M. there was a small sink in the corner of the dining room with an empty soap and paper towel dispenser. An interview was conducted on May 30, 2024 at 1:16 P.M. with a cook (staff #115). He stated that the dining area did not have a sink for guests to wash their hands but that there were bathrooms. An interview was conducted on May 30, 2024 at 4:29 P.M. with certified nursing assistant (CNA/staff #87). She stated that the residents could wash their hands using the sink in the dining area in the mini corner, and residents were assisted with hand hygiene before going to the dining room area and leaving the dining room. She added that there was no hand sanitizer in the dining room. An interview was conducted on May 31, 2024 at 9:07 A.M. with Culinary Service Director (CSD/staff #144). He stated that they have different color-coded cutting boards and that everything was wiped down in the morning, and sanitized before starting work. The CSD stated that every staff must wash their hands before performing any kitchen duties. He added that staff washed their hands every time after they touch their face, touch paper that comes from the outside, and every time they touch any products to avoid cross-contamination. Further, the CSD said if the staff come into the kitchen, they must wear hairnet and wash their hands. When someone goes outsid

Based on observation, interviews, and records review the facility failed to ensure appropriate infection control practices were used during catheter care for one resident (#57). The deficient practice could result in the spread of multi-drug resistant organisms (MDROs) to residents. The findings include: Resident #57 was admitted to the facility on May 6, 2024 for diagnoses of fracture of sacrum, low back pain, chronic obstructive pulmonary disease, atrial fibrillation, and long-term use of anticoagulants. The admission Minimum Data Set (MDS) assessment dated May 12, 2024 revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment also coded the resident had an indwelling catheter. Review of the physician order dated May 11, 2024 revealed the following orders: -Catheter size 16 French/10 cubic centimeters balloon for diagnosis of retention/failed void trial -Catheter care as needed for catheter maintenance. -Catheter care every shift, every day and night shift for catheter maintenance. -Change catheter for dislodgement/clogging as needed for catheter maintenance. Review of the physician order dated May 29, 2024 revealed an order to maintain enhanced barrier precautions per facility policies and procedure; however, medical records reveal a Foley catheter was started on May 11, 2024 for resident #57. An observation was conducted on May 30, 2024 at 1:05 P.M., an enhanced barrier precaution (EBP) signage on the resident #57's door frame. An observation of catheter care was conducted on May 30, 2024 at 1:13 P.M. with certified nursing assistant (CNA/staff #108). During the catheter care the CNA's scrubs were touching the resident and the CNA was not wearing a gown. After the catheter care was completed the resident asked the CNA to be repositioned. The CNA (staff #108) left the room to get another CNA (staff #148) to assist with repositioning the resident. Both CNAs were not wearing a gown while repositioning the resident. An interview was conducted on May 30, 2024 at 1: 30 P.M. with a CNA (staff #148) who stated the sign on the door meant the resident was on precaution and that gown and gloves had to be work to protect staff from exposure to bodily fluids. The CNA stated that they should have worn a gown when repositioning the resident. An interview was conducted on May 30, 2024 at 1:31 P.M. with a CNA (staff #108) while standing outside of resident #57's room. The CNA stated that the signage on the door meant the resident was on EBP. The CNA stated that the sign meant a gown and gloves had to be work when residents had an IV (intravenous line), Foley catheter, or ostomy. The CNA added that she should have worn a gown when handling resident #57's Foley catheter. The CNA stated wearing a gown "protected him" (referring to the resident). The CNA stated that PPE (personal protective equipment) did not have to be worn to reposition the resident. An interview was conducted on May 30, 2024 a

-Regarding the Pill Cutter During an observation of medication administration on May 30, 2024 at 8:33 A.M. the licensed practical nurse (LPN/staff #3) was observed cutting the large pills she identified as hydralazine, vitamin C, and amlodipine using a white pill cutter. After breaking the pills, she returned the pill cutter in the top drawer of the medication cart without first cleaning it. An interview was conducted on May 30, 2024 at 9:14 A.M. with an LPN (staff #3). The LPN stated that there was only one pill cutter in the drawer and that she was not familiar with the process after using it to cut medications. An interview was conducted on May 30, 2024 at 9:19 A.M. with the Director of Nursing (DON/staff #143). The DON stated that to cut big pills, a pill cutter was used and the medication was given to the resident one at a time. She stated that there was a pill cutter in the medication cart. Further, the DON stated that after using the pill cutter to cut a medication the nurse had to wipe it with a tissue or clean it with bleach wipes before putting it back in the medication cart. In addition, the DON said that the risk for not cleaning the pill cutter was that medication left in the pill cutter can mix with other medications and possibly cause an interaction. The DON said her expectation was for staff to clean a pill cutter after each use.

Based on observation, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#269) was assessed to determine clinical appropriateness to self-administer medications. The deficient practice could result in medications not being taken as ordered. Findings include: Resident #269 was admitted to the facility on May 25, 2024 with diagnoses that included chronic respiratory failure with hypoxia, congestive heart failure and asthma. Review of the physician order summary revealed an order dated May 25, 2024 for albuterol sulfate HFA (hydrofluoroalkane) inhalation 2 inhalation inhale orally every 6 hours as needed for cough, azelastine HCL (hydrochloride) nasal solution 1 spray in both nostrils one time a day for allergies, Budesonide-Formoterol Fumarate Inhalation Aerosol 2 inhalation inhale orally two times a day for interstitial lung disease rinse mouth and throat after use, and Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes one time a day for glaucoma. Further review of the physician order revealed no order for the resident to self-administer medications. During an observation on May 28, 2024 at 9:46 A.M. in resident #269's room, a light blueish inhaler and a nasal spray was observed on the resident's over the bedside table and an eye drop was observed on top of the round table in his room. There were no staff present. At 9:52 A.M. licensed practical nurse (LPN/staff #76) was asked to come in resident #269's room and he identified the items as an inhaler, nasal spray, and an eye drop. Review of clinical records revealed no documentation that the resident was assessed by the interdisciplinary team (IDT) as a candidate to self-administer. Review of the care plan revealed no evidence that self-administration of medication was part of resident's care planning. An interview was conducted on May 30, 2024 at 10:29 A.M. with LPN (staff #57). The LPN stated that when administering medications, she makes sure that it is the right patient, route, dose, and documentation. Further, the LPN stated that she does not leave the medications with the resident but instead observes the resident take the medication. The LPN said the reason for that was the patient might not take the medication or somebody might come and take it from the resident. The LPN said she could be written up if she left the medication with the resident. An interview was conducted on May 31, 2024 at 10:01 A.M. with the Director of Nursing (DON/staff #143). The DON stated that a doctor's note or order was required in order for residents to self-administer medication. In addition, the DON stated that the resident would require an assessment by a nurse to self-administer a medication and if they can the medications were locked up in the resident's room and the staff would hold the key. The DON further stated that medications are not supposed to be left at the bedside without a doctor's order or assessment. The potential risk for lea

Based on observation, interviews, and records review the facility failed to ensure appropriate personal protective equipment were used during catheter care for one resident (#57). The findings include: Resident #57 was admitted to the facility on May 6, 2024 for diagnoses of fracture of sacrum, low back pain, chronic obstructive pulmonary disease, atrial fibrillation, and long-term use of anticoagulants. The admission Minimum Data Set (MDS) assessment dated May 12, 2024 revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment also coded the resident had an indwelling catheter. Review of the physician order dated May 11, 2024 revealed the following orders: -Catheter size 16 French/10 cubic centimeters balloon for diagnosis of retention/failed void trial -Catheter care as needed for catheter maintenance. -Catheter care every shift, every day and night shift for catheter maintenance. -Change catheter for dislodgement/clogging as needed for catheter maintenance. Review of the physician order dated May 29, 2024 revealed an order to maintain enhanced barrier precautions per facility policies and procedure; however, medical records reveal a Foley catheter was started on May 11, 2024 for resident #57. An observation was conducted on May 30, 2024 at 1:05 P.M., an enhanced barrier precaution (EBP) signage on the resident #57's door frame. An observation of catheter care was conducted on May 30, 2024 at 1:13 P.M. with certified nursing assistant (CNA/staff #108). During the catheter care the CNA's scrubs were touching the resident and the CNA was not wearing a gown. After the catheter care was completed the resident asked the CNA to be repositioned. The CNA (staff #108) left the room to get another CNA (staff #148) to assist with repositioning the resident. Both CNAs were not wearing a gown while repositioning the resident. An interview was conducted on May 30, 2024 at 1: 30 P.M. with a CNA (staff #148) who stated the sign on the door meant the resident was on precaution and that gown and gloves had to be work to protect staff from exposure to bodily fluids. The CNA stated that they should have worn a gown when repositioning the resident. An interview was conducted on May 30, 2024 at 1:31 P.M. with a CNA (staff #108) while standing outside of resident #57's room. The CNA stated that the signage on the door meant the resident was on EBP. The CNA stated that the sign meant a gown and gloves had to be work when residents had an IV (intravenous line), Foley catheter, or ostomy. The CNA added that she should have worn a gown when handling resident #57's Foley catheter. The CNA stated wearing a gown "protected him" (referring to the resident). The CNA stated that PPE did not have to be worn to reposition the resident. An interview was conducted on May 30, 2024 at 2:03 P.M. with the Director of Nursing/Infection Preventionist (DON/IP). The DON/IP stated that residents who had Foley catheters, IVs

Based on observations, staff interviews, and policy review, the facility failed to ensure food was served in accordance with professional standards for food service safety. The deficient practice could result in foodborne illnesses. Findings include: During an observation for lunch preparation on May 30, 2024 at 11:46 A.M. dietary staff #59 was using a food thermometer to check the temperature of a chicken for a chicken sandwich while the sandwich was on top of a white cutting board. At 11:47 A.M. the staff left the thermometer on top of the white cutting board used to cut the chicken sandwich. At 11:51 A.M. another staff (#36) was observed entering the kitchen and proceeded to scoop soup from a pot using a ladle without performing hand hygiene. After scooping the soup, the staff (#36) then attempted to open a plastic bag before washing her hands in the kitchen sink then left the kitchen with the container of soup. At approximately 11:55 A.M. an interview was conducted with staff #36 and she stated that she should have washed her hands before she scooped the soup from the pot. During a continuous observation of lunch preparation, staff #144 was observed leaving the kitchen and walking towards the dining area while holding a Styrofoam container. At 12:07 P.M. staff #144 came back in the kitchen without performing hand hygiene and proceeded to the tray line where the food trays were lined up. Staff #144 then opened the refrigerator door and removed milk cartoons out of the refrigerator without performing hand hygiene. At 12:09 P.M. staff #144 then washed his hands. During a dining room observation on May 30, 2024 at 12:14 P.M. there was a small sink in the corner of the dining room with an empty soap and paper towel dispenser. An interview was conducted on May 30, 2024 at 1:16 P.M. with a cook (staff #115). He stated that the dining area did not have a sink for guests to wash their hands but that there were bathrooms. An interview was conducted on May 30, 2024 at 4:29 P.M. with certified nursing assistant (CNA/staff #87). She stated that the residents could wash their hands using the sink in the dining area in the mini corner, and residents were assisted with hand hygiene before going to the dining room area and leaving the dining room. She added that there was no hand sanitizer in the dining room. An interview was conducted on May 31, 2024 at 9:07 A.M. with Culinary Service Director (CSD/staff #144). He stated that they have different color-coded cutting boards and that everything was wiped down in the morning, and sanitized before starting work. The CSD stated that every staff must wash their hands before performing any kitchen duties. He added that staff washed their hands every time after they touch their face, touch paper that comes from the outside, and every time they touch any products to avoid cross-contamination. Further, the CSD said if the staff come into the kitchen, they must wear hairnet and wash their hands. When someone goes outsid