Sante of North Scottsdale

Based on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to complete a thorough investigation regarding an allegation of misappropriation for one resident (#22). Finding include: Resident #22 was admitted to the facility on November 23, 2024 with diagnoses that included periprosthetic fracture around internal prosthetic left hip joint, fall on the same level, Parkinson's Disease, and dementia. The inventory of personal effects dated November 23, 2024 revealed: one black purse, one brown wallet, one credit card, two forms of identification (ID), #53.00, and a medical card. The form was signed by a certified nursing assistant (CNA/staff #15). Review of the schedule dated November 24, 2025, revealed the following staff worked the noc shift from 6:00 p.m. to 6:30 a.m.: -licensed practical nurse (LPN/staff #82) -certified nursing assistant (CNA/staff #15) was assigned to rooms #200 to #205 and #219 to #225 -(CNA/staff #90) was assigned to rooms #206 to #218 Review of the time card from November 24, 2024 through November 30, 2024 for (LPN/staff #82) revealed that staff worked: -November 24, 2024 from 7:26 p.m. to 6:31 a.m. -November 25, 2024 from 6:08 p.m. to 6:32 a.m. -November 26, 2024 from 6:24 p.m. to 7:44 a.m. -November 29, 2024 from 6:08 p.m. to 6:46 a.m. Review of the time card from November 23, 2024 through November 30, 2024 for (CNA/staff #15) revealed that staff worked: -November 23, 2024 from 6:13 p.m. to 6:36 a.m. -November 24, 2024 from 6:08 p.m. to 6:35 a.m. Review of the time card from November 23, 2024 through November 30, 2024 for (CNA/staff #90) revealed that staff worked: -November 23, 2024 from 5:55 p.m. to 6:14 a.m. -November 24, 2024 from 5:54 p.m. to 6:26 a.m. -November 26, 2024 from 6:13 p.m. to 6:05 a.m. -November 28, 2024 from 5:59 p.m. to 6:00 a.m. Review of the schedule dated November 25, 2025, revealed the following staff worked the day shift from 6:00 a.m. to 6:30 p.m.: -LPN/staff #10) -(LPN/staff #94) -(LPN/staff #117) -(CNA/staff #99) was assigned to the 200 hall -CNA/staff #118) was assigned to the 200 hall -(CNA/staff #205) was assigned to the 200 hall Review of the Comment and Concern Form dated November 25, 2024 at 9:30 a.m. revealed that resident #22 reported that her wallet was missing. The Property Response and Investigation Form dated November 25, 2024 at 9:45 a.m. revealed that after completing a thorough search of the resident's room, #204, with the resident, the wallet was not located. Review of the 5-day investigation revealed that Administrator in Training (AIT/staff #3) was notified on November 25, 2024 at 9:30 a.m. that resident #22 was unable to locate her wallet with $53.00 and her identification (ID) the previous day. Immediately after receiving the notification, he went to the resident's room and searched the room, including her personal belongings with the resident present. He was unable to locate the wallet and started his investigation. CNAs

Based on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that resident (#22) was given a safe place to store valuable personal belongings and personal/medical information for safe keeping in her room to prevent personal property from being misappropriated. Findings include: Resident #22 was admitted to the facility on November 23, 2024 with diagnoses that included periprosthetic fracture around internal prosthetic left hip joint, fall on the same level, Parkinson's Disease, and dementia. The inventory of personal effects dated November 23, 2024 revealed: one black purse, one brown wallet, one credit card, two forms of identification (ID), #53.00, and a medical card. The form was signed by a certified nursing assistant (CNA/staff #15). The minimum data set (MDS) dated November 27, 2024 included a brief interview for mental status score of 15 indicating the resident was cognitively intact. The care plan dated December 24, 2024 revealed the resident has a impaired cognitive function/dementia or impaired thought process. Interventions included for staff to use approaches that maximize involvement in daily decision making and activity (specify: limit choices, use cueing, task segmentation, written lists, instructions). Review of the Comment and Concern Form dated November 25, 2024 at 9:30 a.m. revealed that the resident reported that her wallet was missing. The Property Response and Investigation Form dated November 25, 2024 at 9:45 a.m. revealed that after completing a thorough search of the resident's room with the resident, the wallet was not located. Review of the nurse practitioner (NP) note dated November 25, 2024 revealed that the resident was was referred for an evaluation of mental status. The resident is a 82-year old female, appears stated age, alert and oriented times three, with good eye contact. The resident reported a possible visual hallucination (VH) of seeing someone stealing her ID and cards from her wallet. The resident reports being unsure if this was a VH or if someone actually stole from her. The resident states seeing this the other night. Documentation of a letter dated November 29, 2024 by the Administrator in Training (AIT/staff #3) revealed that the facility was not able to locate the resident's wallet with $53.00 and the resident's identification. The resident's room and personal belongings were searched with the resident present and the wallet was not located. An interview was conducted on December 4, 2024 at 10:27 a.m. with the Senior Vice President of Clinical Operations and Compliance, who is currently the Acting Administrator (staff #1). She stated that the staff who completes the admission process with the resident also, completes the inventory of personal effects form and talks about the lock box, where valuables can be stored, in the resident's room with the resident. If the resident wants to use the lock box, the resident can request a key. On Dec

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#2) received treatment and care in accordance with professional standards of practice regarding anticoagulant therapy. Findings include: Resident #2 was admitted to the facility on August 19, 2024 with the diagnosis that included acute cystitis without hematuria, thrombocytopenia, left bundle branch block, personal history of transient ischemic attack (TIA) and cerebral infraction without residual deficits. Review of clinical record dated August 20, 2024 at 09:53 revealed a nurse practitioner progress note "Cardiology was consulted given his anticoagulation needs for mechanical aortic valve status post aortic valve replacement. They advised to continue to monitor INR until therapeutic range 2.5-3.5". Review of Resident's Minimum Data Set (MDS) dated August 23, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 13.0 which revealed resident was cognitively intact. The MDS included that the resident has a history of anemia, hypertension, hemiplegia, trans ischemic attack (TIA). Review of physician order included following orders: - Warfarin Sodium oral tablet (anti-coagulant) give 6 mg (milligram) by mouth one time a day every Tuesday and Thursday for A-fib. with order date of August 19, 2024, hold date from September 2 to 3, 2024, hold date from September 5 to 6, 2024, hold date from September 6 to 7, 2024 and hold date from September 10 to 10, 2024 and hold date from September 10 to 25, 2024. - Warfarin Sodium oral tablet give 5 mg by mouth one time a day every Monday, Wednesday, Friday, Saturday, Sunday for A-fib with order date of August 19, 2024, hold date from September 2 to 3, 2024, hold date from September 5 to 6, 2024, hold date from September 6 to 7, 2024 and hold date from September 10 to 10, 2024 and hold date from September 10 to 25, 2024. - INR (International Normalized Ratio that measures how long it takes for blood to clot) daily on Monday and Thursday for A-fib with start date of August 29, 2024 and d/c (discontinue) date of September 6, 2024. - INR daily one time a day for A-fib with start date of September 7, 2024 Review of clinical record revealed that the resident's INR was at 8.0 on September 5, 2024 and September 7, 2024. Review of clinical record dated September 6, 2024 at 16:29 revealed a physician's progress note that stated that the resident's INR was elevated on September 6, 2024. It further included for September 5, 2024 to hold coumadin x 3 days and stated to not dose vitamin K. However, the review of September MAR (Medication Administration Record) revealed that warfarin sodium 5 mg was administered at 1700 on September 7, 2024. The INR result on September 7 was 8.0 which is above the therapeutic range of 2.5-3.5. In addition, the physician progress note dated September 6, 2024 stated to hold coumadin for 3 days. The MAR revealed that warfarin sodium 5 mg was administered at 1700 on Septemb