Skilled Nursing Unit at Oro Valley Hospital

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.

Nutrition and Dietary Deficiencies

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

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Nutrition and Dietary Deficiencies

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

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

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.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Based on record review and staff interviews, the facility failed to maintain correct operation of the door.

Based on observations, staff interviews, and policy review, the facility failed to ensure proper food hygiene practices were maintained and kitchen equipment were in good repair. Findings include: During the initial kitchen observation conducted with the Dietary Director (staff #84) on July 1, 2024 at 9:54 am, there was one female staff wearing black scrubs and was standing inside the kitchen without any hair restraints. Another staff (#45) who was in the kitchen was introduced as one of the facility's dieticians did not have any hair restraints on . Staff #45 proceeded to go inside the office located in the back entrance of the kitchen. An observation of the hot dishwasher was conducted with Executive Chef (staff #87) on July 2, 2024 at 8:38 am. While the hot dishwasher was running, the temperature gauge for the final rinse was at 187 degrees Fahrenheit. Staff #87 stated that according to the machine instruction, the minimum temperature for the wash cycle was 150 degrees Fahrenheit and the minimum temperature for the rinse cycle was 160 degrees Fahrenheit. At 8:42 am, the dishwashing power wash temperature was below 150 degrees Fahrenheit. Staff #87 stated that the temperature gauge was not working. He then checked the temperature by using a portable thermometer. He opened the lid of the power wash and stated that it was hot with the thermometer reading between 152 and 157 degrees Fahrenheit. Staff #87 said that the facility was in the process of changing the equipment; and that, he will place a work order for the company to come fix or check out the power wash temperature gauge. In another observation of the kitchen conducted with another cook (staff #67) on July 2, 2024 at 8:47 a.m., staff # 67 was in the dishwashing area of the kitchen and was not wearing any hair restraints. He stated that the power wash was not working for 3 weeks; and, he checked the dishwasher temperature using his own thermometer. While waiting to observe the tray line service on July 2, 2024 at 11:15 a.m., the driver nutrition services staff (#39) was walking in the kitchen from one of the prep section area of the kitchen carrying a box. She was not wearing any hair restraints and stated she just walked in. She then proceeded to placed a hair restraint (hairnet) over her head. An interview was conducted on July 3, 2024 at 9:29 a.m. with nutritional supervisor (staff #69) who stated that her job included scheduling, maintaining retail programing, checking diets, making sure resident allergies were correct and excluded from meals, cooking, prepping, and dishwashing. She stated that if there was a problem with the equipment, staff would request for a work order. She also said that if a warmer was broken, staff would use another warmer. The nutritional supervisor stated that her staff reports to management for equipment not working; and that, the staff knows how to place a work order request. Further, she stated that once the work order was cleared, she receives notice in h

Based on record review, interviews, and policy review, the facility failed to ensure that 2 out of 4 employees complied with fingerprint requirements. Findings include: A review of personnel file for the maintenance staff (#64) revealed a start of employment date of July 25, 2022. There was no evidence that staff #64 had a valid fingerprint card on file. The personnel file for another maintenance staff (#44) revealed a start of employment date of January 24, 2022. There was no evidence that staff #44 had a valid fingerprint card on file. An interview was conducted on July 3, 2024 with Human Resources (staff #2) and the Administrator (staff #80) who both stated that the facility does not do fingerprint cards for maintenance employees as the hospital does not have this requirement. The administrator stated that the rest of the staff who work with residents in the skill nursing unit have fingerprint clearance cards. When asked how the facility ensures the safety of the residents when maintenance staff enter the resident rooms, the administrator was unable to provide an answer. In an interview with the interim maintenance director (staff #1) conducted on June 3, 2024 at 1:04 p.m., the interim maintenance director said that he had been in his current role for a month but had worked at the facility since 2013. Staff #1 said that the maintenance staff enter the resident rooms if repairs were needed to be made while the residents were present in their rooms. He also said that he was still learning about the hiring process and that he worked closely with the Human Resources department. Staff #1 further stated that all of his staff have had background checks. An interview with the maintenance staff (#64) was conducted on July 3, 2024 at 1:14 p.m. Staff #64 said that he does not have his fingerprint clearance card. In another interview with the administrator conducted on July 3, 2024 at 2:06 p.m., the administrator stated that staff #64 and 44 did not have fingerprint clearance cards on file. A review of the facility policy, titled "Employee Recruiting and Retention" revealed there is no language regarding an employee needing to receive valid fingerprint clearance card within twenty working days of the start of employment.

Based on observations, staff interviews, and policy review, the facility failed to ensure proper food hygiene practices were maintained were maintained and kitchen equipment were in good repair. The deficient practice has the potential to cause foodborne illness. Findings include: During the initial kitchen observation conducted with the Dietary Director (staff #84) on July 1, 2024 at 9:54 am, there was one female staff wearing black scrubs and was standing inside the kitchen without any hair restraints. Another staff (#45) who was in the kitchen was introduced as one of the facility's dieticians did not have any hair restraints on . Staff #45 proceeded to go inside the office located in the back entrance of the kitchen. An observation of the hot dishwasher was conducted with Executive Chef (staff #87) on July 2, 2024 at 8:38 am. While the hot dishwasher was running, the temperature gauge for the final rinse was at 187 degrees Fahrenheit. Staff #87 stated that according to the machine instruction, the minimum temperature for the wash cycle was 150 degrees Fahrenheit and the minimum temperature for the rinse cycle was 160 degrees Fahrenheit. At 8:42 am, the dishwashing power wash temperature was below 150 degrees Fahrenheit. Staff #87 stated that the temperature gauge was not working. He then checked the temperature by using a portable thermometer. He opened the lid of the power wash and stated that it was hot with the thermometer reading between 152 and 157 degrees Fahrenheit. Staff #87 said that the facility was in the process of changing the equipment; and that, he will place a work order for the company to come fix or check out the power wash temperature gauge. In another observation of the kitchen conducted with another cook (staff #67) on July 2, 2024 at 8:47 a.m., staff # 67 was in the dishwashing area of the kitchen and was not wearing any hair restraints. He stated that the power wash was not working for 3 weeks; and, he checked the dishwasher temperature using his own thermometer. While waiting to observe the tray line service on July 2, 2024 at 11:15 a.m., the driver nutrition services staff (#39) was walking in the kitchen from one of the prep section area of the kitchen carrying a box. She was not wearing any hair restraints and stated she just walked in. She then proceeded to placed a hair restraint (hairnet) over her head. An interview was conducted on July 3, 2024 at 9:29 a.m. with nutritional supervisor (staff #69) who stated that her job included scheduling, maintaining retail programing, checking diets, making sure resident allergies were correct and excluded from meals, cooking, prepping, and dishwashing. She stated that if there was a problem with the equipment, staff would request for a work order. She also said that if a warmer was broken, staff would use another warmer. The nutritional supervisor stated that her staff reports to management for equipment not working; and that, the staff knows how to place a work order reques