Splendido at Rancho Vistoso

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.

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.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Pharmacy Service Deficiencies

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

Nutrition and Dietary Deficiencies

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

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 Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Assessment and Care Planning Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

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

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95° F and 120° F in the areas of a facility used by residents. The deficient practice posed a health and safety risk to the residents. Findings include: 1. During a tour of the facility with E1, the Compliance Officer observed the hot water temperature in a resident’s bathroom measured 125° F. 2. In an interview, E1 acknowledged that the hot water temperature was not maintained between 95° F and 120° F in the areas of a facility used by residents.

Violation cited

Violation cited

Violation cited

Based on clinical record review, interviews, review of facility policies and the State Agency (SA) complaint tracking system, the facility failed to use a two-person transfer, as identified by the comprehensive care plan, resulting in the resident #1's fall with injury. The deficient practice could result in increased risk of injury to the resident. Findings include: Resident #1 was admitted to the facility on February 23, 2022 with diagnoses of unspecified dementia, degenerative disease of nervous system and repeated falls. A review of a Minimum Data Set (MDS) assessment dated July 10, 2024 revealed a staff assessment for mental status indicating resident #1 had a memory problem with both short-term memory and long-term memory. It was also assessed that resident #1's cognitive skills for daily decision making to be moderately impaired. The same MDS assessment also indicated resident #1 was entirely dependent on staff for assistance or the assistance of 2 or more helpers required with sit to stand and bed-to-chair transfer. The MDS also revealed the resident was receiving hospice care. A review of the physician's orders revealed the following orders; Hoyer lift for transfers only, which was dated March 22, 2024. A review of a comprehensive care plan revealed a focus on the resident's risks of falls due to his use of psychotropic medications and fall risk score. An intervention was initiated on March 25, 2024 that indicated resident #1 was a two person assist with Hoyer lift with transfers. A review of the facility's assessment titled, "Assessment Criteria for Safe Resident Handling and Movement," dated July 5, 2024 indicated resident #1 was not weight bearing as they did not have any bilateral upper-extremity strength. The same assessment also indicated resident #1 was a 2-person transfer by staff with a full body lift with full sling. A review of the progress notes for resident #1 revealed an entry dated September 2, 2024 that was created by Licensed Practical Nurse (LPN/Staff #147). The note revealed that staff #147 was summoned to resident #1's room by another staff member. The note continues to indicate that resident #1 was sitting on the floor with a CNA and that the "CNA stated she slid him down to the floor when trying to transfer to (wheelchair)". The note indicated that staff #147 and three other staff members assisted the resident into the wheelchair and vitals were taken. A review of another progress note for resident #1 which was dated September 3, 2024 and was created by LPN/Staff #53. The note indicated resident #1 was complaining of pain when he moved in bed and during peri-care. At this time, the resident was assessed and it was noted that there was bruising to the lateral right knee with some swelling. The note indicates that a new order for increased morphine and an x-ray was received. A review of the physician's orders revealed an order for an X-ray to the right knee and hip due to increased pain caused by a fall which was date

Based on clinical record review, interviews, review of facility policies and the State Agency (SA) complaint tracking system, the facility failed to use a two-person transfer, as identified by the comprehensive care plan, resulting in the resident #1's fall with injury. Findings include: Resident #1 was admitted to the facility on February 23, 2022 with diagnoses of unspecified dementia, degenerative disease of nervous system and repeated falls. A review of a Minimum Data Set (MDS) assessment dated July 10, 2024 revealed a staff assessment for mental status indicating resident #1 had a memory problem with both short-term memory and long-term memory. It was also assessed that resident #1's cognitive skills for daily decision making to be moderately impaired. The same MDS assessment also indicated resident #1 was entirely dependent on staff for assistance or the assistance of 2 or more helpers required with sit to stand and bed-to-chair transfer. The MDS also revealed the resident was receiving hospice care. A review of the physician's orders revealed the following orders; Hoyer lift for transfers only, which was dated March 22, 2024. A review of a comprehensive care plan revealed a focus on the resident's risks of falls due to his use of psychotropic medications and fall risk score. An intervention was initiated on March 25, 2024 that indicated resident #1 was a two person assist with Hoyer lift with transfers. A review of the facility's assessment titled, "Assessment Criteria for Safe Resident Handling and Movement," dated July 5, 2024 indicated resident #1 was not weight bearing as they did not have any bilateral upper-extremity strength. The same assessment also indicated resident #1 was a 2-person transfer by staff with a full body lift with full sling. A review of the progress notes for resident #1 revealed an entry dated September 2, 2024 that was created by Licensed Practical Nurse (LPN/Staff #147). The note revealed that staff #147 was summoned to resident #1's room by another staff member. The note continues to indicate that resident #1 was sitting on the floor with a CNA and that the "CNA stated she slid him down to the floor when trying to transfer to (wheelchair)". The note indicated that staff #147 and three other staff members assisted the resident into the wheelchair and vitals were taken. A review of another progress note for resident #1 which was dated September 3, 2024 and was created by LPN/Staff #53. The note indicated resident #1 was complaining of pain when he moved in bed and during peri-care. At this time, the resident was assessed and it was noted that there was bruising to the lateral right knee with some swelling. The note indicates that a new order for increased morphine and an x-ray was received. A review of the physician's orders revealed an order for an X-ray to the right knee and hip due to increased pain caused by a fall which was dated September 3, 2024. A review of a third progress note for resident #1, dated Sep