The Center at Tucson

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Administration Deficiencies

Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary 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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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 enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

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

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.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Infection Control Deficiencies

Report COVID19 data to residents and families.

Emergency Preparedness Deficiencies

Establish policies and procedures including evacuation.

Based on clinical record review, resident and staff interviews and facility policy review, the facility failed to ensure that the preference for a gluten free diet for one resident (#17) was honored. Findings include: Resident #17 was admitted July 13, 2024 with diagnoses of fractured right femur with closed fracture with routine healing, type 2 diabetes mellitus, and cognitive communication deficit. The physician order dated July 13, 2024 included for a diet order of regular diet, regular texture and thin consistency. The nutrition assessment dated July 15, 2024 revealed the resident followed a gluten free diet. Review of the clinical record revealed no evidence of a physician order for a gluten-free diet for resident #17. The nutrition care plan dated July 19, 2024 included the resident had a potential and/or was at risk for inability to maintain nutrition. Interventions included resident food preferences, food selections, portion sizes honored via selective menu per resident request and to provide food in a form that is acceptable and culturally acceptable. An admission Minimum Data Set (MDS) assessment dated July 20, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS assessment did not code for any nutritional approaches; and, nutritional status did not trigger for care planning. The social services progress note dated July 25, 2024 included the resident had a BIMS score of 15 indicating the resident had intact cognition. A late entry physician progress note dated July 25, 2024 included the resident was alert and oriented. Plan was to maximize nutrition and mobility. Review of the diet roster by wing dated August 15, 2024 revealed that resident #17 had regular diet and regular texture. During an interview conducted on August 14, 2024 at 9:41 a.m. resident #17 stated that he was gluten free but would pasta and bread. he resident stated that the facility should have gluten free food. An interview was conducted on August 15, 2024 at 11:00 a.m. with cook (staff #93) who stated that if a resident had a preference or was on a gluten free diet, this will be honored. The cook stated that in order to honor the resident's preference, the kitchen staff must be made aware by either the nursing staff or the RD (Registered Dietitian). The cook stated that the dietician evaluates the resident's preferences and allergies; and, this information is then sent to the kitchen and it gets printed out to the kitchen's diet roster, which is a sheet of paper that tells him their residents' food textures, allergies, preferences, and dislikes. An interview was conducted on August 15, 2024 at 2:47 pm with registered nurse (RN/staff #401) who stated that the appropriate diet order or information for a new resident was taken from the hospital verbal report, discharge orders, packet received from the hospital and from the speech therapist. The RN stated that resident preferences and/or allergies were

Based on review of facility documentation, State Agency (SA) Licensing database, and staff interview, the facility failed to ensure written notification of a change in administrator was made to the SA at the time of the change. Findings include: Review of the list of current facility staff revealed that staff #114 was listed as the Administrator. A copy of an email confirmation dated February 2, 2024 from the State nursing care institution administrator (NCIA) board revealed that they received the administrator's notice of appointment. The personnel file for the administrator revealed a hire date of February 25, 2024. A review of the monthly quality assurance meeting sign sheets from January through June 2024 revealed that the staff #114 signed in as the administrator. Review of the SA licensing database revealed that the administrator (staff #114) was not the administrator on record. An interview was conducted on August 16, 2024 at 11:14 a.m. with the administrator (staff #114) who stated that she became the administrator of the facility on February 25, 2024; and that, a notification regarding an administrator change was made to the State NCIA board. However, the administrator was not able to say whether a notification was made to the SA as well. Further, the administrator stated that the expectation was that a notification of the Administrator change was to happen within 30 days of the change; and, if that did not take place, she would be at risk of losing her license and the facility would be out of compliance.

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure that a care plan related to food preference for one resident (#17) was implemented. Findings include: Resident #17 was admitted July 13, 2024 with diagnoses of fractured right femur with closed fracture with routine healing, type 2 diabetes mellitus, and cognitive communication deficit. The physician order dated July 13, 2024 included for a diet order of regular diet, regular texture and thin consistency. The social history note dated July 15, 2024 included that the resident appeared to be alert, oriented to person, place, time and situation. The nutrition assessment dated July 15, 2024 revealed the resident followed a gluten free diet. The nutrition care plan dated July 19, 2024 included the resident had a potential and/or was at risk for inability to maintain nutrition. Interventions included resident food preferences, food selections, portion sizes honored via selective menu per resident request and to provide food in a form that is acceptable and culturally acceptable. An admission Minimum Data Set (MDS) assessment dated July 20, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS assessment did not code for any nutritional approaches; and, nutritional status did not trigger for care planning. The social services progress note dated July 25, 2024 included the resident had a BIMS score of 15 indicating the resident had intact cognition. A late entry physician progress note dated July 25, 2024 included the resident was alert and oriented. Plan was to maximize nutrition and mobility. The diet roster by wing dated August 15, 2024 revealed that resident #17 had regular diet and regular texture. Despite documentation of a gluten-free diet preference, the clinical record revealed no evidence that this diet preference was implemented. During an interview conducted on August 14, 2024 at 9:41 a.m. resident #17 stated that he was gluten free but would pasta and bread. he resident stated that the facility should have gluten free food. An interview was conducted on August 15, 2024 at 2:15 p.m. with the kitchen manager (staff #56) who stated that they have the diet order from the speech therapist or the hospital printed out. from their dietary printer. He stated that the dietician evaluates the residents' preferences and allergies, sends the information to the kitchen printer and it gets printed to their diet roster, which was a sheet of paper that tells him the residents' food textures, allergies, preferences, and dislikes. In an interview with the registered dietician (RD/staff #400) conducted on August 15, 2024 at 2:23 p.m., the RD that the residents are interviewed for food preferences by their dietary technicians who would then communicate this to the dietary staff/department and the RD. She stated that the MNA or nutritional assessment was followed up by the