Apache Junction Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident involving staff to resident abuse was documented completely in the clinical record for 1 of 4 sampled residents (#2), and that medical records were maintained for the regulated timeframe for 3 out of 4 residents (#450, #451, #16). The deficient practice could result in incomplete documentation in resident medical records. Findings Include: -Regarding Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses that included hypertension, multiple sclerosis, anxiety disorder, and paraplegia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. An allegation of staff to resident abuse that occurred on November 19, 2022 was investigated by the facility on November 24, 2022. However, review of the resident ' s clinical record dated November 19, 2022 through February…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one of 2 sampled residents (#2) were not verbally abused by a Licensed Practical Nurse (LPN/Staff#207). The deficient practice could result in residents being emotionally harmed. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included hypertension, multiple sclerosis, anxiety disorder, and paraplegia. There was no evidence in the clinical record that the care plan had been updated regarding an allegation of abuse that occurred on November 19, 2022. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also indicated no behaviors were exhibited. Further review of the resident ' s clinical record from November 19, 2022 through February 21, 2022 revealed no evidence of the verbal abuse allegation that occurred on November 19, 2022. Review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure controlled narcotic medications of one resident (#449) were not diverted and misappropriated by a Licensed Practical Nurse (LPN/Staff#210). The deficient practice could result in residents not receiving pain medication as ordered, and pain not being controlled. Findings include: Resident #449 was admitted to the facility on [DATE] with diagnoses that included artificial hip joint, diabetic neuropathy, depression, and anxiety A Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. Review of medication orders revealed that oxycodone 10 MG tablets were initiated on the following dates: -April 13, 2023 -April 17, 2023 -April 23, 2023 Further review of the medication orders revealed no evidence of stopped/discontinued/completed dates for oxycodone on the above dates. Review of medication administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, resident and staff interviews, the facility failed to ensure abuse policies were followed regarding one of 2 sampled residents (#2) who was verbally abused by a Licensed Practical Nurse (LPN/Staff#207). The deficient practice could result in abuse policies not being followed, which could result in residents being harmed. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included hypertension, multiple sclerosis, anxiety disorder, and paraplegia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also indicated no behaviors were exhibited. Review of a facility investigation dated November 24, 2022, revealed a substantiated allegation that a verbal altercation occurred on November 19, 2022, between an LPN (staff #207) and Resident #2. The investigation revealed that the LPN resigned from the facility. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for one of eight sampled residents (#46) by failing to administer medication following physician ordered parameters. The deficient practice could result in undesirable medication-induced harm and uncontrolled pain. Finding Includes: Resident #46 was admitted into the facility on January 17, 2025 with diagnoses that included type 2 diabetes, depression and obstructive uropathy. A physician order dated January 18, 2025 was written for tylenol oral tablet 325 milligram (acetaminophen) to give 2 tablets by mouth every 6 hours, as needed for pain 1-3. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. It further revealed that the resident had pain occasionally effected her sleep and therapy activities. A care plan initiated on February 12, 2025, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, clinical record review and facility documentation and policy review, the facility failed to ensure that a medication was administered as ordered for 3 sampled residents (#6, #32 and #25). This deficient practice could result in residents not receiving the necessary treatment to address their medical issues/problems. Findings include: -Resident #6 was admitted on [DATE] with diagnoses of urinary tract infection, dysphagia, and neurogenic bladder. A care plan dated [DATE] for altered skin integrity included and intervention to notify the Physician or Nurse Practitioner as needed. The admission notes dated [DATE] revealed the resident was readmitted with diagnosis of MDR (multi-drug resistant) UTI (urinary tract infection); and was at the facility for IV (intravenous antibiotic). A care plan dated [DATE] revealed the resident had fluid overload. Interventions include to administer medications as ordered. A physician order dated [DATE] included for Ertapenem Sodium…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that one resident (#7) was free from staff physical abuse. The deficient practice could result in further incidents of staff to resident abuse. Findings Include: Resident #7 was admitted on [DATE] with diagnoses of malnutrition, bipolar disorder, depression, anxiety, chronic obstructive uropathy, and dorsalgia. A behavioral care plan with a start date of July 13, 2023 revealed the resident self-directed her own care, routines and decisions with potential for harm to self and others and that the resident confabulated and deflected conversation when confronted regarding behaviors when boundaries were discussed. The goal was that the resident would not be harmed. Interventions included to discuss safety reasons for rules and boundaries with resident as needed. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of policy, the facility failed to ensure that an account of all controlled drugs was maintained and reconciled. The deficient practice could result in misappropriation of residents' medications. Findings include: During an observation conducted on June 14, 2023 at 10:53 AM with a Licensed Practical Nurse (LPN/staff #6), of the Station B medication cart. Review of the Controlled Substance Card Inventory form revealed that two cards had been added to the cart, but did not have a two-nurse reconciliation. She stated that both nurses would initial the form that the reconciliation had been completed. During an observation conducted on June 14, 2023 at 11:07 AM with a Licensed Practical Nurse (LPN/staff #33), of the Station C medication cart. Review of the Controlled Drugs-Count Record dated June 2023, revealed 3 shifts that did not have a two-nurse reconciliation. The LPN stated that she forgot to sign off on the reconciliation form this morning, and the expectation is that it is initialed by both nurses, the on-going and out-going…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident and staff interviews, and policy and procedures, the facility failed to ensure that one sampled resident (#65) was assessed to determine clinical appropriateness to self-administer medications. The deficient practice could result in medications not being taken as ordered and unsafe storage of medications. Findings include: Resident #65 was admitted on [DATE] with diagnoses of encounter for palliative care, Chronic Obstructive Pulmonary Disease, and personal history of traumatic brain injury. A Physician's Order dated April 26, 2022 included tramadol (opioid analgesic) HCl Tablet 50 MG (milligrams). Give 2 tablets by mouth every 4 hours as needed for PAIN SCALE 1-3. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. An observation was conducted in the resident's room on May 31, 2022 at 9:04 AM. A medication cup was observed with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, resident family, and staff interviews, clinical record review, the Centers for Medicare & Medicaid Services (CMS), and policies and procedures, the facility failed to ensure one sampled resident (#44) had the right to receive visitors of their choosing and at the time of their choosing. The deficient practice could result in residents' rights regarding visitation not being honored. Findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses of aphasia following cerebral infarction, and other sequelae of nontraumatic intracerebral hemorrhage. A Care Plan dated July 1, 2021 revealed the resident has psychosocial needs as evidenced by restricted visitation due to COVID-19 mandatory measures. Interventions included assisting the resident with alternate ways to communicate with family/loved ones and providing alternate activities as available such as courtyard fresh air as possible. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy reviews, the facility failed to ensure medication was administered in accordance with professional standards for one resident (#95). The deficient practice could result in residents not receiving the total dose of ordered medication. Findings include: Resident #95 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, hypertension, and renal insufficiency. A review of the admission MDS assessment dated [DATE] revealed a BIMS score of 08, indicating the resident had moderate impaired cognition. During a medication administration observation conducted on 06/02/22 in the morning after 7:58 AM with a Registered Nurse (RN/staff #30), the RN was observed to prepare resident #95's medication which included a MiraLAX drink for bowel care and a fluticasone-salmeterol inhaler for breathing. The resident was presented with a cup of MiraLAX and drank approximately a quarter of the medication. The inhaler was then administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, resident and staff interviews, and policy reviews, the facility failed to ensure that one resident (#76) had orders for oxygen, and one resident (#404) had orders for use of a CPAP (continuous positive airway pressure) unit. The sample size was 2 residents. The deficient practice could result in residents receiving respiratory care without orders. Findings include: -Resident #404 was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes mellitus, morbid obesity, depression, and dependence on supplemental oxygen. An observation and interview with the resident were conducted on May 31, 2022 at 9:43 AM. A CPAP unit was observed sitting on the bedside table, with the tubing attached. During the interview the resident stated that she had not been reminded by staff to use the CPAP the last two nights. The resident further stated that she has not yet cleaned the unit, but would need assistance. Review of the admission Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to ensure medications were secured and not left unattended on top of the medication cart. The deficient practice could result in misappropriation of medications. Findings include: During a medication administration observation conducted on 06/02/22 in the morning after 7:58 AM with a Registered Nurse (RN/staff #30), the RN was observed to prepare the medications for a resident, which included aspirin, citalopram (antidepressant), docusate sodium (stool softener), and donepezil (medication for dementia). Staff #30 then realized she needed another medication that was not in the medication cart, so she locked the medication cart but left the cup of prepared medications on top of the locked medication cart. Staff #30 then went down the hall to another medication cart. The RN's back was to the unattended cart, which was facing the resident's room. An interview was conducted on 06/02/22 at 12:03 PM with the Director of Nursing (DON/staff #8). The DON stated medication should not be left on top of a medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.