Arizona State Veteran Home-Phx

In the surveyor’s words

From the most serious findings on record at Arizona State Veteran Home-Phx, in the surveyor’s own words.

• Actual harm, isolatedF760Jan 22, 2025

  Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#79) was free from a significant medication error. The deficient practice resulted in the resident experiencing a Fentanyl overdose, requiring treatment at the hospital's Intensive Care Unit (ICU). Findings include: Resident #79 was admitted to the facility on [DATE] with diagnoses including acute on chronic right heart failure, urinary tract infection, and Parkinson's disease. […]

• Actual harm, isolatedF689May 8, 2024

  Based on observations, clinical record review, staff and resident interviews and review of facility policy, the facility failed to ensure adequate supervision was provided to prevent one resident (#84) from committing suicide. The deficient practice resulted in injury and hospitalization of the resident; and, increased risk of death by suicide. Findings include: Resident #84 was admitted on [DATE] with diagnoses of suicidal ideations, recent history of major depressive disorder, generalized anxiety disorder with racing thoughts, and pain. Review of a progress note from a prior facility dated [DATE] included that the resident had a history of chronic pain, suicidal intention and weakness; and, was transferred to that facility for continued care. […]

• Actual harm, isolatedF690Nov 2, 2023

  Based on clinical record review, staff and resident interviews, review of facility policy, and the rules of the State Board of Nursing, the facility failed to ensure appropriate care and services related to indwelling catheter care was provided to two residents (#20 and #1). The deficient practice could result in residents not receiving necessary treatment and infection or the catheter having to be replaced sooner. Findings include: -Resident #1 was admitted on [DATE] with diagnoses of history of urinary tract infections, urogenital implant, neuromuscular dysfunction of bladder and benign prostatic hyperplasia with lower urinary tract symptoms. […]

• No harm, potential for more than minimal, widespreadF851May 30, 2025

  Based on facility documentation, staff interviews, and policy review, the facility failed to ensure that the required staffing information and Certification and Survey Provider Enhanced Reporting (CASPER) Payroll-Based Journal (PBJ) data was submitted to CMS (Centers for Medicare & Medicaid Services) for one quarter. The deficient practice could result in residents receiving inadequate care due to a potential lack of staffing. Findings include: A review of the [NAME] PBJ Staffing Data Report that was run on May 21, 2025 revealed that the facility was triggered for failure to submit data for the quarter for the following: Fiscal year, quarter four (July 1 - September 30) 2024 Interview was attempted with the staffing coordinator on May 30, 2025 at 10:37AM, but she could not be reached for… […]

• No harm, potential for more than minimal, patternF842May 30, 2025

  Based on documentation, resident and staff interviews, and facility policy and procedures, the facility failed to ensure that the medical record, including recorded weights, was complete and accurate for two residents (#59). The deficient practice could lead to interdisciplinary team members not being aware of the resident's status and could lead to a gap in care. Findings include: Resident #59 was admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver, major depressive disorder, and enterocolitis due to clostridium difficile. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. […]