Skilled Nursing Unit at Oro Valley Hospital

In the surveyor’s words

From the most serious findings on record at Skilled Nursing Unit at Oro Valley Hospital, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF552Jan 19, 2023

  Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure two residents (#60 and #114) and/or their representatives were informed of the risks and benefits of psychotropic medications prior to administration. The sample size was 5. The deficient practice could result in residents and/or their representatives not being fully informed of the risks, benefits and alternatives to proposed treatment. Findings include: -Resident #60 admitted to the facility on [DATE] with diagnoses including acute pain, anxiety and hypertensive disorder. Review of physician,s order dated 01/05/23 included buspirone (anxiolytic) 10 milligrams (mg) twice daily with no diagnostic indication. […]

• No harm, potential for more than minimal, patternF758Jan 19, 2023

  Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure three of five residents (#60, #114 and #112) receiving psychotropic medications received consistent monitoring for behaviors and side effects. The facility census was 15. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: -Resident #60 admitted to the facility on [DATE] with diagnoses including acute pain, anxiety and hypertensive disorder. Review of physician's order dated 01/05/23 included buspirone (anxiolytic) 10 milligrams (mg) twice daily with no diagnostic indication. A physician's order dated 01/09/23 included mirtazapine (antidepressant) 7.5 mg daily at bedtime with no diagnostic indication. […]

• No harm, potential for more than minimal, patternF842Jan 19, 2023

  Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure that three residents' (#9, #2) Minimum Data Set (MDS) assessments were complete and accurately documented the residents condition. The sample size was 8. The deficient practice could result in an inaccurate/insufficient assessment. Findings include: -Resident #9 admitted to the facility on [DATE] with diagnoses including catheter-associated urinary tract infection, acute metabolic encephalopathy, improving, and COVID-19, sub-acute. However, the 5-day admission MDS assessment dated [DATE] did not provide evidence that a Brief Interview for Mental Status (BIMS) assessment had been conducted. […]

• No harm, potential for more than minimal, isolatedF761May 14, 2026

  Based on observations, staff interviews, and policy review the facility failed to ensure that medications were not left at bedside for 1 (Resident #32) out of 56 sampled residents. The deficient practice could lead to the medication being incorrectly administered or accidentally ingested by a resident.Findings include:Resident #32 was admitted on [DATE] with diagnoses including fracture of part of neck and right femur, encounter for neck and right femur orthopedic aftercare, and chronic kidney disease.A MDS (minimum data set) assessment dated [DATE], revealed a BIMS (brief interview of mental status) score of 14, which revealed intact cognition. […]

• No harm, potential for more than minimal, isolatedF812May 14, 2026

  Based on observations, staff interviews, and facility policy and procedure the facility failed to ensure that food items were stored, dated, labeled, and maintained at an appropriate temperature to prevent food borne illnesses in accordance with professional standards. The deficient practice could lead to food borne illnesses. The census was 33 residents. Findings include:A kitchen observation was conducted on April 12, 2026 at 10:28 a.m. with the Dietary Supervisor (Staff #62) who is currently ServSafe certified. […]