Wellsprings of Gilbert

In the surveyor’s words

From the most serious findings on record at Wellsprings of Gilbert, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF690Aug 11, 2023

  Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure a physician order for indwelling catheter use was obtained for two residents (#2 and #1) and for external female catheter use for one resident (#20). The deficient practice could increase the risk of complications including infections related to catheter use. Findings include: -Resident #2 was admitted on [DATE] with benign prostatic hyperplasia with lower urinary tract symptoms. The admission nursing evaluation dated July 14, 2023 revealed resident was admitted with a catheter type/size 16Fr (French) 10 cc (cubic centimeter); and that, the resident had recurrent urinary tract infections (UTI) as a result of the catheter. […]

• No harm, potential for more than minimal, patternF887Aug 11, 2023

  Based on observation, clinical record review, staff interviews, and the Centers for Medicare and Medicaid Services (CMS) regulation, the facility failed to ensure that four residents (#12, #16, #125, #227) were offered and received education on the risks and benefits associated with the COVID-19 vaccine. Findings include: A review of the immunization records and the clinical records for residents #12, #16, #125 and #227, revealed no evidence that residents #12, #16, #125 and #227 were offered and educated on the risks and benefits associated with the COVID-19 vaccine. The clinical record of residents #12, #16, #125 and #227 revealed no documentation that these residents refused the COVID-19 vaccine. In an interview with a resident (#12) conducted on August 7, 2023, at 9:30 a.m. […]

• No harm, potential for more than minimal, patternF686Jul 27, 2022

  Based on clinical record reviews, staff interviews, and review of policies and procedures, the facility failed to ensure that timely assessments and consistent treatments were provided to two residents (#1 and #3) with pressure ulcers. The deficient practice could result in additional residents not receiving timely assessments and consistent treatments for pressure ulcers. Findings included: -Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated January 25, 2019 for impaired skin integrity included a goal that resident #1 would regain integrity of the skin surface. […]

• No harm, potential for more than minimal, patternF880Feb 1, 2021

  Based on observations, staff interviews, policies and procedures and the Center for Disease Control (CDC) recommendations, the facility failed to ensure infection control standards were followed by failing to ensure the outside door to the COVID-19/Observation unit was secured and that signage was placed on the outside door indicating that it was the COVID-19/Observation unit, and regarding Personal Protective Equipment (PPE) reuse. The deficient practices could result in the spread of infection, including COVID-19 to residents and staff. Findings include: Regarding COVID-19/Observation unit: On February 1, 2021 at 9:37 a.m., the surveyor was directed to enter the COVID-19/Observation unit through the outside side entrance of the building. […]

• No harm, potential for more than minimal, isolatedF552Aug 11, 2023

  Based on clinical record review, staff interviews, and the facility's policy, the facility failed to ensure one resident (#126) was informed of the risks and benefits of a psychotropic medication prior to the administration of the medication. The deficient practice could result in not being informed and not able to exercise the right to choose the preferred option. Findings include: Resident #126 was admitted to the facility on [DATE], with diagnoses of dementia, anxiety, and mood disturbance. A physician's order dated August 3, 2023, revealed an order for Amitriptyline (antidepressant) 100 milligrams by mouth at bedtime for depression. Review of the MAR (Medication Administration Record) for August 2023 revealed the resident was administered Amitriptyline on August 3, 2023. […]