Haven Health Green Valley, LLC

Inspectors wroteBased on clinical record review, interviews, and review of the facility's policy and procedures, the facility failed to ensure a significant change in condition assessment was completed for Resident #120. The universe was 19. The deficient practice could result in residents not receiving the necessary care and services to maintain the highest and practicable wellbeing.

Inspectors wroteBased on the clinical record review, observations, interviews, facility documentation, and policy, the facility failed to ensure that infection control practices for Enhanced Barrier Precautions (EBP) were followed for one resident (Resident #11). This deficient practice can result in contamination and the spread of infection. The universe is 15, and the sample is one resident.

Inspectors wroteBased on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that floor tiles, laminate flooring, shower drain, and door frame in common areas were safe for residents ambulating and showering. The deficient practice could result in residents falling and/or being injured.

Inspectors wroteBased on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents. Findings Include: A review of the personnel file for the role of activity manager (staff #432) was conducted on May 21, 2024. However, review of file did not reveal evidence that staff #432 possessed the qualifications required for the role of activities director. An interview was conducted on May 21, 2024 at 1:12 P.M. with staff #498, human resource manager. Staff #498 stated that the role of activity manager had no additional qualifications needed beyond the scope of qualifications that staff #432 had. [...]

Inspectors wroteBased on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that code status was accurate and consistent in the medical record for one resident, #242. The deficient practice could result in resident not receiving care consistent with their signed advance directive.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#47) had the right to privacy. The deficient practice could result in residents being denied their rights and impact psychosocial well-being.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#50, and #3) to be free from abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedure, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level I for one resident (#24), and failed to submit the PASRR Level II to the state agency. The deficient practice could result in residents not receiving additional services that are needed.

Inspectors wroteBased on observation, interviews and policy review, the facility failed to ensure that physician's orders was followed regarding one resident's (#31) AV (arteriovenous) fistula. The deficient practice could result in the resident's AV fistula failing.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#75 , #241) were assessed, monitored and had orders for self-administration of medications and that one resident (#23) was monitored with appropriate level of supervision. The deficient practice could result in residents being injured.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#41). The deficient practice could result in residents not receiving care and services for oral/dental conditions.

Inspectors wroteBased on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#17) was free from sexual abuse from another resident (resident #51). The deficient practice could result in further incidents of resident to resident abuse. Findings Include: -Resident #17 (Alleged victim) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia, depression, anxiety, chronic kidney disease, and type 2 diabetes. [...]

Inspectors wroteBased on personnel file review, staff interviews, and facility policy, the facility failed to ensure that two of two sampled Certified Nursing Assistants (CNA/staff #100 and #91) were able to demonstrate competencies and skills necessary to provide care for residents. The census was 80. The deficient practice could result in inadequate care for residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure their system of medication records is complete to enable accurate reconciliation and accounting for all controlled medications. The deficient practice could result in misappropriation of residents' medications. Findings Include: -Prior to medication pass observation conducted on January 11, 2023 at 8:26 a.m. with a licensed nurse (LPN/ staff #47), she was observed handed medication cards wrapped in the reconciliation sheets to the assistant director of nursing (ADON/staff #109). Staff #109 walked away with medication cards in her hands to another unit. Following this observation, an interview was conducted with staff #47 on January 11, 2023 at 8:50 a.m. [...]

Inspectors wroteBased on review of the clinical record , staff interviews and review of the facility policy, the facility failed to ensure the pharmacist identified adequate monitoring for the use of medications in the pharmacy review for 5 residents (#32,#14,#37, #41 and #25). The deficient practice could allow for medication side effects and adverse consequences to go unadressed.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure five out of five residents (#32, #41, #14, #37, and #25) receiving psychotropic medications received consistent monitoring for behaviors and side effects. The facility census was 80. The deficient practice could result in unnecessary medication use and adverse side effects.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy, the facility failed to ensure that one resident (#54) was assisted in obtaining routine dental care. The sample size was 20. The deficient practice could result in residents ' dental needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#32) and/or their representative was informed of the risks and benefits of psychotropic medications prior to administration. The sample size was 20. The deficient practice could result in residents and/or their representatives not being fully informed of the risks, benefits and alternatives to proposed treatment.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure an advanced directive was accurate for one resident (#54). The sample size was 20. The deficient practice could result in residents ' wishes not being honored.

Inspectors wroteBased on record review, staff interviews, policy review and CMS regulations, the facility failed to ensure that one resident (#56) received a timely Advanced Beneficiary Notification, within 48-hours, for termination of part A Medicare services.

Inspectors wroteBased on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that an updated pre-admission screening and resident review (PASRR) was completed for one resident (#14). The deficient practice could lead to residents not receiving needed care and services.

Inspectors wroteBased on clinical record review, staff interviews and review of policy, the facility failed to ensure two residents (#51 and #56) care plans were updated/revised to meet their changing needs. The sample size was 20. The deficient practice could result in inadequate care and/or not meeting the needs of the resident.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#183) did not receive oxygen without a physician ' s order. The sample size was 20. The deficient practice may increase the risk for residents to receive unnecessary medications.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure that a discharge summary for one resident (#3) contained a recapitulation of the resident's stay and all pre and post discharge medications.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#56) received treatment and services in accordance with professional standards of practice. The deficient practice could result in resident not receiving the treatment based on their assessed need.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#54) was provided assistance with obtaining audiology services. The sample size was 20. The deficient practice may contribute to the resident ' s confusion and agitation.

Inspectors wroteBased on clinical record reviews, observations, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure that one resident (#51) received care and services, consistent with professional standards of practice, to prevent, treat, and/or heal a pressure ulcer. The sample size was 20. The deficient practice could result in development, worsening, and/or infection of pressure ulcers.