Haven of Camp Verde

Inspectors wroteBased on staff interviews, clinical record review, facility documentation, and facility's policy and procedure, the facility failed to ensure physician's orders were followed for one out of three sampled residents (Resident #17) related to blood glucose management. The deficient practice could result in residents not receiving treatment as ordered, placing them at risk for potential harm.

Inspectors wroteBased on review of facility documentation and policy, and staff interviews, the facility failed to ensure that daily staff postings were posted accurately regarding actual number of licensed and unlicensed staff that worked each shift and actual hours worked by licensed and unlicensed staff for 17 out of 17 days reviewed. The census was 43. The deficient practice could result in residents, visitors, and facility staff not being informed of accurate and current staffing information.

Inspectors wroteBased on interviews, clinical record review, and review of facility policies and procedures, the facility failed to protect the rights of one (#75) of eleven sampled residents by failing to ensure the resident was free from abuse by another resident (#74). The census was 43 residents. The deficient practice resulted in resident-to-resident sexual abuse and had the potential to result in ongoing abuse and further harm to other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that care and treatment were provided in accordance with physician orders for 1 of 4 sampled residents. This deficient practice resulted in the implementation of resident safety interventions without physician authorization. Findings Include:Resident #77 was admitted to the facility on [DATE], with diagnoses including unspecified dementia without behavioral, psychotic, or mood disturbance; anxiety; type 2 diabetes mellitus with diabetic neuropathy and foot ulcer; alcohol abuse; and acquired absence of another left toe. An admission Minimum Data Set (MDS) assessment completed on January 13, 2023, indicated that Resident #77 had a Brief Interview for Mental Status (BIMS) score of 12, reflecting moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for two of the four sampled residents. The deficient practice could result in injury to residents. Findings Include:About Resident #77:Resident #77 was admitted to the facility on [DATE], with diagnoses including unspecified dementia without behavioral, psychotic, or mood disturbance; anxiety; type 2 diabetes mellitus with diabetic neuropathy and foot ulcer; alcohol abuse; and acquired absence of another left toe. An admission Minimum Data Set (MDS) assessment completed on January 13, 2023, indicated that Resident #77 had a Brief Interview for Mental Status (BIMS) score of 12, reflecting moderate cognitive impairment. [...]

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure one (#8) out of the three sample residents received activities of daily living (ADL) care as per facility policy. The deficient practice could result in resident's hygiene needs not being met, skin breakdown, and psychosocial harm.

Inspectors wroteBased on clinical record review, staff interviews, facility policy and procedure and police report, the facility failed to ensure life-saving measures including cardiopulmonary resuscitation (CPR) were provided according to the advance directives for one resident (#10) who was found unresponsive. The deficient practice resulted in the resident not receiving life-saving measures and death.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one resident (#2) to be free from physical abuse by another resident (#4). The deficient practice could lead to physical or psychosocial harm of a resident.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure the facility abuse policy was implemented for a resident (#2) with an allegation of abuse. The deficient practice could lead to physical or psychosocial harm of a resident. Finidngs include: -Resident #2 was admitted to the facility March 28, 2025, and re-admitted to the facility on [DATE], with diagnoses that included cognitive communication deficit, pressure ulcer of sacrum, laceration of right foot with foreign body, and unspecified dementia. The clinical record review revealed no evidence of a description of a resident to resident incident on May 6, 2025, any monitoring or that the resident was placed on alert charting, notification of the incident to the medical provider, and any assessment for injury following the incident. [...]

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a baseline care plan was developed to meet the needs of one resident (#2). The deficient practice could lead to care team members not being aware of a resident's medical conditions and/or plan of care to address the resident's individual needs.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for one resident (#2) following an allegation of abuse. The deficient practice could lead to care team members not being aware of a resident's status, and lead to missed or delayed treatment.

Inspectors wroteBased on clinical record review, facility documentation, interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#3) received showering assistance per facility policy and resident preference. The deficient practice could have a potential to cause a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings Include: Resident #3 was re-admitted into the facility on May 15, 2024, with diagnoses of pulmonary hypertension, chronic obstructive pulmonary disease, acute on chronic congestive heart failure, and unspecified dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident's Brief Interview for Mental Status (BIMS) assessment score was 12, indicating the resident had moderately impaired cognition. [...]

Inspectors wroteBased on observations, clinical record review, facility documentation, staff interviews and policy review, the facility failed to ensure professional standards of quality were met regarding accurate documentation for two of two sampled residents (#10, #20). The deficient practice could result in residents' clinical record not being accurate and complete.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure infection control standards were maintained during medication administration, regarding equipment sanitizing and hand hygiene. The deficient practice could result in cross contamination and the spread of infections to others.

Inspectors wroteBased on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure the necessary treatment and services were provided for one resident (#10), as ordered by the physician. The deficient practice could result in residents not receiving the necessary treatment and services they need.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that medications were administered as ordered by physician for two residents ( #20, # 26) as observed during medication administration. The deficient practice could result in medications not being available to meet resident needs. Findings Include: -Regarding Resident #20: Resident #20, was admitted on [DATE], with diagnoses including hypertensive heart disease, dementia, and peripheral vascular disease, had inconsistencies in their eye drop administration documentation. A physician's order, dated January 30, 2024, prescribed Artificial Tears eye drops, two drops in each eye, four times daily. A January 2025 Medication Administration Record (MAR) revealed that two drops of Artificial Tears had been administered on January 29, 2025. [...]

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure that food items in the kitchen storage room were properly covered, labeled and dated. The deficient practice could result in food contamination and pest infestation which could result in sickness and potential food poisoning among the residents.

Inspectors wroteBased on observations, facility documentation, staff interviews and facility policy, the facility failed to ensure there was sufficient nursing staff on a 24-hour basis based on staffing schedule, postings and in accordance with the facility assessment (completed 8/31/23, Updated 10/12/23).

Inspectors wroteBased on review of facility documentation, staff interviews and policy review, the facility failed to ensure that the nurse staffing information was accurately posted on a daily basis, which included the actual hours worked by licensed and unlicensed nursing staff.

Inspectors wroteBased on observations, facility documentation, staff interviews and facility policy, the facility failed to submit accurate staffing information base on payroll data in a uniform format to CMS (Centers for Medicare & Medicaid Services).