Haven of Flagstaff

Inspectors wroteBased on observations, interviews, clinical record reviews, facility documentation, and facility policies, the facility failed to ensure that medications were not diverted for two residents (#13 and #15). This deficient practice could result in Controlled Substance being diverted and not being available to residents as prescribed. Findings Include: -Regarding Resident #15:Resident #15 was admitted to the facility on [DATE], with diagnoses of hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), and heart failure. A care plan initiated on November 13, 2025, revealed a focus area for the Resident #15 to be on Opiate medications related to post-surgical. The care also revealed a goal to be free of adverse reactions related to opiate medication and an intervention to administer medication as needed. [...]

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident (#10) was free from a preventable accident that resulted in serious injury. The deficient practice could lead to further instances of accidents resulting in injuries to residents.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one of five sampled resident (#136) were safe to self-administer medication. The deficient practice could result in a medication overdose. Findings Include: Resident #136 was admitted on [DATE] with diagnosis of dysphasia, chronic obstructive pulmonary disease, bipolar disorder, depression, anxiety and pressure ulcer. The admission Assessment Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A Care Plan dated March 07, 2025 revealed no indication of a focus for medication self-administration. Review of the clinical record revealed no evidence of a medication self-administration order. [...]

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 5 sampled residents (Resident # 284) was free from abuse by another resident (#183). The deficient practice could result in other residents being abused.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to implement their abuse policy involving an allegation of abuse with two residents (#284 and #183) to law enforcement. The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure an allegation of resident (#183) to resident (#284) abuse was reported to all applicable state agencies. The deficient practice could result in further allegations of abuse not being reported.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated, when stored for residents' use. The deficient practice could increase the risk of foodborne illness.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to maintain medical records that are complete and accurate in accordance with professional standards for 2 of 15 sampled residents (# 183, 284). The deficient practice could result in records that do not accurately and completely reflect the care and services provided to residents. Findings Include: -Regarding Resident #183 Resident #183 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and history of falling. A comprehensive care plan dated January 18, 2024 revealed that Resident #183 had communication problems due to dementia. The care plan also revealed that she had impaired cognitive function due to dementia. A late entry change of condition summary note dated February 26, 2024 at 11:44 p.m., revealed that the resident was adjusting well to a new room. [...]

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#1 and #2) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to submit a 5-day written investigation summary regarding physical altercation between 2 residents (#1 and #2). The deficient practice could result in allegations of abuse not being investigated.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one resident (#3) received care for pressure ulcers consistent with professional standards when observed wound care assessments were not completed on a weekly basis. This had the potential for pressure ulcers for resident #3 to worsen.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#71) was free from abuse of another. The deficient practice could result on resident being physically and psychosocially harmed by other residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedures, the facility failed to provide evidence that the an allegation of abuse for one resident (#71) was thoroughly investigated and results of the investigation was reported to the State Agency within 5 working days of the incident. The deficient practice could result on further abuse of residents and appropriate actions not taken.

Inspectors wroteBased on personnel record review, staff interview, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in not providing activities that meet the physical and psychosocial needs of the residents.

Inspectors wroteBased on clinical record review, resident and staff interviews and policy review, the facility failed to ensure that a resident (#39) had been assessed to self adminster medications. The deficient practice could result in resident not receiving medications needed to maintain or improve their physical health.

Inspectors wroteBased on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure that alleged violations involving abuse were reported within required timeframe for one resident (#13). This resulted in the allegation of abuse not being investigated. Findings Include: Resident #13 admitted to the facility on [DATE] with diagnoses that included sepsis, scoliosis, osteoporosis, acute kidney failure, and acute respiratory failure. In her current care plan there is a goal with appropriate interventions related to her limited physical mobility related to contracture. In a 30 day look back period Resident #13 needed extensive assistance from staff when transferring (moving from bed to wheelchair and vice versa for example) with one occasion of full staff performance September 22, 2023 at 4:00 PM. [...]

Inspectors wroteBased on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that a PASRR Level 2 referral was completed for one resident (#30). The deficient practice could lead to residents not receiving needed care and services.

Inspectors wroteBased on clinical record review, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I was updated appropriately for one resident (#47). The deficient practice could result in specialized services not being identified and provided to residents.

Inspectors wroteBased on clinical record review, resident and staff interviews and policy review, the facility failed to ensure rehabilitation services were provided for one resident (#16) as ordered by the physician. The deficient practice could result in resident not receiving rehabilitation services needed to maintain or improve their physical health.

Inspectors wroteBased on observations, staff interviews, manufacturer manual, and policy reviews, the facility failed to ensure the dishwasher sanitation was monitored, kitchenware was clean and dry, and that the electrical cord and outlets above the tray line were clean. The deficient practice could increase the risk of foodborne illness.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure an allegation of resident (#183) to resident (#184) abuse was reported timely to the State Agency (SA). The deficient practice could result in further allegations of abuse not being reported timely.

Inspectors wroteBased on clinical record review, staff interview, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge MDS (Minimum Data Set) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) System within the required time frame for one resident (#2). The deficient practice could result in lack of resident specific information for quality measure purposes.

Inspectors wroteBased on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure one resident's (#68) Minimum Data Set (MDS) assessment was accurate. The sample size was 23. The deficient practice could result in inaccurate discharge tracking information.

Inspectors wroteBased on observations, resident and staff interviews, facility documentation, and policy reviews, the facility failed to ensure that activities were provided according to one resident's (#16) preferences. The sample size was 4. The deficient practice could result in residents not having the opportunity to participate in activities of their choice.