Haven of Globe

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to protect one resident's (#96) rights to be free from staff-to-resident physical abuse. The deficient practice could result in residents being physically and emotionally harmed.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident of staff-to-resident abuse for one resident (#96). The deficient practice could result in residents being physically and emotionally harmed.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident of staff-to-resident abuse was reported within the required timeframe for one resident (#96). The deficient practice could result in residents being physically and emotionally harmed.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident of staff-to-resident abuse involving one resident (#96) was thoroughly investigated. The deficient practice could result in residents being physically and emotionally harmed.

Inspectors wroteBased on an observation, clinical record review, interviews, facility documentation and policies, and review of the State Agency (SA) database, the facility failed to protect the rights of 3 out of 18 sampled residents (#92, #93, #8) to be free from physical and verbal abuse by another resident. The deficient practice could result in further resident abuse.

Inspectors wroteBased on review of the facility assessment, facility documentation, interviews, and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving the appropriate care to maintain safety, and the highest practicable physical, mental, and psychological well-being as determined by resident assessments and individual plans of care.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure that drugs and biologicals were stored, secure, and inaccessible to unauthorized staff and residents in accordance with facility policy, state, and federal laws for four of eighteen sampled residents (#5, #22, #69, #89). The universe was seventy-one. The deficient practice could lead to medications being incorrectly administered or accidentally ingested by a resident. Findings Include: -Regarding Resident #5 Resident #5 was admitted on [DATE] with diagnosis including bipolar disorder, current episode-depressed, dementia-unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, psychosis not due to a substance or known psychological condition, schizoaffective disorder, essential hypertension, edema, dermatitis, cellulitis and pruritis. [...]

Inspectors wroteBased on record review, staff interviews, review of facility documents and policy, the facility failed to ensure one out of eighteen sampled residents (#47) received treatment and care related to insulin and blood pressure medications in accordance with the provider's order, professional standards of practice and the resident's comprehensive person-centered care plan. The deficient practice could place the residents' health at risk.

Inspectors wroteBased on record review, staff interviews, observations, and review of facility policies and procedures, the facility failed to ensure that 2 out of 18 sampled residents (#1 and #2) received appropriate treatments and services to prevent urinary tract infections. The deficient practice could lead to a high risk of CAUTI (catheter-associated urinary tract infections), contamination transfer, tube obstruction or resident injury. Findings Include: -Regarding Resident #1 Resident #1 was admitted on [DATE] with diagnosis including type 2 diabetes mellites without complications, encephalopathy, end stage renal disease, bacteriuria, paroxysmal atrial fibrillation, dependence on renal dialysis, urinary tract infection, systemic inflammatory response syndrome of non-infectious origin, epilepsy, dementia with other behavioral disturbance, and obstructive and reflux uropathy. [...]

Inspectors wroteBased on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure four residents (#50, #150, #100 and #250) were free from abuse from other residents (#100, #250, #200). The deficient practice could lead to other resident to resident altercations which could result in harm.

Inspectors wroteBased on observations, staff interview, and policy, the facility failed to ensure the kitchen (lower kitchen) and the serving area (upstairs kitchen) was clean and sanitary when preparing food for residents. The deficient practice could increase the risk of foodborne illness.

Inspectors wroteBased on observation, interviews, and review of facility documentation and policy, the facility failed to ensure an effective pest control program was maintained. This deficient practice can result in the spread of disease, and not promoting a home like environment for the residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that a resident's representative was notified of a transfer. The deficient practice could result in resident's representative being unaware of residents discharge.

Inspectors wroteBased on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure necessary blood pressure medications and insulin were administered according to provider instruction for one resident (#68). This deficient practice could result in side effects leading to negative resident outcomes.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#3) and (#4) to prevent further resident to resident altercations. The deficient practice could result in further incidents of inadequate resident supervision.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#3) and (#4) to prevent further resident to resident altercations. The deficient practice could result in further incidents of inadequate resident supervision.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policies, the facility failed to ensure oxygen was administered as ordered by the physician for one of 3 sampled residents (#21). The deficient practice could result in residents not receiving adequate oxygen to prevent hypoxia.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and review of policy, the facility failed to ensure a physician order for an X-ray was carried out timely for one resident (#46) and failed to ensure physician was notified regarding a change in condition for one resident (#76). The sample size was 18. The deficient practice may increase the risk for residents to sustain complications including hospitalization and/or death.